Nursing NLCEX Questions
A nurse is caring for a client who is diagnosed with a urinary tract infection and is prescribed ciprofloxacin (Cipro) 250 mg PO two times daily. The amount of available is 100 mg/tablet. How many tablets should the nurse administer with each dose? _____________ tablets
2.5 tablets
A nurse is providing discharge education to the parents of a preschooler who is prescribed acetaminophen (Tylenol) 300 mg every 4hr as needed. The acetaminophen liquid suspension that has been prescribed provides 120 mg/5mL. How many teaspoons should the nurse teach the parents to administer per dose? ______________ tsp 5ml = 1.01 tsps
2.5 tsps
A charge nurse is reviewing the steps of the nursing process with a group of nurses. Which of the following data should the charge nurse identify as objective data? (Select all that apply) a. Respiratory rate is 22/min with even, unlabored respirations b. The client's partner states, "They said they hurt after walking about 10 minutes." c. The client's pain rating is 3 on a scale of 0 to 10. d. The client's skin is pink, warm, and dry e. The assistive personnel reports that the client walked with a limp
A, D, E Explanation: Objective data includes information the nurse measures (vital signs), (skin appearance), (observations of other)
A nurse is discussing the nursing process with a newly licensed nurse. Which of the following statements by the newly licensed nurse should the nurse identify as appropriate for the planning step of the nursing process? a. "I will determine the most important client problem that we should address" b. "I will review the past medical history on the client's record to get more information" c. "I will carry out the new prescriptions from the provider" d. "I will ask the client if their nausea has resolved."
A. Explanation: Prioritize the client's problems during the planning step of the nursing process
A charge nurse is observing a newly licensed nurse care for a client who reports pain. The nurse checked the client's MAR and noted the last dose of pain medication was 6 hr ago. The prescription reads every 4 hr PRN for pain. The nurse administered the medication and checked with the client 40 min later, when the client reported improvement. The newly licensed nurse left out which of the following steps of the nursing process? a. Assessment b. Planning c. Intervention d. Evaluation
A. Assessment Explanation: The newly licensed nurse should have used the assessment step of the nursing process by asking the client to evaluate the severity of the pain on a 0 to 10 scale. The nurse also should have asked about the characteristics of the pain and assessed for any changes that might have contributed to worsening of the pain.
A nurse is assessing a client who has a fracture of the femur. The nurse obtains vital signs on admission and again in 2 hrs. Which of the following changes in assessment should indicate to the nurse that the client could be developing a serious complication? a. Increased respiratory rate from 18 to 44/min b. Increased oral temperature from 36.6 C to 37 C c. Increased blood pressure from 112/68 to 120/72 mm Hg d. Increased heart rate from 68 to 72/min
A. Increased respiratory rate from 18 to 44/min
A nurse is developing a plan of care for a client who has a feature to achieve the outcome of functional healing. To assist in meeting this goal, which of the following nursing interventions is the highest priority? a. Maintain immobilization and alignment b. Provide optimal nutrition and hydration c. Promote independence in activities of daily living d. Provide relief from pain and discomfort
A. Maintain immobilization and alignment
A nurse is assessing a client who is being admitted from the PACU following an abdominal hysterectomy. Which of the following assessments is the nurse's priority? a. oxygen saturation b. abdominal dressing c. urinary output d. pain level
A. Oxygen saturation
By the second postoperative day, a client has not achieved satisfactory pain relief. Based on the evaluation, which of the following actions should the nurse take, according to the nursing process? a. Reassess the client to determine the reasons for inadequate pain relief b. Wait to see whether the pain lessens during the next 24 hr. c. Change the plan of care to provide different pain relief interventions d. Teach the client about the plan of care for managing the pain
A. Reassess the client to determine the reasons for inadequate pain relief Explanation: Collect further data from the client to determine why they have not achieved satisfactory pain relief, because various factors might be interfering with their comfort. The nursing process repeats in an ongoing manner across the span of client care.
