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Class 1 Exams

Week One

 

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Nclex Content Review Class One – Week One

Week One Assessment

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1 / 100

A client arrives in the emergency department for treatment of a surface injury sustained when sand blew into the eye. Which action does the nurse take first?

2 / 100

A nurse receives a telephone call from a neighbor, who says that her child was just hit in the eye with a swing. The nurse rushes to the neighbor’s house and notes that the child has sustained a contusion of the eye. The nurse advises the child’s mother to immediately:

3 / 100

A nurse provides home care instructions to a client after a scleral buckling procedure. The nurse should tell the client:

4 / 100

During a client’s yearly eye examination, the nurse checks the intraocular pressure. The nurse notes that the pressure in the right eye is 12 mm Hg and 19 mm Hg in the left. The nurse tells the client:

5 / 100

A nurse is providing discharge instructions to a client after outpatient surgery for cataract removal. The nurse determines that the client needs additional instructions if the client indicates that he will:

6 / 100

A client is transported to the recovery area of the ambulatory care unit after cataract surgery. In which position does the nurse place the client?

7 / 100

A nurse provides home care instructions to a client with Ménière disease about measures to control and treat vertigo. The nurse should tell the client to:

8 / 100

A stapedectomy is performed on a client with otosclerosis. During the preparations for discharge, which home care instruction does the nurse give the client?

9 / 100

A nurse is providing instructions to an unlicensed assistive personnel (UAP) about effective measures for communicating with a hearing-impaired client. The nurse instructs the UAP to:

10 / 100

A nurse provides instructions to a client about measures to prevent an acute attack of gout. The nurse determines that the client needs additional instructions if the client states:

11 / 100

A nurse provides instructions to a client with rheumatoid arthritis about joint exercises that are important to prevent deformity and reduce pain. Which statement by the client indicates the need for further instruction?

12 / 100

A nurse provides home care instructions to a client with a below-the-knee amputation (BKA) about residual limb and prosthesis care. Which statement by the client indicates a need for further instruction?

13 / 100

Buck extension traction is applied to the right leg of a client who sustained a right hip fracture. Which intervention should the nurse include in the plan of care?

14 / 100

A client with a leg fracture who has been placed in skeletal traction is transported to the orthopedic unit after surgery. Which finding would indicate the need to contact the orthopedic specialist?

15 / 100

A client has just had a plaster leg cast applied, and the nurse has given the client instructions on cast care. Which statement by the client indicates the need for further instruction?

16 / 100

A client who sustained a fracture of the left arm requires the application of a plaster cast. The nurse tells the client that the procedure for applying the cast involves:

17 / 100

A client is found to have AIDS. What is the nurse’s highest priority in providing care to this client?

18 / 100

A client arrives at the emergency department with reports of a headache, hives, itching, and difficulty swallowing. The client states that he took ibuprofen (Motrin) 1 hour earlier and believes that he is experiencing an allergic reaction to this medication. After ensuring that the client has a patent airway, which intervention does the nurse prepare the client for first?

19 / 100

A nurse is assessing a client with AIDS for signs of Pneumocystis jiroveci infection. Which sign of the infection is the earliest manifestation?

20 / 100

An emergency department (ED) nurse receives a telephone call from emergency medical services and is told that a client who has sustained severe burns of the face and upper arms is being transported to the ED. Which action does the nurse, preparing for the arrival of the client, plan to implement first?

21 / 100

A nurse is monitoring a client who has just undergone radical neck dissection. The nurse notes that the client’s blood pressure has dropped from 132/84 to 90/50 mm Hg and that the pulse has increased from 78 to 96 beats/min. On the basis of these findings, the nurse immediately:

22 / 100

A client with a spinal cord injury suddenly complains of a pounding headache. The nurse quickly assesses the client and notes that the client is diaphoretic, that his blood pressure has increased, and that his heart rate has slowed. Suspecting that the client is experiencing autonomic dysreflexia, the nurse elevates the head of the client’s bed and immediately:

23 / 100

A nurse is providing home care instructions to a client with Parkinson disease about measures to avoid rigidity and to overcome tremor and bradykinesia. The nurse tells the client to:

24 / 100

A nurse is teaching a client who is experiencing homonymous hemianopsia after a brain attack (stroke) about measures to overcome the deficit. The nurse tells the client to:

25 / 100

A client who is recovering from a brain attack (stroke) has residual dysphagia. Which measure does the nurse plan to implement at mealtimes?

26 / 100

A client who experienced a brain attack (stroke) exhibits right-sided unilateral neglect. The nurse caring for this client plans to place the client’s personal care items:

27 / 100

A nurse answers the call bell of a client who has been fitted with an internal cervical radiation implant, and the client states that she thinks that the implant has fallen out. The nurse checks the client and sees the implant lying in the bed. Which action should the nurse take first?

28 / 100

A female client who has undergone placement of a sealed radiation implant asks the nurse whether she can take a walk around the nursing unit. How should the nurse respond to the client’s request?

29 / 100

A nurse develops a nursing care plan for a client with a sealed radiation implant. Which stipulation does the nurse include in the plan?

30 / 100

The nurse has instructed a client who is about to begin external radiation therapy in how to maintain optimal skin integrity during therapy. Which statement by the client indicates a need for further instruction?

31 / 100

A client with cancer of the larynx is receiving external radiation therapy of the neck. Which side effect related specifically to the site of irradiation does the nurse tell the client to expect?

32 / 100

A nurse is having dinner at a restaurant when a man sitting at the next table collapses and falls to the floor. The nurse yells for help and quickly assesses the client, noting that the client is not breathing and does not have a pulse. The nurse initiates cardiopulmonary resuscitation (CPR) immediately, and the restaurant manager rushes to the scene with an automatic external defibrillator (AED). What should the nurse do next?

33 / 100

A nurse is working in the emergency department. Which client should be assessed first?

34 / 100

A nurse attending a recertification course in basic life support (BLS) for healthcare professionals is practicing BLS on an infant mannequin. Where does the nurse place the fingers to assess the infant’s pulse?

35 / 100

A pediatric nurse finds a hospitalized child unresponsive. A quick assessment reveals that the child is not breathing and does not have a pulse. The nurse initiates cardiopulmonary resuscitation (CPR). How many chest compressions per minute does the nurse deliver?

36 / 100

The nurse is administering cardiopulmonary resuscitation (CPR) to an adult client. Which compression-ventilation ratio is correct?

37 / 100

A nurse arrives at the scene of a code and begins to assist with cardiopulmonary resuscitation (CPR) of an adult. The nurse delivers compressions by pushing down on the chest to a depth of:

38 / 100

A nurse enters a client’s room and finds the client unconscious. The nurse quickly performs an assessment and determines that the client is not breathing. Which action does the nurse take first?

39 / 100

A nurse is caring for a client with Crohn disease whose magnesium level is 1.0 mEq/L (0.5 mmol/L). Which assessment findings does the nurse expect to note? Select all that apply.

40 / 100

A nurse is monitoring a client with hyperparathyroidism for signs of hypercalcemia. For which clinical manifestations, associated with this electrolyte imbalance, does the nurse assess the client? Select all that apply.

