practice nclex
Working in ED triaging 4 clients. Which of the following clients should the nurse recommend for treatment first?
A middle aged adult client who has unstable vital signs
Teaching a group of newly licensed nurses about the need to complete an incident report. Which of the following is an example of reportable incident and an indication for completing a report
A nurse administered a medication via the wrong route.
Nurse on pediatric unit received shift report on 4 children. Which should the nurse assess first?
A 10-year old child who is awaiting surgery for an appendectomy and experienced sudden relief of pain. Can indicate peritonitis from a ruptured appendix.
Outpatient mental health clinic clients which of the following clients is effectively using sublimation as a defense mechanism
A client who channels her energy into a new hobby following the loss of her job
Nurse must recommend clients for discharge in order to make room for several critically injured clients from a local disaster
A client who has cellulitis and is receiving oral antibiotics every 8 hours.
Postpartum nurse is caring for 4 clients which one should be on seizure precautions.
A client who is as 33 wks of gestation and has severe gestational hypertension
Just received change of shift report on 4 clients. Which should the nurse assess first
A client who is postop with abdominal distention and no bowel sounds
Received change of shift report on 4 clients. Which one should the nurse intervene to prevent food and medication interaction?
A client who is receiving a MAOI and is requesting a cheeseburger for dinner. -Contains tyramine can cause hypertension
Charge is providing educational session about infection control for a group of staff on isolation precautions
A client who requires airborne precautions should be placed in a negative pressure airflow room
Mental health clinic caring for clients. Which of the following clients is using dissociation as a defense mechanism?
A client who was abused as a child describes the abuse as if it happened to someone else
Developing discharge plan for school age child with thrombocytopenia. What should the child avoid
Blowing the nose it increases the risk for bleeding or hemorrhaging.
Assessing a client who has depressive disorder taking amitriptyline. Identify adverse effects.
Blurred vision
Preparing an educational session about advocacy to a group of nurses
Advocacy is a leadership role that helps others to self actualize
Assessing a client with history of seeking counseling for relationship problems. Shows the nurse multiple superficial self-inflicted lacerations on her forearms. This behavior should be identified as a characteristic of which personality disorder
Borderline-emotionally unstable, have troubled interpersonal relationships and often engage in harmful behaviors such as cutting, substance use and suicidal thoughts.
Rural community health nurse developing a plan to improve health care delivery for migrant farmworkers.
Agency for Healthcare Research and quality
Caring for older adult who is experiencing chronic anorexia and receiving tube feedings. Lab values that indicate additional nutrients are needed
Albumin 2.8 g/dL
Caring for a client in stage 4 of labor who is receiving oxytocin via continuous IV. Priority assessment
Amount of vaginal bleeding
Caring for a group of clients which one should the nurse see first
An older adult client who is anxious and attempting to pull out his IV line
Dietary teaching for a new prescription of phenelzine
Broccoli, Yogurt, Cream Cheese
Assess 1 wk old for palmer grasp reflex
By touching the palms of the infant's hands near the base of the digits causing the flexion of the fingers
Caring for 4 clients. Which task should be delegated to assistive personnel
Arrange the lunch tray for a client who has a hip fracture.
Patient refused a newly open fentanyl patch. Which of the following actions should the nurse take?
Ask another nurse to witness the disposal of the new patch.
Caring for a client who has gastrointestinal bleeding and an NG tube in place. Action that should be taken while performing gastric lavage.
Ask the client to lie on the left side
Assessing correct placement of a client's NG feeding tube prior to administering a bolus feeding.
Aspirate contents form the tube and verify the pH level
Caring for a multiparous client following a vaccum assisted birth. Assess for which possible complication.
Cervical laceration
Caring for a client postop after receiving moderate conscious sedation suddenly becomes restless and reports feeling lightheaded
Check the client's oxygen saturation level
Caring for a newborn with herpes simplex virus which precautions should be initiated
Contact
School age child with scald burns on both hands and wrists suspected abuse
Contact child protective services.
Assessing a client taking propranolol. Indication of adverse reaction
Coughing at night.
Caring for a client receiving hemodalysis with AV fistula
Auscultate the affected extremity for a bruit
Assessing a newborn heart rate follow actions the nurse should take
Auscultate the apical pulse and count beats for at least 1 min.
Reviewing client's right with the nurses on the unit. Informed consent promotes which of the following ethical principles
Autonomy
Assessing client for compartment syndrome expected findings
Edema
A nurse at an urgent care clinic is assessing a client who reports impaired vision in one eye . Which indicates the client has a detached retina
Floating dark spots
Assessing a client who has COPD
pH 7.31. Respiratory acidosis is an expected finding for a client who has COPD
Reviewing lab report for client in end stage kidney disease who received hemodialysis 24 hr ago. Findings to report to provider
sodium 148 mEq/
Client with cancer deciding between two treatment plans
tell me more about your understanding of the options.