A nurse is teaching a client who has rheumatoid arthritis about increasing physical rest as part of her treatment plan. Which of the following outcomes of this intervention should the nurse document as a goal for this client? a. Reduced joint stress b. Maintenance of joint function c. Suppression of the inflammatory process d. Decrease stiffness
A. Reduced joint stress
A nurse is receiving change of shift report for a group of assigned clients. The nurse anticipates which of the following activities first in delivering client care using the nursing process? a. Critically analyze client data to determine priorities b. Collect and organize client data c. Set client-centered, measurable, and realistic goals d. Determine effectiveness of interventions
B. Collect and organize client data
A nurse is planning care for a client who has terminal cancer and has a prescription for morphine. Which of the following interventions should the nurse include in the plan of care? a. Instruct the client to take diphenoxylate/atropine 5 mg PO twice a day b. Instruct the client to actively cough to prevent a buildup of secretions in the airway c. Instruct the client to stop taking the morphine if itching develops d. Instruct the client to keep room lights dim during waking hours
B. Instruct the client to actively cough to prevent a buildup of secretions in the airway
A charge nurse is talking with a newly licensed nurse and is reviewing nursing interventions that do not require a provider's prescription. Which of the following interventions should the charge nurse include? (Select all that apply) a. Writing a prescription for morphine sulfate as needed for pain b. Inserting a nasogastric (NG) tube to relieve gastric distention c. Showing a client how to use progressive muscle relaxation d. Performing a daily bath after the evening meal e. Repositioning a client every 2 hr to reduce pressure injury risk
C,D,E
A nurse is evaluating the outcomes for an outpatient client who has depression. Which of the following client statements indicates a need for further evaluation? a. "I had a great trip to the Smokey Mountains" b. "Going back to work has been okay" c. "I just don't like going to the movies like I used to" d. "I can't wait to have my family together next weekend"
C. "I just don't like going to the movies like I used to"
A nurse in a clinic is interviewing a client who will undergo diagnostic testing. The nurse should ask about a client's potential allergies during which phase of the nursing process? a. Planning b. Evaluation c. Assessment d. Implementation
C. Assessment
A nurse is caring for a client who is prescribed bedrest. The plan of care indicates that the client should perform isometric exercises every 2 hr. Which of the following actions should the nurse take as directed by the plan of care? a. Ask the client to move her arms and legs while applying resistance b. Move the client's limbs through their complete range of motion c. Have the client move each limb independently through its complete range of motion d. Instruct the client to tighten muscle groups for a short period, and then relax
D. Instruct the client to tighten muscle groups for a short period, and then relax
A nurse is planning care for a client who has acute dysphagia. Which of the following nursing interventions should be included in the plan of care? a. Providing a straw for consumption of liquids b. Encouraging larger bites c. Placing the client in semi-Flowers position during meals d. Instructing the client to tilt head forward when swallowing
D. Instructing the client to tilt head forward when swallowing
A nurse is teaching a newly licensed nurse about using a stethoscope. Which of the following instructions should the nurse include? a. "Insert the earpieces at a downward angle toward your nose" b. "Use the diaphragm to listen to low-pitched sounds" c. "Drape the stethoscope over your neck when not in use." d. "Clean the stethoscope by immersing it in soapy water"
a. "Insert the earpieces at a downward angle toward your nose" Helps ensure that sounds are effectively transmitted to their eardrums
A nurse is caring for a 4 year old child who has a new diagnosis of diabetes mellitus and is distressed after an insulin injection. Which of the following play activities should the nurse recognize is therapeutic in helping the child deal with the injection? a. A needless syringe and a doll b. A video game c. A story book about a child who has diabetes d. A period of play in the playroom
a. A needless syringe and a doll Playing with a needless syringe and a doll is appropriate therapeutic activity for the child, because they will allow the child to act out feelings of anger and helplessness.
A nurse working on the cardiac unit hears an alarm and finds one of the heart monitor screens at the nurse's stations is displaying a straight line, indicating a client is in cardiac arrest. Which of the following actions should the nurse first take? a. Check on the client b. Unlock the crash cart c. Being cardiopulmonary resuscitation d. Announce a code
a. Check on the client
A nurse is preparing a sterile field. The nurse should identify that which of the following actions contaminates the sterile field? (Select all that apply) a. Cotton ball dampened with sterile normal saline is placed on the field b. A contaminated instrument touches the outer edge of the sterile field c. A sterile instrument is dropped on the near side of the sterile field d. The nurse turns to address the client's question concerning the procedure e. A liquid is poured into a sterile container from a distance of 25 cm (10 in.) f. The procedure is postponed for 30 min to accommodate the client is correct
a. Cotton ball dampened with sterile normal saline is placed on the field d. The nurse turns to address the client's question concerning the procedure e. A liquid is poured into a sterile container from a distance of 25 cm (10 in.) f. The procedure is postponed for 30 min to accommodate the client is correct
A nurse is performing a respiratory assessment on a client. The nurse auscultates a wet, popping sound upon inspiration of the client's breathing. The nurse should identify this observation as which of the following findings? a. Crackles b. Stridor c. Wheezes d. Friction rub
a. Crackles Crackles are wet, popping sounds created by air moving through liquid or by collapsed alveoli snapping open on inspiration.