41 / 100

A nurse is caring for a client experiencing hyponatremia who was admitted to the medical-surgical unit with fluid-volume overload. For which clinical manifestations of this electrolyte imbalance does the nurse monitor this client? Select all that apply.

42 / 100

A nurse notes that a client’s serum potassium level is 5.8 mEq/L(5.8 mmol/L). The nurse interprets this as an expected finding in the client with:

43 / 100

A healthcare provider writes a prescription for the administration of intravenous (IV) potassium chloride to a client with hypokalemia. What does the nurse plan to do when preparing and administering this medication?

44 / 100

A nurse notes that a client has ST-segment depression on the electrocardiogram (ECG) monitor. With which serum potassium reading does the nurse associate this finding?

45 / 100

A nurse is caring for a client who is being treated for congestive heart failure and has been assigned a nursing diagnosis of excessive fluid volume. Which assessment finding causes the nurse to determine that the client’s condition has improved?

46 / 100

A nurse is reviewing the medical records of the clients to whom she is assigned on the 7 am–7 pm shift. Which client will the nurse monitor most closely for excessive fluid volume?

47 / 100

A client with gastroenteritis who has been vomiting and has diarrhea is admitted to the hospital with a diagnosis of dehydration. For which clinical manifestations that correlate with this fluid imbalance would the nurse assess the client? Select all that apply.

48 / 100

A nurse is assigned to care for four clients on the medical-surgical unit. Which client should the nurse see first on the shift assessment?

49 / 100

A nurse is caring for a client who has undergone pulmonary angiography with catheter insertion through the right femoral vein. The nurse assesses for allergic reaction to the contrast medium by monitoring for the presence of which?

50 / 100

A client who has just undergone bronchoscopy was returned to the nursing unit 1 hour ago. With which assessment finding is the nurse most concerned?

51 / 100

A client has just undergone insertion of a chest tube that is attached to a closed chest drainage system. Which action should the nurse plan to take in the care of this client?

52 / 100

A nurse is reading the radiology report of a client with a chest tube attached to a closed drainage system who has undergone a chest x-ray. The report states that the client’s affected lung is fully reexpanded. The nurse anticipates that the assessment of the chest tube system will reveal which finding?

53 / 100

A nurse is monitoring the respiratory status of a client who has just undergone surgery and is wearing a pulse oximeter. Which coexisting problem is cause for the nurse to suspect that the oxygen saturation readings are not entirely accurate?

54 / 100

A nurse is performing nasotracheal suctioning on a client. Which observations should be cause for concern to the nurse? Select all that apply.

55 / 100

A client has a chest drainage system in place. The fluid in the water seal chamber rises and falls during inspiration and expiration. The nurse interprets this finding as an indication of which?

56 / 100

A client who experienced the sudden onset of respiratory distress has been intubated with an endotracheal tube. After the tube is placed in the trachea, the nurse should take which immediate action?

57 / 100

Oxygen by way of nasal cannula has been prescribed for a client with emphysema. The nurse checks the health care provider’s prescriptions to ensure that the prescribed flow is not greater than which liter (L) per minute (min)?

58 / 100

A nurse is watching as a nursing student suctions a client through a tracheostomy tube. Which actions on the part of the student would prompt the nurse to intervene and demonstrate correct procedure? Select all that apply.

59 / 100

A nurse is watching as an unlicensed assistive personnel (UAP) measure the blood pressure (BP) of a hypertensive client. Which actions on the part of the UAP would interfere with accurate measurement and prompt the nurse to intervene? Select all that apply.

60 / 100

A client has undergone pericardiocentesis to treat cardiac tamponade. For which signs should the nurse assess the client to determine whether the tamponade is recurring?

61 / 100

A nurse has a prescription to apply a Holter monitor to a client for continuous cardiac monitoring for a 24-hour period. What steps should the nurse take to initiate this prescription? Select all that apply

62 / 100

A nurse has a prescription to apply a Holter monitor to a client for continuous cardiac monitoring for a 24-hour period. What steps should the nurse take to initiate this prescription? Select all that apply

63 / 100

A nurse in a health care provider’s office has just made an appointment for a client to undergo an exercise stress test. The nurse, in providing pre-procedure teaching, should provide which information to the client?

64 / 100

A client who has sustained a myocardial infarction is scheduled to have an echocardiogram. Which measure should the nurse take before the procedure?

65 / 100

A nurse provides information to a client who is scheduled for cardiac catheterization to rule out coronary occlusion. The nurse should provide which information to the client?

66 / 100

A nurse reviews a client’s urinalysis report. Which finding does the nurse recognize as abnormal?

67 / 100

A client has undergone renal angiography by way of the right femoral artery. The nurse determines that the client is experiencing a complication of the procedure on noting which finding?

68 / 100

A client who has undergone renal biopsy complains of pain, radiating to the front of the abdomen, at the biopsy site. For which finding should the nurse assess the client?

69 / 100

A nurse is preparing a client for intravenous pyelography (IVP). Which action by the nurse is most important?

70 / 100

A nurse has a prescription to collect a 24-hour urine specimen from a client. Which measure should the nurse take during this procedure?

71 / 100

A client has just undergone a renal biopsy. Which intervention should the nurse include in the post-procedure plan of care?

72 / 100

A CD4+ lymphocyte count is performed on a client who is infected with HIV. The results of the test indicate a CD4+ count of 450 cells per cubic millimeter of blood. The nurse interprets this test result as indicating which?

73 / 100

A client is tested for HIV with the use of an enzyme-linked immunosorbent assay (ELISA), and the test result is positive. The nurse should provide which information to the client about the test?

74 / 100

A nurse is providing post-procedure instructions to a client returning home after arthroscopy of the shoulder. The nurse should provide the client with which information?

75 / 100

A nurse is providing post-procedure instructions to a client returning home after arthroscopy of the shoulder. The nurse should provide the client with which information?

76 / 100

Blood is drawn from a male client with suspected uric acid calculi for a serum uric acid determination. Which value does the nurse recognize as a normal uric acid level?

77 / 100

A client reports for a scheduled electroencephalogram (EEG). Which statement by the client indicates a need for additional preparation for the test?

78 / 100

A client has just returned to the nursing unit after computerized tomography (CT) with contrast medium. Which action should the nurse plan to take as part of routine after-care for this client?

79 / 100

A client has just undergone lumbar puncture. Into which position does the nurse assist the client after the procedure?

80 / 100

A client has been scheduled for magnetic resonance imaging (MRI). For which condition, a contraindication to MRI, does the nurse check the client’s medical history?

81 / 100

A client who underwent preadmission testing 1 week before surgery had blood drawn for several serum laboratory studies. Which abnormal laboratory results should the nurse report to the surgeon’s office? Select all that apply.

82 / 100

A client without a history of respiratory disease has a pulse oximeter in place after surgery. The nurse monitors the pulse oximeter readings to ensure that oxygen saturation remains above which value?

83 / 100

A nurse receives a telephone call from a nurse on the post-anesthesia care unit, who reports that a client is being transferred to the surgical unit. What should the nurse plan to do first on arrival of the client?

84 / 100

A nurse is preparing a client for transfer to the operating room. Which action should the take in the care of this client at this time?

85 / 100

A nurse administers scopolamine as prescribed to a client. For which side effect of this medication does the nurse monitor the client?