Manager in long term care having difficulty with staffing weekend shift is planning to implement changes to the scheduling procedure.
Form a committee of staff members to investigate current staffing issues.
Community health nurse providing teaching on home safety for older adults
Have grab bars installed around your bathtub and toilet.
Caring for a client with active TB about disease transmission
Have the client wear a surgical mask while being transported outside the room.
Assessing an adolescnet who has been taking ibuprofen for 6 months to treat juvenile idiopathic arthritis. Assess for adverse effects
Have you had any stomach pain or bloody stools
Assessing a client who received 2 units of packed RBCs 48 hr ago. Findings that indicate the therapy is effective?
Hemoglobin 14.9 g/dL
Caring for a client who is in resuscitation phase of burn injury
Hyponatremia
Providing teaching about advance directives to a middle adult client. Which response indicates understanding?
I can designate my partner as my health care surrogate
Talking with a client with stage IV breast cancer. Which statement is a constructive use of a defense mechanism
I told my doctor that I would like to start a support group for other women who are sick in my community
Providing info to a client immediately before Romberg test
I will be checking you once with your eyes open and once with them closed
Discharge instructions about newborn care to a client 2 days postpartum
I will cover my baby's body when I wash her hair. I will use the bulb syringe first in her mouth and then in her nose.
Providing education to the parent of school age child with asthma. Indicates understanding?
I will make sure my child receives a yearly influenza vaccination
Discussing common prenatal discomfort 20 weeks gestational
I will wear a supportive bra overnight
Charge nurse notices one of the nurses on the shift frequently violates unit policies by taking an extended amount of time on break. Statement that addresses the conflict
I would like to talk to you about the nit policies regarding break time.
Conducting a mental status examination on newly admitted client. Priority assesment
Ideals of self harm
caring for a client who has schizophrenia who recently started risperidone
Implement fall precautions for the client
Assessing a client with decreased visual acuity due to cataracts. Identify physiological changes
Increased opacity of the lens
Caring for a client with COPD and becomes extremely short of breath. Interventions by the nurse requires completion of an incident report
Increasing oxygen via nasal cannula to 6 L/min
Child with sickle cell anemia and is having a vaso-occlusive crisis
Infuse IV fluids
Caring for a client with a magnesium level of 2.5 mEq/l
Initiate continuous cardiac monitoring
Caring for a child with a fever and fluid filled vesicles on trunk and extremities. Identify priority
Initiate transmission based precautions
Preparing to mix haloperidol lactate 5 mg/mL and diphenhydramine 25 mg/1.5 mL to administer IM to an agitated client
Inject air into both vials prior to withdrawing the medications.
Caring for a client who has a fecal impaction actions to be taken when digitally evacuating the stool
Insert a lubricated gloved finger and advance along the rectal wall.
Oncology unit nurse is administering doxorubicin to breast cancer patient
Inspect the client's mucosa for petechiae every 8 hrs. This med causes thrombocytopenia and increases the risk of bleeding
Performing an abdominal assessment on a client Sequence of actions
Inspect, auscultate, purcuss then palpate.
Preparing to assist with a thoracentesis for a client who has pleurisy
Instruct the client to avoid deep breathing during the procedure
caring for a client with DVT
Instruct the client to elevate the affected extremity when sitting
Preparing client for paracentesis. Action to take
Instruct the client to void.
Continuous bladder irrigation following transurethral resection of prostate. Bladder spasms and decreased urinary output
Irrigate the catheter with 0.9% sodium chloride irrigation
Teaching a client who newly diagnosed with DM. Instructions on manifestations of hypoglycemia
Irritability
infant with hydrocephalus 6 hr post op following ventriculoperitoneal shunt placement . finding to report to provider
Irritability when being held. signifies increased ICP
Caring for a client who is taking valproic acid for seizure control. Adverse effect to monitor and report
Jaundice-clients are at risk for liver damage.
Preparing a sterile field for sterile dressing change.
Maintain sterile objects within the line of vision
Caring for a client with a new diagnosis of terminal cancer. Client states he would like to go home to be with family and loved ones.
Make a referral for social services
Preparing to teach a group of newly licensed nurses about effective time management. Include as priority
Making a list of activities to complete
Client who has fluid volume overload. Which tasks can nurse delegate to UAP
Measure the client's daily weight
Assessing a newborn following vaginal birth. Findings to report to provider
Nasal flaring
Teaching about lithium to client who has bipolar disorder
Notify your provider if your experience increarsed thirst
Assigning task roles for group of clients in community mental health clinic. Which should be assigned to group functioning the orienter
Noting the progress of the group toward assigned goals
Assessing a client following vaginal delivery and notes heavy lochia and a boggy fundus. Which med should be administered
Oxytocin
Planning to delegate client care tasks to an assistive personnel. Which task can be delegated?