A nurse is admitting a client who has experienced a weight loss of 11 kg (25lb) in the past 3 months. The clients weighs 40 kg (88lb) and believes she is fat. Which of the following aspects of care should the nurse consider the first priority for this client? a. Identify the client's nutritional status b. Request a mental health consult c. Plan a therapeutic diet for the client d. Provide a structured environment for the client
a. Identify the client's nutritional status The assessment identifies client nutrition needs as well as complications the client might be experiencing related to the eating disorder
A newly hired nurse is reviewing the facility's emergency preparedness plan. Based on a review of the four triage categories, the nurse should provide priority care to clients who are in which of the following categories during a disaster? a. Immediate b. Delayed c. Minimal d. Expectant
a. Immediate The highest priority is assigned to the client with injuries that are severe, but has the potential to survive with treatment
A nurse is reviewing the documentation of a newly licensed nurse. Which of the following actions by the newly licensed nurse while documenting requires the nurse preceptor to intervene? a. Including in a client's nurses' note that an incident report was completed after a medication error b. Drawing horizontal lines through blank spaces left in the nurses' notes followed by a signature c. Refusing to chart the vital signs taken by another nurse on a client's graphic flow sheet d. Documenting the provider was contacted to clarify a questionnable prescription
a. Including in a client's nurses' note that an incident report was completed after a medication error
A nurse is assessing a parent who lost a 12 year old child in a car crash 2 years ago. Which of the following findings indicates the client is exhibiting manifestations of prolonged grieving? a. Leaves the child's room exactly as it was before the loss b. Volunteers at a local children's hospital c. Talks about the child in the past tense d. Visits the child's grave every week after worshipping services
a. Leaves the child's room exactly as it was before the loss An example of dysfunctional grieving is making the loved one's room a shrine for more than a year
A nurse in a provider's office is orienting a newly licensed nurse on how to position a client for a vaginal examination. The nurse should include the teaching to place the client in which of the following positions? a. Lithotomy b. Doral recumbent c. Prone d. Lateral recumbent
a. Lithotomy
A nurse is caring a client who is diagnosed with active pulmonary tuberculosis and is taking isoniazid (INH) and ethambutol (Myambutol). Which of the following manifestations reported by the client necessitate the discontinuation of ethambutol? a. Loss of color discrimination b. Nausea and vomiting c. Red-Orange discoloration to body fluids d. Edema of feet and hands
a. Loss of color discrimination
A nurse is caring for a client who has a serum potassium level of 3.1 mEq/L. Which of the following actions should the nurse take first? a. Obtain an ECG b. Administer oral potassium c. Encourage potassium-rich foods d. Monitor I & O.
a. Obtain an ECG
A nurse is reinforcing discharge teaching to a new mother regarding SIDS. Which of the following is the highest priority to include in the instructions? a. Place the infant in a supine position when sleeping. b. Place the infant on a firm mattress when sleeping c. Avoid covering the infant with loose bedding while sleeping d. Avoid leaving stuffed animals in the crib with the sleeping infant
a. Place the infant in a supine position when sleeping. Positioning the infant supine while sleeping has the greatest impact on reducing the occurrence of SIDS
A nurse in a mental health clinic is discussing guided imagery with a newly licensed nurse. Which of the following clients should the nurse suggest offering the therapy to? a. Post-traumatic Stress Disorder b. Schizophrenia c. Pedophilia d. Paranoid Personality Disorder
a. Post-traumatic Stress Disorder Guided imagery is a recommended treatment to relieve the anxiety associated with post-traumatic stress disorder. It is a complementary alternative therapy also used to treat sleep disorders, anxiety, and pain
A nurse is caring for a client who had a cerebrovascular accident and is having difficulty swallowing. Which of the following health care professionals should attend the client's next interdisciplinary team meeting to address this complication? a. Speech pathologist b. Occupational therapist c. Social Worker d. Respiratory therapist
a. Speech pathologist
A nurse is reinforcing teaching by demonstrating deep breathing and coughing exercises to a client who is scheduled for abdominal surgery. For which of the following responses by the client should the nurse postpone teaching? a. States that pain is an 8 on a scale of 0 to 10. b. States that her partner should be given the information c. Expresses concern about the exercises causing pain when performed after surgery d. Expresses uncertainty about the benefits of exercises
a. States that pain is an 8 on a scale of 0 to 10.