86 / 100

A client in the postanesthesia care unit has an as-needed prescription for ondansetron. Which occurrence would prompt the nurse to administer this medication to the client?

87 / 100

A nurse is caring for a client who has just regained bowel sounds after undergoing surgery. The health care provider has prescribed a clear liquid diet for the client. Which item does the nurse ensure is available in the client’s room before allowing the client to drink?

88 / 100

A client recovering from surgery has a large abdominal wound. Which food, high in vitamin C, should the nurse encourage the client to eat as a means of promoting wound healing?

89 / 100

A nurse is assessing the chest tube drainage system of a postoperative client who has undergone a right upper lobectomy. The closed drainage system contains 300 mL of bloody drainage, and the nurse notes intermittent bubbling in the water seal chamber. One hour after the initial assessment, the nurse notes that the bubbling in the water seal chamber is now constant, and the client appears dyspneic. On the basis of these findings, what should the nurse assess first?

90 / 100

A nurse is preparing for intershift report when an unlicensed assistive personnel (UAP) pulls an emergency call light in a client’s room. Upon answering the light, the nurse finds a client who returned from surgery earlier in the day experiencing tachycardia and tachypnea. The client’s blood pressure is 88/60 mm Hg. Which action should the nurse take first?

91 / 100

A nurse is getting a client out of bed for the first time since surgery. The nurse raises the head of the bed, and the client complains of dizziness. Which action should the nurse take first?

92 / 100

A nurse is assessing a postoperative client on an hourly basis. The nurse notes that the client’s urine output for the past hour was 25 mL. On the basis of this finding, the nurse should take which action first?

93 / 100

A nurse assesses the closed chest tube drainage system of a client who underwent lobectomy 24 hours ago. The nurse notes that there has been no chest tube drainage for the past hour.
Which action should the nurse take first?

94 / 100

A nurse is suctioning a client through a tracheostomy tube. During the procedure, the client begins to cough, and the nurse hears a wheeze. The nurse tries to remove the suction catheter from the client’s trachea but is unable to do so. Which action should the nurse take first?

95 / 100

A nurse performing nasopharyngeal suctioning and suddenly notes the presence of bloody secretions. Which action should the nurse take first?

96 / 100

A nurse is helping a client with a closed chest tube drainage system get out of bed and into a chair. During the transfer, the chest tube is caught on the leg of the chair and dislodged from the insertion site. What is the immediate nursing action?

97 / 100

A nurse is assessing a client who has a closed chest tube drainage system. The nurse notes constant bubbling in the water seal chamber. What actions should the nurse take? (Select all that apply).

98 / 100

A client who has just undergone surgery suddenly experiences chest pain, dyspnea, and tachypnea. The nurse suspects that the client has a pulmonary embolism and immediately sets about to take which action?

99 / 100

A client who just returned from the recovery room after a tonsillectomy and adenoidectomy is restless and the pulse rate is increased. As the nurse continues the assessment, the client begins to vomit a copious amount of bright-red blood. The nurse should take which immediate action?

100 / 100

A client who has undergone abdominal surgery calls the nurse and reports that she just felt “something give way” in the abdominal incision. The nurse checks the incision and notes the presence of wound dehiscence. The nurse should take which immediate action?

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Week Two

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Nclex Content Review Class One – Week Two

Week Two Assessment

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User Information

1 / 96

A nurse is assisting a client with a closed chest tube drainage system in bathing. As the nurse is turning the client onto his side, the chest tube is disconnected. What should the nurse do first?

2 / 96

A nurse is performing suctioning through an adult client’s tracheostomy tube. The nurse notes that the client’s oxygen saturation is 89% and terminates the procedure. Which action would the nurse take next?

 

3 / 96

A client whose right leg is in skeletal traction complains of pain in the leg. Which action should the nurse take first?

 

4 / 96

A nurse is reading the nurse practice act for the state in which she is employed. The nurse uses the information in this act to:

 

5 / 96

A nurse is reviewing the notes written by a nurse on a previous shift. Which note in the client’s record reflects the correct use of guidelines for documentation?

 

6 / 96

A nurse is supervising a new nursing graduate in various procedures. Which of the following actions by the new nursing graduate constitutes a negligent act?

 

7 / 96

An 18-year-old client is brought to the emergency department (ED) by emergency medical services after sustaining life-threatening injuries in an automobile accident. The client is unconscious and requires an emergency splenectomy. A nurse in the ED assists in quickly preparing the client for surgery and tries to contact the client’s parents but is unsuccessful. In regard to informed consent for the surgery:

 

8 / 96

A 17-year-old client arrives at the clinic and asks to be examined because she believes that she has contracted a sexually transmitted infection. In regard to informed consent, the nurse tells the client that:

9 / 96

The nurse notes that a health care provider has documented the following prescription in a client’s record: Furosemide (Lasix) 40 mg stat once. What action should the nurse take?

10 / 96

A nurse manager discusses staff empowerment with the nursing team. The nurse manager explains that staff empowerment:

 

11 / 96

A nurse employed at a hospital is asked by a nurse manager to review the organizational chart. The nurse reviews the chart so that he will:

 

 

12 / 96

An emergency department nurse is performing an assessment of a client who has sustained circumferential burns of both legs. What should the nurse assess first?

 

13 / 96

A health care provider asks the nurse who is caring for a client with a new colostomy to ask the hospital’s stoma nurse to visit the client and assist the client with care of the colostomy. The nurse initiates the consultation, understanding that the stoma nurse will be able to influence the client because of his:

14 / 96

A nurse is preparing to administer medications to a client by way of a nasogastric (NG) tube. Before administering the medication, the nurse must first:

15 / 96

A client with terminal cancer is receiving a continuous intravenous infusion of morphine sulfate. On assessment of the client, what does the nurse check first?

 

16 / 96

A client with a left arm fracture complains of severe diffuse pain that is unrelieved by pain medication. On further assessment, the nurse notes that the client experiences increased pain during passive motion, compared with active motion, of the left arm. On the basis of these assessment findings, which action should the nurse take first?

 

17 / 96

A nurse who works in a medical care unit is told that she must float to the intensive care unit because of a short-staffing problem on that unit. The nurse reports to the unit and is assigned to three clients. The nurse is angry with the assignment because she believes that the assignment is more difficult than the assignment delegated to other nurses on the unit and because the intensive care unit nurses are each assigned only one client. The nurse should most appropriately:

 

18 / 96

A client receives cefazolin sodium (Ancef) by way of the intravenous route. During the infusion, the client begins exhibiting signs of an allergic reaction. The client states that his skin is itchy, and the nurse notes that the skin is warm and flushed, with a red rash on the arms, chest, and back. The nurse immediately discontinues the medication, further assesses the client, contacts the physician, and begins to document the reaction in an incident report. The nurse most accurately documents which of the following?

 

19 / 96

A nurse leader in a medical-surgical unit overhears the nursing staff openly discussing a client and stating that the client is “uncooperative and a real pain to care for.” The nurse leader would most appropriately manage this issue by:

20 / 96

A nurse sees another nurse changing an intravenous (IV) solution because the wrong solution is infusing into the client. The nurse who changed the IV solution does not report the error. What should the nurse who observed the error do first?