Perform gastrectomy feeding through a client's established gastrostomy tube.
Teaching self administration of insulin to a client with short acting and intermediate acting insulin
Pinches the skin prior to injecting the insulin
Assessing a client who has pulmonary edema. Finding to expect
Pink, frothy sputum-due to fluid leaking across the pulmonary capillaries and into the lung tissue.
Providing care for a client with a colostomy
Place the skin barrier over the stoma and hold it for 30 seconds.
Assessing client who is 11 wks gestation and reports drinking ginger tea. signs of it's effectiveness
The client reports a decrease in episodes of nausea
Caring for a client who is 2 days postpartum. Which behaviors should indicate the client is bonding with newborn
The client tells visitors how much the newborn looks like her sister.
Assessing a 2 wk old newborn with a birth weight of 3.64 kg being breastfed. Indicators of effective breastfeeding
The newborn has 6 to 8 wet diapers per day
Checking for Chvostek's sign
The nurse should assess for a Chvostek's sign by tapping the client's facial nerve about an inch in front of the tragus of the ear. Facial twitching is a positive finding that indicates hypocalcemia.
Nurse administers incorrect dose of medication. Which facts related to incident report should the nurse document in the client's medical record?
Time the medication was given
Caring for a client who asks about taking ginseng to improve her appetite. Identify that ginseng can decrease the effectiveness of which medication.
Timolol
Caring for a client who has hyperthyroidism
Tremors
Caring for a client with a prescription for continuous passive motion machine following total knee arthroplasty
Turn off the CPM machine during mealtime.
Caring for a client reporting nausea and vomiting the past 2 days
Urine specific gravity 1.052
Caring for a newborn immediately after delivery. Which interventions should be implemented to prevent heat loss by conduction?
Use a protective cover on the scale when weighting the infant.
Providing teaching to parents of child with autism spectrum disorder
Use a reward system to modify the child's behavior
Providing teaching for teaching for a client who has a fracture of the right fibula with a short leg cast in place. Client is non weight bearing for 6 weeks.
Use a three-point gait
Providing teaching to a client who speaks a different language than the nurse about an upcoming diagnostic procedure.
Use pictures to illustrate the procedure to the client
A nurse is preparing to administer an IM injection to a client who is obese
Use the ventrogluteal site because it has a thick area of muscle and contains no large nerves or blood vessels.
Preparing to administer a blood transfusion to a client . Ensure proper client identification
Verify the client and blood product information with another licensed nurse
Hospice nurse consulting about receiving home services
We can expect the hospice nurse to provide support for us after our mother's death
Discharge instructions to client to received home oxygen therapy
Wear clothing made with cotton fabrics while oxygen is in use.
Client receiving heparin continuous IV infusion and warfarin 5 mg PO daily. Lab values are aPTT 98 seconds and INR 1.8
Withhold the heparin infusion
Caring for a client who is unconscious and requires emergency medical procedures. Unable to locate family to obtain consent
Proceed with provision of medical care
Reviewing urinalysis report of client with acute glomerulonephritis expected findings
Protein
Caring for an 18-month old toddler who has a blood lead level of 3mcb/dL. Which of the following actions should the nurse take
Recommend re-screening in 1 year
Caring for a client who recently signed informed consent to donate a kidney to her sibling in ERF. States "I don't want my brother to die, but what if I need this kidney one day?"
You afraid that you other kidney will fail at some point after the organ donation
Teaching for client about right to confidentiality
You can provide a list of family members who can receive information about the diagnosis.
Client with major depressive disorder has signed informed consetn for ECT. Client states I'm not sure about this now I'm afraid it's too risky
You have the right to refuse to have the ECT even after you have agreed to it
Assessing a client whose partneer recently died. States I don't know what to do without my partner. Life is not worth living
You seem to be having a difficulty time right now
Conducting visual acuity testing using the Snellen letter chart for a school age child with eyeglasses
You should keep both eyes open during the testing.
Provide teaching to client 24 wks gestation scheduled for glucose tolerance test
You will need to fast the night before the test.
Client teaching about the basal body temp method for birth control
Your body temperature might decrease slightly just prior to ovulation
Caring for a client receiving a continuous heparin infusion. Lab test to review prior to adjusting the client's heparin?
aPTT
Assessing older adult client with pneumonia
acute confusion
Teaching a client 26 wks gestation about a glucose tolerance test.
avoid caffeine
Enters a client's room and sees smoke coming from a small fire in the trash can. Action to take first.