A nurse should identify that which of the following is the goal of surgical asepsis? a. To create and maintain a micro-organism-free environment b. To kill all micro-organisms on all instruments involved in a procedure c. To reduce the present of pathogenic organisms in the environment d. To minimize exposure to the client's blood urging an invasive procedure
a. To create and maintain a micro-organism-free environment
A nurse preceptor is working with a newly licensed nurse to transfer a client from the bed to a chair. Which of the following actions by the new nurse indicates a need for further teaching to prevent lift injuries? a. Twisting at the waist and shoulders b. Ständing with feet in a wide stance c. Positioning self close to the client d. Using arms and legs to lift
a. Twisting at the waist and shoulders
A nurse is collecting data on a client who has received a preoperative dose of morphine. Which of the following indicates the client is experiencing an adverse effect of the medication? a. Urinary retention b. Rapid respirations c. Dilated pupils d. Diarrhea
a. Urinary retention
A nurse is providing education about a new prescription for nitroglycerin to a client who is diagnosed with angina. Which of the following statements by the client indicates a need for further teaching? a. "Ill make sure that the medication container is kept tightly sealed." b. "Im lucky I have a prescription plan that allows me to buy pills in bulk quantities." c. "Ill keep my pills in the medicine cabinet when Im home." d. "Ill go to the emergency room if my chest pain doesnt go away."
b. "Im lucky I have a prescription plan that allows me to buy pills in bulk quantities."
A nurse on the coronary care unit is caring for a client who was transferred from the medical floor after experiencing a myocardial infarction. After the client stabilized, she asks the nurse why she had to be transferred to a unit where her family will be unable to stay with her all the time. Which of the following responses is appropriate? a. "I know this must be frightening, but you are going to be fine." b. "Let's talk for a minute about your concerns" c. "You were transferred because it is in your best interest" d. "Why do you feel a family member should be with you?"
b. "Let's talk for a minute about your concerns"
A nurse is caring for a client who has cancer. The client has decided to stop treatment and requests a referral to hospice. By making the referral as requested, the nurse is illustrating which of the following ethical principles? a. Justice b. Autonomy c. Veracity d. Fidelity
b. Autonomy
A nurse is caring for a client who is diagnosed with gastroenteritis. Which of the following actions should the nurse take first when evaluating for a fluid volume deficit? a. Obtain an arterial pH level b. Check the heart rate and blood pressure c. Inset an indwelling catheter d. Collect a serum BUN and creatinine
b. Check the heart rate and blood pressure Least invasive option
A nurse is assisting with the admission of a client who has decreased circulation in the left leg. Which of the following is the first action the nurse should take? a. Administer an anticoagulant b. Check the leg for warmth and edema c. Apply elastic stockings d. Promote bed rest and extremity elevation
b. Check the leg for warmth and edema If the warmth and edema is found in the leg, this indicates that the decreased circulation could be due to a deep vein thrombosis
While collecting data on a client who is immobile, a nurse locates a reddened area of skin on the left scapula. Which of the following actions should the nurse take? a. Reposition the client every 4hr b. Cover the area with a transparent wound barrier c. Massage areas surrounding the redness d. Wash the area with hot water every 8 hr
b. Cover the area with a transparent wound barrier
A nurse discovers that a client who is diagnosed with dementia received the wrong medication. Which of the following should be the nurse's first action? a. Inform the nurse manager b. Determine the client's condition c. Notify the provider d. Complete an incident report
b. Determine the client's condition
A nurse in a long-term care facility is assisting with the admission of several clients. To prevent falls in hospitalized clients, which of the following actions should the nurse take first? a. Provide assistance with ambulation when indicated b. Determine the mobility status of each client c. Maintain the side rails of each bed in the raised position d. Plan a fall prevention program for clients at risk
b. Determine the mobility status of each client Determine the mobility status of each client will help identify those patients who are at risk for falls
A nurse is preparing to perform a comprehensive physical assessment on a client. Which of the following actions should the nurse plan to take first? a. Document accurate data b. Develop a plan of care c. Validate previous data d. Evaluate outcomes of care
b. Develop a plan of care The first action the nurse should take using the nursing process is to assess the client and develop a plan of care
A nurse is conduction therapeutic medication monitoring on four clients. Which of the following findings should be immediately reported to the provider? a. Lithium carbonate 0.8 mEq/L b. Digoxin 3.0 ng/mL c. Peak serum gentamicin 6 mcg/mL d. Magnesium sulfate 4 mEq/L
b. Digoxin 3.0 ng/mL The digoxin level is above the expected reference range and indicates digoxin toxicity.