 

21 / 96

A client has signed the informed consent for mastectomy of the left breast. On the morning of the surgical procedure, the client asks the nurse several questions about the procedure that make it obvious that she has does not have an adequate comprehension of the procedure. What is the most appropriate response by the nurse?

 

22 / 96

A nurse is preparing the client assignments for the day. One of the registered nurses on the team has just learned that she is pregnant. Which client does the nurse refrain from assigning to the pregnant team member?

 

23 / 96

A nursing staff member approaches a nurse manager and announces that another nurse is not using alcohol swabs to clean the intravenous port when administering intravenous push medications. What is the appropriate way for the nurse manager to handle this situation?

24 / 96

A nurse manager notes that an employee is constantly calling in sick. Which action should the nurse manager take initially to handle this problem?

 

25 / 96

A health care provider repeatedly asks a nurse to write his verbal prescriptions in his clients’ charts after he makes his rounds. The nurse is uncomfortable with writing the prescriptions and explains this to the physician, but the health care provider tells the nurse that she will be reported if she does not write the prescriptions. How should the nurse manage this conflict?

26 / 96

A nurse who has been employed in a hospital for 8 weeks is consistently taking extended lunch breaks. The nurse’s behavior has caused problems with client care during lunch hours. What is the appropriate way for the nurse manager to deal with this situation?

 

27 / 96

A nurse manager arrives at work and is immediately faced with several activities that require his attention. Which activity will the nurse manager attend to first?

 

28 / 96

A nurse manager asks a nurse to work overtime because of a short-staffing problem. The nurse has made plans to do her Christmas shopping after work and does not want to work overtime. What is the most assertive response by the nurse to her nurse manager?

 

29 / 96

A nurse is preparing for the admission of a client with pulmonary tuberculosis. Which of the following actions reflects the use of evidence-based practice in the care of the client?

 

30 / 96

Which of the following situations is an example of the use of evidence-based practice in the delivery of client care?

31 / 96

In which situation is the nurse upholding the ethical principle of fidelity?

32 / 96

A nurse educator describes the standards of care formulated by the American Nurses Association to a group of new nursing graduates hired by the hospital. Which of the following options are accurate descriptions of these standards of care? Select all that apply.

33 / 96

A registered nurse is in charge of the emergency department (ED) during the night shift. A client arrives at the ED for treatment after a sexual assault. The nurse has never cared for anyone who has been raped. To determine the necessary actions in regard to this client’s injury, the nurse should:

 

34 / 96

A nursing instructor asks a nursing student to describe accountability. Which statement(s) by the student indicate(s) an accurate description of accountability? Select all that apply.

35 / 96

A nurse employed in a community hospital as a nurse manager understands that in this position, the term authority most appropriately refers to:

36 / 96

A nurse, newly employed by a home health agency, is told that the organization’s decision-making process is centralized. The nurse determines that this means that the authority to make decisions is vested in:

37 / 96

A new nurse employed at a community hospital is reading the organization’s mission statement. The new nurse understands that this statement:

38 / 96

A nurse is assisting a new nursing graduate with organizational skills in delivering client care. The nurse determines that the new nursing graduate needs assistance with time management if he:

 

39 / 96

A nurse is planning the client assignments for the shift. Which client should the nurse assign to the nursing assistant?

40 / 96

A nurse is assigned to care for four clients. Which client should the nurse assess first?

 

41 / 96

A nurse is planning client assignments for the day. Which of the following assignments is the least appropriate for the nursing assistant?

42 / 96

A client with diabetes mellitus who takes a daily dose of NPH insulin has a hard time drawing the insulin into a syringe because he has difficulty seeing the markings on the syringe. To which of the following services does the nurse suggest a referral?

 

43 / 96

A case manager is reviewing notations made in clients’ records. Which note indicates an unexpected outcome and the need for immediate follow-up?

44 / 96

A client who had a stroke has left-side weakness and is having difficulty holding utensils while eating. To which of these services does the nurse suggest a referral?

45 / 96

A registered nurse (RN) must determine how best to assign co–workers (another RN and one licensed practical nurse [LPN]) to provide care to a group of clients. Which of the following is the best assignment?

46 / 96

A nurse manager is planning client assignments for the day. Which of the following clients should the nurse assign to the nursing assistant (unlicensed assistive personnel)?

47 / 96

A nurse manager tells the nursing staff that they will need to comply with the mandatory overtime policy that the hospital has implemented. Later that day, the nurse manager overhears a nurse complaining about the policy and telling other nurses that she will not work the overtime if she has made other plans after her regular shift. What is the best approach for the nurse manager to use in dealing with the conflict?

48 / 96

The nurse is preparing client assignments for the day. Which client should the nurse assign to a nursing assistant?

49 / 96

A graduate nurse hired to work in a medical unit of a hospital is attending an orientation session. The nurse educator, discussing care maps, asks the graduate nurse whether she understands how a care map is used. Which response indicates understanding?

50 / 96

A registered nurse (RN) is watching as a new licensed practical nurse (LPN) administer an intramuscular (IM) injection in a client’s deltoid muscle. The RN determines that the LPN is performing the procedure correctly if the LPN:

51 / 96

A registered nurse (RN) is supervising a nursing assistant ambulating a client with right-sided weakness. The RN would conclude that the nursing assistant is performing the procedure incorrectly after observing that the nursing assistant:

52 / 96

A nurse planning care for her assigned clients understands that the purpose of the hospital’s standards of care is to:

53 / 96

A case manager is serving on a community task force on violence in schools. The members of the task force are planning to develop interventions to help prevent violence. According to the nursing process, the first activity that the nurse would suggest to the task force is:

54 / 96

A case manager is reviewing the records of the clients in the nursing unit. Which note(s) in a client’s record indicate an unexpected outcome and the need for follow-up? Select all that apply.

55 / 96

A registered nurse (RN) has received the assignment for the day shift. Once the RN has made initial rounds and checked all of the assigned clients, which client will she plan to care for first?

56 / 96

A registered nurse (RN) is planning assignments for five clients on the nursing unit. The team includes a licensed practical nurse (LPN) and a nursing assistant. Which clients should the nurse assign to the LPN? Select all that apply.

57 / 96

A registered nurse (RN) is planning client assignments for the day. Which clients should the nurse assign to a nursing assistant (unlicensed assistive personnel)? Select all that apply.

58 / 96

A nurse manager has announced a change to computerized documentation of nursing care. A licensed practical nurse (LPN) on the team, resistant to the change, is not taking an active part in facilitating implementation of the new procedure. Which of the following strategies would be the best approach to dealing with the conflict?

59 / 96

The nurse reviewing a client’s record sees that the following medications are prescribed. Which medication should the nurse plan to administer first?
Client Medications
1. Atorvastatin (Lipitor) 10 mg orally
2. Zolpidem (Ambien) 5 mg orally daily
3. Ferrous sulfate (Feosol) 1 tablet orally
4. Levothyroxine (Synthroid) 137 mg orally

60 / 96

A case manager is reviewing progress notes in a client’s medical record. Which notation indicates the need for follow-up?

S/NoClient ConditionNotation
1.Client 1
Status post–mastectomy:18 hours		Five milliliters of bloody drainage was emptied from the Jackson–Pratt drain.
2.Client 2
Heart Failure		Crackles were heard in the lower lung lobes bilaterally on auscultation.
3.Client 3
Status post–appendectomy: 24 hours		The surgical dressing is clean and dry.
4.Client 4
Diabetes mellitus		 Blood glucose level is is124 mg/dL (6.9 mmol/L).