Remove the client from the room
Assessing a client after administering epinephrine for anaphylactic reactions. Identify adverse effect of this med
Report of Chest pain
Client receiving IV fluids of 150 mL/h which indicates fluid overload
dyspnea
Reviewing ABG values of a client. Client has a pH of 7.20, PaCO2 of 60 mmHg, and HCO 3 of 25 mEq/l
Respiratory acidosis
Developing a client education program about osteoporosis for older adult clients
Sedentary lifestyle
Manager planning to use a democratic leadership style. Which of the actions demonstrates democratic leadership style?
Seeks input from the other nurses
Caring for a school age child taking valporic acid. Diagnostic tests
Serum liver enzyme levels
Caring for a child who has hypotonic dehydration and is receiving an oral re-hydration solution. Lab results indicates treatment effective
Serum sodium 136 mEq/L
Providing discharge teaching for preschool age child with a new prescription for Amoxicillian/clavulanate suspension.
Shake the medication bottle well before each dose is given. Report diarrhea to the provider immediately. Store medication in refrigerator
Teaching a client undergoing ECT about adverse effects
Short term memory loss
Nurse preceptor is evaluating the performance of newly licensed nurse. which action should the preceptor intervene on
Starts a task by determining what supplies are needed. Should gather prior to beginning task for effective time management.
Planning care for a client with left sided weakness following a stroke
Support the client's left arm on a pillow while sitting
School nurse is notified of an emergency which several children were injured following the collapse of playground equipment.
Survey the scene for potential hazards to staff and children.
Teaching to school age child with asthma using albuterol dose inhaler instructions
Take the medication 15 min before playing sports
Caring for a client with a prescription of chlorpromazine indications of effectiveness
Decreased hallucinations
Manger preparing an educational session for staff about how to provide cost effective care
Delegate non-nursing tasks to ancillary staff.
Updating the plan of care for a client who is 48 hr post op following laryngectomy and unable to speak. Plan to take first
Determine the client's reading skills
Assessing a client who has had a stroke. For which shoudl the nurse initiate referral for occupational therapy
Difficulty performing ADLs
Caring for a client who is receiving positive end expiratory pressure via mechanical ventilation. Adverse effects of PEEP
Tension pneumothorax
Admitting a client who has pneumonia. Should initiate which type of isolation precautions?
Droplet
Rn observing a LPN and a AP move a client up in bed. When should the nurse intervene
The LPN and the AP grasp the client under his arms to life him up in bed.
Caring for a client with a new prescription of Clonidine. Adverse side effects
Dry mouth
Assessing a preschooler with facial laceration. Identify potential indication of sexual abuse
The child exhibits discomfort while sitting.
Reviewing lab results of a toddler with hemophilia A. Which aPTT values should the nurse expect?
45 seconds
Creating plan of care for child with acute lymphooid leukemia and an absolute netrophil count of 400/mm3
Administer granulocyte colony-stimulating factor to the child
Newly admitted child. Which of the following actions should the nurse include in the plan
Administer high dose antibiotic therapy
Providing teaching to client with peripheral arterial disease. Indications of understanding
Applies lubricating lotion to her feet to prevent cracked skin. Store the medication in the refrigerator.
Providing discharge teaching about disease management for a client who has a new diagnosis of DM. Priority activities
Ensure the client understand the medication regimen. Because this position limits the flow of th instilled solution out of the stomach and prevents aspiration.
Client who has acute blood loss following trauma refuses potentially life saving blood transfusion
Explore the client's reasons fro refusing the treatment
Preparing to teach about dietary management to a client with Crohn's disease with a enteroenteric fistula. Which of the following nutrients should the nurse instruct the client to decrease in his diet
Firber
Assessing a client who has bipolar. Which of the following alterations in speech is the client using
Flight of Ideas
Preparing to transfer a client to a rehab facility who had a stroke Family is concerned about the level of care the client will receive?
Facilitate an interdisciplinary conference at the new facility for the family
Admission assessment on a client who had a recent positive pregnancy test. First day of her last menstrual period was May 8 . Nagel's rule EDB
February 15
Change of shift report informs of newly admitted client with disoriented and combative during the night. Actions the day shift nurse should take
Move the client to a room near the nurses' station.
Home health nurse evaluating a school age child with cystic fibrosis initiates a request for high frequency chest compression vest
My child has only a small amount of mucus after percussion therapy
Inpatient mental health unit is monitoring a visit between client with aggressive behavior and the client's partner
The client is pacing around the chair in which his partner is sitting.
Preparing to transfer a client from ICU to the medical floor. Client was recently weaned from mechanical ventilation follow a pneumonectomy. Information to include in change of shift report
The time of the client's last dose of pain medication. So the receiving nurse can anticipate what time to give the next dose.