A nurse preceptor is orienting a newly licensed nurse. Which of the following actions by the newly licensed nurse indicates a breach of confidentiality and requires intervention by the nurse preceptor? a. Faxing laboratory results to a client's provider b. Discussing changes in a client's plan with his fired who is a nurse on another unit c. Describing a client's level of independence to the case manger arranging home health services d. Remaining in the room with the client while he reviews his own medical records
b. Discussing changes in a client's plan with his fired who is a nurse on another unit
A nurse is caring for a client who is diagnosed with rheumatoid arthritis and is prescribed dexamethasone (Prednisone). Which of the following indicates the client is experiencing an adverse effect of the medication? a. Hypomagnesemia b. Hyperglycemia c. Hyponatremia d. Hyperkalemia
b. Hyperglycemia
A nurse is performing a complete, head to toe physical examination for a client. Which of the following physical assessment techniques should the nurse perform first? a. Auscultation b. Inspection c. Percussion d. Palpation
b. Inspection
A nurse is performing a physical examination of the spine for an older adult client. The nurse should identify that which of the following findings is common with aging? a. Lordosis b. Kyphosis c. Ankylosis d. Scoliosis
b. Kyphosis "Humpback"
A nurse is caring for a client who is having difficulty breathing. Which of the following actions should the nurse take first? a. Place O2 at 2 L per nasal cannula on the client b. Place the client in the orthopneic position c. Perform chest percussion d. Perform nasotracheal suctioning
b. Place the client in the orthopneic position Less invasive option
A nurse is reviewing the lab results for four clients. The clients with which of the following values requires immediate intervention? a. Cholesterol 220 mg/dL b. Platelets 95,000 mm3 c. BUN 20 mg/dL d. Potassium 3.5 mEq/L
b. Platelets 95,000 mm3 Below the expected range
A nurse is caring for a client who has been admitted to the medical unit with vomiting and possible dehydration. Which of the following findings requires immediate intervention? a. Blood glucose 150 mg/dL b. Potassium 2.5 mEq/L c. Total protein 5.2 g/dL d. Urine specific gravity 1.040
b. Potassium 2.5 mEq/L
A nurse is assisting with preparation of a teaching program about healthy nutrition for a group of clients who are tactile learners. Which of the following activities should be included as a learning strategy in the program? a. Watch a video discussing healthy meal preparation b. Prepare a healthy meal to serve at the end of class c. Read pamphlets about preparing a healthy meal d. Discuss healthy meal preparation as a class
b. Prepare a healthy meal to serve at the end of class
A nurse at a college campus mental health counseling center is caring for a student who just failed an examination. The student spends the session berating the teacher and the course. The nurse should recognize this behavior as which of the following defense mechanisms?: a. Conversion b. Projection c. Undoing d. Regression
b. Projection Client refuses to acknowledge unacceptable personal characteristics and transfers feelings, thoughts, or traits onto another person. Instead of dealing with his own failures, the client is describing the shortcomings of the course and teacher
A nurse is palpating a tender are of a client's abdomen. The nurse slowly applies pressure over the area with their fingertips, then quickly releases it. The client reports increased pain on the release of pressure. Which of the following findings should the nurse document? a. Borborygmi b. Rebound tenderness c. Tympany d. Abdominal guarding
b. Rebound tenderness
A nurse is caring for a 48 year old client who is grieving following the death of her husband seven months ago. The client reports that she has lost 30 lb, and is having difficulty sleeping. Which of the following factors indicate the client is experiencing maladaptive grieving? a. The client is 48 years old b. The client's husband died seven months ago c. The client has lost 30 lbs d. The client is having difficulty sleeping
b. The client's husband died seven months ago One of the defining factors of maladaptive grieving is greed that lasts 6 months or longer after the loss
A nurse is assessing a client who is experiencing chronic stress. Which of the following findings should the nurse expect? a. Hypotension b. Viral Infection c. Increased Energy d. Increased Cognitive Awareness
b. Viral Infection The nurse should expect to find the client with a decreased immune response, which leads to viral or bacterial infections in response to chronic stress
A nurse is precasting a newly licensed nurse while he is charting. Use of which of the following indicates a need for further teaching? a. mcg b. q.d. c. mL d. PO
b. q.d
A nurse is reinforcing teaching about transdermal nitroglycerin to a client who has stable angina. Which of the following statements by the client indicates teaching has been effective? a. "I should leave the patch on for 16 to 20 hours each day." b. "I will apply a new patch in the same location each day." c. "The patch should be effective within an hour of being applied" d. "The medication is not absorbed as well when placed on the abdomen."