61 / 96

A nurse has delegated several nursing tasks to staff members. The nurse’s primary responsibility after delegation of the tasks is:

62 / 96

A nurse working the 7 am–to–3 pm shift is reviewing the records of her assigned clients. Which client should the nurse assess first?

63 / 96

A nurse is providing a change-of-shift report on his assigned clients, using an audiotape. Which of the following pieces of information should the nurse include in the report about each assigned client? Select all that apply.

64 / 96

A registered nurse (RN) in charge of a long-term care facility who is working with a nursing assistant on the night shift prepares to take her break. To ensure client safety during her break, which of the following actions should the nurse take? Select all that apply.

65 / 96

A registered nurse (RN) who has a licensed practical nurse (LPN) and a nursing assistant on the nursing team is planning client assignments for the day. Which of the following clients should the RN assign to the LPN?

66 / 96

A registered nurse (RN) is planning client assignments for the day. Which of the following clients should the RN assign to the nursing assistant?

67 / 96

A client admitted to the hospital has a do-not-resuscitate (DNR) order in his medical record. The nurse understands that:

68 / 96

A man who is visiting his wife in a long-term care facility for people with Alzheimer’s disease collapses and is transported to a hospital. The client remains unconscious, and testing reveals that he has cancer that has metastasized to bone, brain, and liver. The nursing staff at the wife’s care facility report to the hospital health care provider that the client has no other family members and that his wife is mentally incompetent. What information regarding do-not-resuscitate (DNR) orders does the nurse remember?

69 / 96

A 51-year-old client with amyotrophic lateral sclerosis (Lou Gehrig’s disease) is admitted to the hospital because his condition is deteriorating. The client tells the nurse that he wants a do-not-resuscitate (DNR) order. The nurse should tell the client that:

70 / 96

A health care provider informs a nurse that the husband of an unconscious client with terminal cancer will not grant permission for a do-not-resuscitate (DNR) order. The health care provider tells the nurse to perform a “slow code” and let the client “rest in peace” if she stops breathing. How should the nurse respond?

71 / 96

A nurse on the night shift is making client rounds. When the nurse checks a client who is 97 years old and has successfully been treated for heart failure, he notes that the client is not breathing. If the client does not have a do-not-resuscitate (DNR) order, the nurse should:

72 / 96

A nurse is taking a morning break with the unit secretary in the nurses’ lounge. The unit secretary says to the nurse, “I read in Mr. Gage’s medical record that he has gonorrhea.” How should the nurse respond to the secretary?

73 / 96

A married couple is attending a hospital program about in vitro fertilization. During the program, a crew from a local television station arrives to film the proceedings because the station is publicizing a series on hospital services. The nurse conducting the program should:

74 / 96

A client with cancer is transported to the radiology department for a bone scan to determine whether the cancer has metastasized to bone. While the client is in the radiology department, the client’s wife arrives for a visit and asks what test is being performed on the client. What should the nurse tell the wife?

75 / 96

A nursing student is assigned to care for a client who requires a total bed bath. When the student explains to the client that she is going to gather supplies to administer the bath, the client states, “I don’t want a bath. I’ve been up all night, and I’m clean enough.” The student reports the client’s refusal to the nurse in charge. Which action by the nurse in charge is appropriate?

 

76 / 96

The nurse enters a client’s room to administer a medication that has been prescribed by the health care provider. The client asks the nurse about the medication. Which response by the nurse is appropriate?

77 / 96

A client asks the nurse about the procedure for becoming an organ donor. What should the nurse tell the client?

78 / 96

The charge nurse on the 11 pm–to–7 am shift is gathering the nursing staff together to listen to the 3-to-11 pm intershift report. The charge nurse notes that a staff member has an odor of alcohol on her breath, slurred speech, and an unsteady gait and suspects alcohol intoxication. Which is the most appropriate action for the charge nurse to take?

79 / 96

The nurse calls a health care provider to question a prescription written for a higher-than-normal dosage of morphine sulfate. The health care provider changes the prescription to a dosage within the normal range, and the nurse documents the new telephone prescription in accordance with the agency’s guidelines in the client’s record. Which other statement does the nurse document in the nursing notes?

80 / 96

The nurse discovers that another nurse has administered an enema to a client even though the client told the nurse that he did not want one. Which action is the most appropriate for the nurse to take?

81 / 96

The nurse is planning to administer an oral antibiotic to a client with a communicable disease. The client refuses the medication and tells the nurse that the medication causes abdominal cramping. The nurse responds, “The medication is needed to prevent the spread of infection, and if you don’t take it orally I will have to give it to you in an intramuscular injection.” Which statement accurately describes the nurse’s response to the client?

82 / 96

A client scheduled for surgery tells the nurse that he signed an informed consent for the surgical procedure but was never told about the risks of the surgery. The nurse serves as the client’s advocate by taking which action?

83 / 96

A nurse is assisting a health care provider in assessing a hospitalized client. During the assessment, the health care provider is paged to report to the recovery room. The health care provider leaves the client’s bedside after giving the nurse a verbal prescription to change the solution and rate of the intravenous (IV) fluid being administered. What is the appropriate nursing action in this situation?

84 / 96

The nurse calls a health care provider to report that a client with congestive heart failure (CHF) is exhibiting dyspnea and worsening of wheezing. The health care provider, who is in a hurry because of a situation in the emergency department, gives the nurse a telephone prescription for furosemide (Lasix) but does not specify the route of administration. What is the appropriate action on the part of the nurse?

85 / 96

The nurse monitoring a client with a chest tube notes that there is no tidaling of fluid in the water seal chamber. After further assessment, the nurse suspects that the client’s lung has reexpanded and notifies the health care provider. The health care provider verifies with the use of a chest x-ray that the lung has reexpanded, then calls the nurse to asks that the chest tube be removed. Which action should the nurse take first?

86 / 96

A health care provider writes a medication prescription in a client’s record. While transcribing the prescription, the nurse notes that the prescribed dose is three times higher than the recommended dose. The nurse calls the health care provider, who states that this is the dose that the client takes at home and that it is acceptable for this client’s condition. What is the appropriate action for the nurse to take?

87 / 96

The nurse preparing a client to go to the radiology department for a chest x-ray notes that the client is wearing a religious medal on a chain around the neck. The client, a Catholic, expresses a concern about removing the medal. What is the most appropriate action for the nurse to take?

88 / 96

The nurse providing preoperative care to a client who is scheduled for a left mastectomy and axillary lymph node dissection notes that the client is wearing a wedding band on her left ring finger. Which action should the nurse take?

89 / 96

The nurse preparing a client for a bronchoscopy notes that the client is wearing a gold necklace. What should the nurse do to safeguard the client’s necklace?

90 / 96

The nurse manager of a quality improvement program asks a nurse in the neurological unit to conduct a retrospective audit. Which action should the auditing nurse plan to perform in this type of audit?

91 / 96

The registered nurse has accepted a new position as case manager in a hospital. Which responsibilities are part of the nurse’s new role? Select all that apply.

92 / 96

Which action exemplifies the use of evidence-based practice in the delivery of client care?

93 / 96

The nurse and an unlicensed assistive personnel (UAP)enter a client’s room to provide care and find the client lying on the floor. Which action should the nurse take first?

94 / 96

The nursing instructor asks a student to name an example of false imprisonment. Which situation reflects a violation of this client right?

95 / 96

Which action by the nurse represents the ethical principle of beneficence?

96 / 96

A client with leukemia is being considered for a bone marrow transplant. The healthcare team is discussing the risks and benefits of this treatment and other possible treatments with the goal of inflicting the least possible harm on the client. Which principle of healthcare ethics is the team practicing?

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Week Three

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Nclex Content Review Class One – Week Three

Week Three Assessment

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1 / 96

A prescription is written to administer hepatitis B vaccine (Recombivax HB) to a newborn infant. Before administering the vaccine, which action should the nurse take?

2 / 96

A nurse is assessing a newborn infant for jaundice. Which action should the nurse take to assess the infant for its presence?

3 / 96

A new mother who is breastfeeding her newborn calls the nurse at the pediatrician’s office and reports that her infant is passing mustard-yellow stools. What should the nurse tell the mother?

4 / 96

The mother of a newborn who was circumcised before discharge from the hospital calls the nurse at the pediatrician’s office and tells the nurse that she is concerned because she has noticed a yellow crust over the circumcision site. Which instruction should the nurse give the mother?

5 / 96

A nurse demonstrates the procedure for bathing a newborn to a new mother. The next day, the nurse watches as the mother bathes the infant. The nurse determines that the mother is performing the procedure correctly if she performs which action?

6 / 96

A newborn infant’s blood glucose level is analyzed by the laboratory. The laboratory staff calls the nurse and reports that the blood glucose level is 40 mg/dL(2.2 mmol/L).   Based on this result, which action should the nurse take first?

7 / 96

Intramuscular phytonadione (vitamin K) 0.5 mg is prescribed for a newborn. After the medication is prepared, in which anatomical site does the nurse administer it?

8 / 96

A nurse in the pediatrician’s office is checking the Babinski reflex in a 3-month-old infant. The nurse determines that the infant’s response is normal if which finding is noted?

9 / 96

A nurse in the newborn nursery, performing an assessment of a newborn, prepares to measure the chest circumference. Where should the nurse place the tape measure?

10 / 96

A nurse monitoring a newborn infant notes that the infant’s respirations are 40 breaths per minute. Based on this finding, what is the most appropriate action for the nurse to take?

11 / 96

A nurse calculates a newborn infant’s Apgar score 1 minute after birth and determines that the score is 6. The nurse should take which most appropriate action?

12 / 96

A nurse, monitoring a client in the fourth stage of labor, checks the client’s vital signs every 15 minutes. The nurse notes that the client’s pulse rate has increased from 70 to 100 beats per minute. Based on this finding, which priority action should the nurse take?

13 / 96

A postpartum nurse provides information to a new mother who is being discharged from the maternity unit about signs and symptoms that should be reported to her health care provider. Which statement by the mother indicates a need for further information?

14 / 96

A woman who delivered a healthy newborn 6 hours earlier complains of discomfort at the episiotomy site. Which action by the nurse is the most appropriate?

15 / 96

A nurse is monitoring the amount of lochia drainage on a perineal pad in a woman who is 1 hour postpartum and notes a 5-inch (12.5 cm) bloodstain (see figure). How does the nurse report the amount of lochial flow?

Question Image

16 / 96

A nurse is taking the vital signs of a woman who delivered a healthy newborn 1 hour ago. The nurse notes that the woman’s radial pulse rate is 55 beats per minute. Based on this finding, which action by the nurse is most appropriate?

17 / 96

Immediately after delivery, the nurse assesses the woman’s uterine fundus. At what location does the nurse expect to be able to palpate the fundus?

18 / 96

A nurse is monitoring a woman who is receiving oxytocin (Pitocin) to induce labor. Which action should the nurse, on suddenly noting the presence of late decelerations on the fetal heart rate (FHR) monitor, take first?

19 / 96

A woman receives a subarachnoid (spinal) block for a cesarean delivery. For which adverse effect of the block does the postpartum nurse monitor the woman?

20 / 96

A woman in labor whose cervix is not completely dilated is pushing strenuously during contractions. Which method of breathing should the nurse encourage the woman to perform to help her overcome the urge to push?

21 / 96

A nurse notes the presence of variable decelerations on the fetal heart rate monitor strip and suspects cord compression. Which action should the nurse take immediately?

22 / 96

A nurse monitoring a client in labor notes this fetal heart rate pattern (refer to figure) on the electronic fetal monitoring strip. Which is the most appropriate nursing action?

23 / 96

A client in labor complains of back discomfort. Which position will best aid in relieving the discomfort?

 

24 / 96

A nurse is caring for a pregnant client in the labor unit who suddenly experiences spontaneous rupture of the membranes. On inspecting the amniotic fluid, the nurse notes that it is clear, with creamy white flecks. What is the most appropriate action for the nurse to take based on this finding?

25 / 96

A nurse is taking the vital signs of a pregnant client who has been admitted to the labor unit. The nurse notes that the client’s temperature is 100.6° F (38.1°C), the pulse rate is 100 beats per minute, and respirations are 24 breaths per minute. Based on these findings, what is the most appropriate nursing action?

26 / 96

A nurse performs a nonstress test on a pregnant client. The nurse determines that the results are nonreactive if which finding is noted on the electronic monitoring recording strip?

27 / 96

An amniocentesis is scheduled for a pregnant client who is in the third trimester of pregnancy. The nurse tells the client that the most common indication for amniocentesis during the third trimester is which?

28 / 96

A pregnant client is scheduled to undergo a transabdominal ultrasound, and the nurse provides information to the client about the procedure. What should the nurse tell the client?

29 / 96

A nurse is teaching a pregnant client about nutrition and food sources that are high in folic acid. Which food item does the nurse tell the client contains the highest amount of folic acid?

30 / 96

A Muslim woman and her husband are seen in the health care clinic because the woman suspects that she is pregnant. When planning for the physical assessment of the woman, which should the nurse ensure?

31 / 96

A pregnant client tells the nurse that she has a 2-year-old child at home and expresses concern about how the toddler will adapt to a newborn infant being brought into the home. Which statement is the most appropriate response for the nurse to make to the client?

32 / 96

A nurse is telling a pregnant client about the signs that must be reported to the health care provider or nurse-midwife. The nurse tells the client that the health care provider or nurse-midwife should be contacted if which occurs?

33 / 96

A pregnant client asks a nurse about the use of noninvasive acupressure as a complementary alternative therapy to relieve nausea. What should the nurse tell the client?

34 / 96

A nurse provides information to a pregnant client with hemorrhoids about measures that will alleviate her discomfort. Which actions does the nurse tell the client to take? Select all that apply.

35 / 96

The nurse provides information to a pregnant client who is experiencing nausea and vomiting about measures to relieve the discomfort. Which statement by the mother indicates the need for further information?

36 / 96

A multigravida pregnant woman asks the nurse when she will start to feel fetal movements. Around which week of gestation does the nurse tell the mother that fetal movements are first noticed?