c. "The patch should be effective within an hour of being applied"
A nurse is performing a cardiovascular assessment on a client. Which of the following findings should the nurse expect? a. A continuous sensation of vibration felt over the second and third left intercostal spaces b. A high-pitched, scraping sound heard in the third intercostal space to the left of the sternum c. A brief thump felt hear the fourth or fifth intercostal space near the left midclavicular line d. A whooshing or swishing sound over the second intercostal space along the left sternal border
c. A brief thump felt hear the fourth or fifth intercostal space near the left midclavicular line This is an expected finding and should be performed when you are preparing to auscultate the apical pulse
A nurse is caring for a group of clients on a mental health unit. Which of the following should the nurse recognize as a maladaptive defense mechanism? a. A client slams a drawer after misplacing her wallet b. A man buys his partner a gift after flirting with his secretary c. A client forgets to schedule needed appointments when fearing chemotherapy d. A client ignores the thought of pain when scheduled for oral surgery
c. A client forgets to schedule needed appointments when fearing chemotherapy Repression occurs when a person deals with anxiety by unconsciously putting the unacceptable or stress-producing thought out of her consciousness. In this case, the repression is maladaptive because the client is not receiving the appropriate health care
A nurse is working with the information technology department of his facility to establish a protocol regarding security mechanisms that will protect the electronic health records of clients. Which of the following could result in a violation of client confidentiality? a. Placement of computer systems in restricted areas b. Installation of firewall software on each computer c. Ability of staff to access electronic health records of clients throughout the facility d. Occurrence of an automatic log-off after a period of inactivity
c. Ability of staff to access electronic health records of clients throughout the facility
A nurse is caring for a client who has been prescribed an indwelling urinary catheter. When preparing to insert the catheter, the nurse should first open the sterile package in which of the following directions? a. To the left b. To the right c. Away from the body d. Toward the body
c. Away from the body
A nurse is caring for a client who is prescribed IV fluids. While inserting the IV catheter, blood is spilled on the flood. Which of the following solutions should the nurse use to clean the spill? a. Isopropyl alcohol b. Chlorhexidine gluconate c. Chlorine (bleach) d. Iodophor
c. Chlorine (bleach)
A nurse is caring for an older adult client who recently experienced the death of her partner. Which of the following is the priority need of the client? a. Establishing a sense of achievement b. Contributing to society c. Creating meaningful social relationships d. Enhancing self-confidence
c. Creating meaningful social relationships The third level of Maslow's Hierarch of Needs includes love, affection, and social relationships in fulfilling love and belonging needs.
A nurse in a local clinic is caring for a female client who is 35 years old. Which of the following screenings should the nurse recommend to the client? a. Mammogram every year to detect breast cancer b. Colonoscopy every 10 years to detect colon cancer c. Dermatologist evaluation every 3 years to detect skin cancer d. Complete eye evaluation every year to detect eye disorders
c. Dermatologist evaluation every 3 years to detect skin cancer
A nurse is conducting a breast examination on a client who has a family history of breast cancer. Which of the following should the nurse report to the provider? a. Silver-colored striae b. Unilateral nipple inversion present since menarche c. Dimpling of the tissue in the upper outer quadrant d. Visible symmetrical venous patterns
c. Dimpling of the tissue in the upper outer quadrant
A nurse is assessing a client's peripheral vascular status of the lower extremities. The nurse should place their fingers on the top of the client's foot, between the tendons of the great toe and those of the toe next to it, in order to palpate which of the following pulses? a. Posterior tibial b. Popliteal c. Dorsalis pedis d. Femoral
c. Dorsalis pedis
A nurse is caring for a newly admitted client. Which of the following client needs should the nurse address first? a. Homelessness b. Lack of family support c. Hypoxic d. Under nourished
c. Hypoxic Hypoxemia indicates reduced blood oxygen levels, which involves the physiological needs of the client and is the first level of Maslow's Hierarchy of Needs
A nurse is reinforcing teaching about HIV with a group of high school students. Which of the following information is appropriate for the nurse to include? a. Medications will eliminate HIV in most clients b. Adolescents are at a lower risk for developing HIV c. Initial HIV symptoms are often similar to the flu d. Using condoms ensures the prevention of HIV during sexual intercourse
c. Initial HIV symptoms are often similar to the flu
A nurse is caring for a client who is in the immediate postoperative period following a tracheotomy. Which of the following is the nurse's priority action? a. Providing pain control b. Preventing hemorrhage c. Maintaining a patient airway d. Ensuring adequate fluid intake
c. Maintaining a patient airway
A nurse is collecting data on a recently admitted client. Which of the following techniques should the nurse use to measure tissue perfusion? a. Determining the client's respiratory rate b. Measuring the client's chest diameter c. Obtaining the client's level of oxygen saturation d. Checking the client's depth of respirations
c. Obtaining the client's level of oxygen saturation
A nurse is caring for a client who is receiving intermittent enteral tube feedings and having diarrhea after each feeding. Which of the following actions should the nurse take in an attempt to prevent diarrhea after subsequent feedings? a. Chill formula prior to administration b. Verify feeding tube placement c. Reduce the rate of the feedings d. Place the client supine during feedings
c. Reduce the rate of the feedings
A nurse is performing an abdominal assessment on a client. Over which of the following areas of the client's abdomen should the nurse attempt to auscultate active bowel sounds first? a. Right upper quadrant b. Left upper quadrant c. Right lower quadrant d. Left lower quadrant
c. Right lower quadrant This is where the small intestine connects to the large intestine, and it is normally very active with bowl sounds.