37 / 96

A hepatitis B screen is performed on a pregnant client, and the results indicate the presence of antigens in the client’s blood. Based on this finding, what does the nurse determine?

38 / 96

A rubella titer is performed on a pregnant client, and the results indicate a titer of less than 1:8. What should the nurse tell the client?

39 / 96

A nurse is determining the estimated date of delivery for a pregnant client, using Nägele’s rule, and notes documentation that the date of the client’s last menstrual period was August 30, 2015. When does the nurse determine the estimated date of delivery to be?

40 / 96

A client is pregnant for the sixth time. She tells the nurse that she has had three elective first-trimester abortions and that she has a son who was born at 40 weeks’ gestation and a daughter who was born at 36 weeks’ gestation. In calculating the gravidity and para (parity), what does the nurse determine?

41 / 96

A nurse-midwife, performing a vaginal examination of a client who suspects that she is pregnant, documents the presence of the Chadwick sign. The nurse reads the client’s record and interprets this sign as indicating which?

42 / 96

A nurse is assessing a fetal heart rate (FHR) and notes accelerations from the baseline rate when the fetus is moving. How should the nurse interpret this finding?

43 / 96

A nurse is assessing a fetal heart rate (FHR) and places the fetoscope on the mother’s abdomen to count the FHR. The nurse simultaneously palpates the mother’s radial pulse and notes that it is synchronized with the sounds heard through the fetoscope. Which action should the nurse take?

44 / 96

A nurse is preparing to auscultate a fetal heart rate (FHR). The nurse performs the Leopold maneuvers to determine the position of the fetus and then places the fetoscope over which area?

45 / 96

A nurse auscultating the fetal heart rate (FHR) of a pregnant client in the first trimester of pregnancy notes that the FHR is 160 beats per minute. Which action should the nurse take?

46 / 96

A nurse is preparing to assess the fetal heart rate (FHR) of a client who is 14 weeks pregnant. Which piece of equipment does the nurse use to assess the FHR?

47 / 96

A nurse is caring for a client who has undergone resection of an abdominal aortic aneurysm (AAA). Which action should the nurse implement to prevent graft occlusion?

48 / 96

A nurse is caring for a hospitalized client who is undergoing peritoneal dialysis. The nurse notes that the outflow is less than the inflow on the first exchange. What should the nurse do first?

49 / 96

A client has an arteriovenous fistula in place for hemodialysis. What should the nurse do to assess the patency of the fistula?

50 / 96

A hospitalized client with chronic renal failure has returned to the nursing unit after a hemodialysis treatment. Which parameters contained in the predialysis and postdialysis documentation does the nurse utilize to determine if the procedure was effective?

51 / 96

A nurse is monitoring a client after transurethral resection of the prostate for benign prostatic hypertrophy. The client has a bladder irrigation infusing, and the urine output is a light cherry color. The nurse performs a follow-up assessment 1 hour later and notes that the urine output is now bright red in color with clots and that the client’s blood pressure has dropped. Which action by the nurse is appropriate?

52 / 96

A nurse is monitoring a client with deep vein thrombosis (DVT) for signs of pulmonary embolism. For which sign of DVT, the most common, does the nurse assess the client?

53 / 96

A client who experiences frequent episodes of chest pain is admitted to the hospital for cardiac monitoring. The client suddenly complains of chest pain, and the nurse obtains a 12-lead electrocardiogram (ECG). Which finding would the nurse expect to note in the event of an ischemic episode?

54 / 96

A nurse has admitted a client with a diagnosis of tuberculosis (TB) to the nursing unit. Which finding that confirms the diagnosis does the nurse expect to see documented in the client’s record?

55 / 96

The wife of a client with angina pectoris calls the health care provider’s office and reports to the nurse that her husband is experiencing chest pain and has taken 2 sublingual nitroglycerin tablets 5 minutes apart, with no relief. The nurse tells the client’s wife to:

56 / 96

A cardiac monitor alarm sounds, and a nurse notes a straight line on the monitor screen. The nurse immediately:

57 / 96

The emergency department nurse assesses a client who has a diagnosis of left-sided heart failure. Which findings does the nurse expect to note? Select all that apply.

58 / 96

A nurse provides instructions to a client with chronic obstructive pulmonary disease (COPD) about the positions that are most effective in alleviating dyspnea. Which statement by the client indicates a need for further instruction?

59 / 96

A ventilator’s low exhaled volume (low-pressure) alarm sounds, and the nurse rushes to the client’s room and quickly assesses the client. The client appears to be having respiratory difficulty. The nurse should first:

60 / 96

A client is found to have viral hepatitis, and the nurse provides home care instructions to the client. The nurse should tell the client to:

61 / 96

A nurse is caring for a client in the intensive care unit (ICU) who is being mechanically ventilated. As the nurse prepares medications, the client suddenly becomes anxious and pulls out the endotracheal tube. The nurse assesses the client for spontaneous breathing and then:

62 / 96

The nurse teaches a client with gastroesophageal reflux disease (GERD) about measures to prevent reflux during sleep. The nurse determines that the client needs additional instructions if the client states:

63 / 96

A home care nurse visits a pregnant client with a diagnosis of mild preeclampsia. During the assessment, the client tells the nurse that she has had an upset stomach and pain in the epigastric area. The nurse most appropriately:

64 / 96

An emergency department nurse is caring for a client with acute pancreatitis who will be admitted to the hospital. Into which position that will ease the abdominal pain does the nurse assist the client?

65 / 96

A nurse is developing a plan of care for a client with a new diagnosis of Graves disease. Which intervention does the nurse include in the plan?

66 / 96

A nurse is teaching a client with diabetes mellitus who requires insulin about methods of preventing diabetic ketoacidosis (DKA) when the client is ill. The nurse tells the client to:

67 / 96

A nurse is conducting an assessment of a client with mild preeclampsia. Which sign indicates improvement in the client’s condition?

68 / 96

A nurse is monitoring a client who is in the active phase of labor and has been experiencing contractions that are coordinated but weak. Which assessment finding indicates to the nurse that the client may be experiencing hypotonic contractions?

69 / 96

A woman in labor suddenly complains of abdominal tenderness and pain and states that she felt as though “something ripped.” For which manifestations does the nurse, suspecting uterine rupture, assess the client? Select all that apply.

70 / 96

A nurse in the labor room is performing a vaginal assessment of a pregnant client who is in active labor. The nurse notes that the umbilical cord is protruding from the vagina and immediately:

71 / 96

A client in the third trimester of pregnancy is experiencing painless vaginal bleeding, and placenta previa is suspected. For which intervention does the nurse prepare the client?

72 / 96

A nurse assessing a client in the fourth stage of labor notes that the uterine fundus is firmly contracted and is midline at the level of the umbilicus. On the basis of this finding, the nurse most appropriately: 

73 / 96

A nurse is reading the medical record of a pregnant client in the second trimester with a diagnosis of abruptio placentae. Which clinical manifestation of the disorder does the nurse expect to see documented?

74 / 96

Mastitis is diagnosed in a client who recently gave birth. The nurse tells the woman that:

75 / 96

A nurse in a newborn nursery receives a telephone call from the delivery room and is told that a newborn with spina bifida (meningomyelocele type) will be transported to the nursery. Which item does the nurse, preparing for the arrival of the newborn, make a priority of placing at the newborn’s bedside?