A nurse is caring for a client who has nausea and a prescription for promethazine (Phenergan) 25 mg IM. Which of the following is appropriate when preparing a medication for administration from an ampule? a. Use a filter needle to administer the promethazine b. Expel air bubbles back into the ampule c. Set the ampule on a flat surface to withdraw the promethazine d. Break the ampule toward the body
c. Set the ampule on a flat surface to withdraw the promethazine
A nurse is collecting data on four clients. Which of the following findings is the most urgent? a. Bladder distension and urgency b. Pedal edema c. Warmth and pain in the calf d. Hypoactive bowel sounds
c. Warmth and pain in the calf Most urgent action required by the nurse
A nurse is caring for a client following a bronchoscopy. Which of the following findings requires immediate intervention? a. Painful swallowing b. Hoarse voice c. difficult breathing d. Blood-tinged sputum
c. difficulty breathing
A nurse is caring for a client who was involved in heavy combat and observed war casualties. The nurse should suspect that the client is suffering from post traumatic stress disorder (PTSD) if the client makes which of the following statements? a. "I check any room because the enemy is still after me and could be hiding anywhere" b. "My child was born with a birth defect due to an exposure I had oversees." c. "I killed four enemy soldiers with my bare hands and saved my entire battalion." d. "In my dreams, all I can see are the wounded reaching out and trying to grab me."
d. "In my dreams, all I can see are the wounded reaching out and trying to grab me." This client's statements about haunting dreams is typical of a client who has PTSD
A nurse is caring for a client who is scheduled for cardiac surgery and tells the nurse, " I don't think im going to have surgery. Everybody has to die sometime." Which of the following responses by the nurse is appropriate? a. "Clients having this surgery are always scared." b. "Why have you changed your mind about the surgery?" c. "You shouldn't worry, everything will be fine." d. "Tell me more about your concerns."
d. "Tell me more about your concerns."
A nurse in a rehabilitation facility has received report on four clients. Which of the following should the nurse evaluate first? a. A client who has peripheral vascular disease and reports numbness in the toes b. A client who has depression and is easily distracted c. A client who has Alzheimer's disease and is unable to complete activities of daily living d. A client who has abdominal surgery 10 days ago and reports feeling his incision pop
d. A client who has abdominal surgery 10 days ago and reports feeling his incision pop Based on the acute versus chronic priority setting framework, the nurse should evaluate this client first
A nurse in a provider's office has collected data on four clients. Which of the following clients should be the nurse's priority concern? a. A client who has a history of heart failure b. A client who has type 1 diabetes mellitus c. A client who is reporting pain associated with osteoarthritis of the knees d. A client who is having a nosebleed associated with hypertension
d. A client who is having a nosebleed associated with hypertension
A nurse is caring for a client who has osteoarthritis and is considering treatment with acupuncture. Which of the following is acceptable for the nurse to include in discussion with the client? a. Acupuncture is loosely regulated by the federal government. b. Acupuncture has been discredited by scientific research c. Acupuncture is thought to be effective only as a placebo d. Acupuncture has been proved to reduce pain and increase function
d. Acupuncture has been proved to reduce pain and increase function
A nurse in an urgent care clinic is caring for a client who has bronchitis with thick pulmonary secretions. The client's oxygen saturation level is 90% on room air. Which of the following actions should the nurse take first? a. Initiate oxygen therapy b. Encourage an increase in oral fluids c. Provide room humidification d. Assist client to cough effectively
d. Assist client to cough effectively This is the first action the nurse should take because a clear airway is necessary for oxygen exchange to occur
A nurse is performing preparing to conduct a Romberg test on a client. The nurse should explain to the client that the Romberg test is used to assess which of the following characteristics? a. Gait b. Hearing c. Vision d. Balance
d. Balance Most common test of balance
A nurse is caring for an older adult client who has an allergy to sulfa, is taking vaproic acid (Depakote) for a seizure disorder, and has been newly diagnosed with osteoarthritis. The client states. "I keep seeing commercials on TV for Celebrex and I want to try it and see if it will help my pain." Upon review of scientific evidence, the nurse should inform the client of which of the following?" a. Celecoxib is contraindicated in clients taking valproic acid b. Celecoxib is contraindicated in older adults c. Celecoxib is contraindicated in clients with seizure disorder d. Celecoxib is contraindicated in clients with an allergy to sulfonamide
d. Celecoxib is contraindicated in clients with an allergy to sulfonamide
A nurse is collecting nutritional data on an older adult client. Which of the following findings is suggestive of a healthy nutritional status? a. Spongy gums that are receding b. Fissures at eyelid corners c. Easily plucked hair d. Deep reddish-colored tongue
d. Deep reddish-colored tongue
A nurse is reinforcing teaching about performing suctioning to a client who is being discharged following a tracheotomy. Which of the following behaviors by the client best indicate to the nurse that teaching has been effective? a. Self-reporting the ability to perform the procedure b. Answering appropriately when questioned orally c. Responding accurately on a written examination d. Demonstrating independent performance of the procedure
d. Demonstrating independent performance of the procedure
A nurse is collecting data on four clients. Which of the following is the highest priority finding by the nurse? a. Malaise b. Anorexia c. Headache d. Diarrhea
d. Diarrhea Diarrhea can deplete the body of fluids and cause a decrease in the circulating blood volume. This is the highest priority finding by the nurse
A nurse is providing teaching to an assistive personnel (AP) about the use of sterile gloves. Which of the following instructions regarding the open-gloving method should the nurse give? a. Ask another team member to assist with donning gloves b. Choose a pair of gloves at least one size smaller than usual c. Grasp only the underside of the cuff with your ungloved hand d. Grasp only the inside of the glove with your ungloved hand
d. Grasp only the inside of the glove with your ungloved hand
A nurse is preparing to administer oral medications to a client who has unilateral weakness following a cerebrovascular accident (CVA). Which of the following should be the priority action of the nurse? a. Administer medications with meals when possible b. Ensure client understanding of medication's effects c. Determine the client's ability to self-administer medications d. Have the client position the head with the chin down while swallowing
d. Have the client position the head with the chin down while swallowing Preventing aspiration is further supported as the priority by the ABC priority setting framework
A nurse is reinforcing teaching to a client who has aphasia. Which of the following actions by the nurse is appropriate when communicating with the client? a. Raising her voice level when speaking to the client b. Asking the client open-ended questions c. Clarifying client statements with the family as needed d. Having the client use eye blinks to indicate yes or no
d. Having the client use eye blinks to indicate yes or no
A nurse is assisting with the preparation of an education program regarding advance directives for newly hired staff. Which of the following information should be included about living wills? a. Living wills require a written prescription from the provider to be legal b. Living wills allow the client to designate a health care proxy c. Living wills ensure the hospital provide emergency care regardless of health care coverage d. Living wills detail treatment wishes of the client in the event of terminal illness
d. Living wills detail treatment wishes of the client in the event of terminal illness
A nurse is caring for a client who lost all his possessions in a house fire and states "I have no idea what I am going to do. I cannot think right now." Which of the following actions should the nurse take? a. Identify other housing options and sources of transportation b. Notify the facility chaplain to request scheduling an appointment c. Confirm that everything will be all right because belongings can be replaced d. Maintain eye contact with the client and summarize the client's feelings.
d. Maintain eye contact with the client and summarize the client's feelings. It is important for the nurse to provide an atmosphere of support and safety. If a person believes that someone is genuinely concerned, then he may believe that help is available
A nurse is caring for a client who has a urinary tract infection. The client is disoriented and found wandering on another unit. Which of the following actions should the nurse take? a. Ensure all four side rails are up b. Administer a prescribed sedative c. Place the client in soft wrist restraints d. Move the client to a room near the nurses' station
d. Move the client to a room near the nurses' station Moving the client to a room near the nurses' stations allows for more frequent observation and promotes client safety
A nurse is caring for a client who is diagnosed with anemia. Which of the following skin color variations is caused by a reduced amount of oxyhemoglobin? a. Cyanosis b. Jaundice c. Erythema d. Pallor
d. Pallor
A nurse is caring for an older adult client who was admitted 3 days ago with fractured ribs bilaterally and is suspected of being abused by his caregivers. Which of the following should the nurse's priority goal? a. Support the client's relationship with his caregivers b. Encourage the client to express his feelings c. Determine who is responsible for the abuse d. Protect the client from further abuse
d. Protect the client from further abuse
A nurse is caring for a male client who has been prescribed an indwelling urinary catheter. In which of the following positions should the client be placed for insertion of the catheter? a. Dorsal recumbent b. Orthopneic c. Side-lying d. Supine
d. Supine
A nurse is assessing a client's cranial nerves. Which of the following client actions is an indication that cranial nerve 1 is intact? a. The client can stick their tongue out b. The client can smile symmetrically c. The client can hear whispered words d. The client can identify a minty scent
d. The client can identify a minty scent Cranial Nerve 1 is Olfactory
A nurse is performing a general client survey and finds that the client has a body mass index (BMI) of 23. Which of the following should the nurse document? a. The client has no nutritional issues or deficits b. The client is at high risk for obesity-related health problems c. The client will need a referral to a dietitian d. The client has a BMI within the expected reference range
d. The client has a BMI within the expected reference range The expected range for a BMI is between 18.5 and 24.9