76 / 96

A mother calls the clinic and tells the nurse that her newborn’s umbilical cord site looks red and swollen. The nurse should tell the mother:

77 / 96

A nurse provides instructions to the mother of a newborn with hyperbilirubinemia who is being breastfed. The nurse determines that the mother understands the instructions if the mother says that she will:

78 / 96

A nurse in the newborn nursery is monitoring a neonate born to a mother with diabetes mellitus. For which finding does the nurse monitor the neonate most closely?

79 / 96

A nurse is assessing a newborn for fetal alcohol syndrome (FAS). Which finding would the nurse expect to note in the newborn?

80 / 96

A nurse is preparing a teaching plan for the parents of an infant with a ventricular peritoneal shunt. Which instruction does the nurse plan to include?

81 / 96

A nurse is preparing a teaching plan for the parents of an infant with a ventricular peritoneal shunt. Which instruction does the nurse plan to include?

82 / 96

An ambulatory care nurse is providing home care instructions to the mother of a child who had a tonsillectomy. The nurse determines that the mother needs further instruction if she indicates that she will:

83 / 96

A nurse is assessing a child with increased intracranial pressure who has been exhibiting decorticate posturing. The nurse notes extension of the upper and lower extremities, with internal rotation of the upper arms and wrists and the knees and feet. The nurse determines that the child’s condition:

84 / 96

A home care nurse has provided instructions to the father of a child with croup regarding treatment measures. Which statement by the father indicates a need for further instruction?

 

85 / 96

A nurse has been assigned to care for an infant with tetralogy of Fallot. The infant suddenly exhibits rapid, deep respirations; irritability; and cyanosis. The nurse determines that the infant is experiencing a hypercyanotic episode and immediately:

86 / 96

A nurse is caring for a hospitalized child with a diagnosis of Kawasaki disease. During the subacute phase, the nurse monitors the child closely for:

87 / 96

A nurse is conducting the initial assessment of a child with rheumatic fever. Which question does the nurse ask the parents to elicit information specific to the development of the disease?

88 / 96

A nurse provides dietary instructions to the mother of a child with celiac disease. Which food does the nurse tell the mother to include in the child’s diet?

89 / 96

A nurse is obtaining subjective data from the mother of a child admitted to the hospital with a diagnosis of intussusception. Which occurrence does the nurse expect the mother to report?

90 / 96

A child with a diagnosis of pertussis (whooping cough) is being admitted to the pediatric unit. As soon as the child arrives to the unit, the nurse first:

91 / 96

A home care nurse is providing instructions to the mother of a 3-year-old with hemophilia regarding care of the child. Which statements by the mother indicate a need for further instructions? Select all that apply.

92 / 96

A nurse is assessing a 12-month-old child with iron-deficiency anemia. Which finding does the nurse expect to note in this child?

93 / 96

A nurse is caring for a child with newly diagnosed type 1 diabetes mellitus who is receiving insulin. The child suddenly exhibits tachycardia and beings to sweat and tremble, and the nurse determines that the child is experiencing a hypoglycemic reaction. The nurse would immediately give the child:

94 / 96

A nurse is reviewing the assessment findings and laboratory results of a child with a diagnosis of new-onset glomerulonephritis. Which finding would the nurse expect to note?

95 / 96

A client has undergone creation of an Indiana pouch for urine diversion after cystectomy, and the nurse provides instructions about reservoir catheterization. The nurse tells the client

96 / 96

A nurse is weighing a breastfed 6-month-old infant who has been brought to the pediatrician’s office for a scheduled visit. The infant’s weight at birth was 6 lb 8 oz (2.9 kg). The nurse notes that the infant now weighs 13 lb (5.9 kg). Which action should the nurse take?

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Week Four

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Nclex Content Review Class One – Week Four

Week Four Assessment

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1 / 96

A nurse is caring for a client with Crohn disease whose magnesium level is 1.0 mEq/L (0.5 mmol/L). Which assessment findings does the nurse expect to note? Select all that apply.

2 / 96

A nurse is monitoring a client with hyperparathyroidism for signs of hypercalcemia. For which clinical manifestations, associated with this electrolyte imbalance, does the nurse assess the client? Select all that apply.

3 / 96

A nurse is caring for a client experiencing hyponatremia who was admitted to the medical-surgical unit with fluid-volume overload. For which clinical manifestations of this electrolyte imbalance does the nurse monitor this client? Select all that apply.

4 / 96

A client with gastroenteritis who has been vomiting and has diarrhea is admitted to the hospital with a diagnosis of dehydration. For which clinical manifestations that correlate with this fluid imbalance would the nurse assess the client? Select all that apply.

5 / 96

A nurse is performing nasotracheal suctioning on a client. Which observations should be cause for concern to the nurse? Select all that apply.

6 / 96

A nurse is watching as a nursing student suctions a client through a tracheostomy tube. Which actions on the part of the student would prompt the nurse to intervene and demonstrate correct procedure? Select all that apply.

7 / 96

A nurse is watching as an unlicensed assistive personnel (UAP) measure the blood pressure (BP) of a hypertensive client. Which actions on the part of the UAP would interfere with accurate measurement and prompt the nurse to intervene? Select all that apply.

8 / 96

A nurse has a prescription to apply a Holter monitor to a client for continuous cardiac monitoring for a 24-hour period. What steps should the nurse take to initiate this prescription? Select all that apply

9 / 96

A nurse has a prescription to apply a Holter monitor to a client for continuous cardiac monitoring for a 24-hour period. What steps should the nurse take to initiate this prescription? Select all that apply

10 / 96

A client who underwent preadmission testing 1 week before surgery had blood drawn for several serum laboratory studies. Which abnormal laboratory results should the nurse report to the surgeon’s office? Select all that apply.

11 / 96

A nurse is assessing a client who has a closed chest tube drainage system. The nurse notes constant bubbling in the water seal chamber. What actions should the nurse take? (Select all that apply).

12 / 96

A client arrives in the emergency department for treatment of a surface injury sustained when sand blew into the eye. Which action does the nurse take first?

13 / 96

A nurse receives a telephone call from a neighbor, who says that her child was just hit in the eye with a swing. The nurse rushes to the neighbor’s house and notes that the child has sustained a contusion of the eye. The nurse advises the child’s mother to immediately:

14 / 96

A nurse provides home care instructions to a client after a scleral buckling procedure. The nurse should tell the client:

15 / 96

During a client’s yearly eye examination, the nurse checks the intraocular pressure. The nurse notes that the pressure in the right eye is 12 mm Hg and 19 mm Hg in the left. The nurse tells the client:

16 / 96

A nurse is providing discharge instructions to a client after outpatient surgery for cataract removal. The nurse determines that the client needs additional instructions if the client indicates that he will:

17 / 96

A client is transported to the recovery area of the ambulatory care unit after cataract surgery. In which position does the nurse place the client?

18 / 96

A nurse provides home care instructions to a client with Ménière disease about measures to control and treat vertigo. The nurse should tell the client to:

19 / 96

A stapedectomy is performed on a client with otosclerosis. During the preparations for discharge, which home care instruction does the nurse give the client?

20 / 96

A nurse is providing instructions to an unlicensed assistive personnel (UAP) about effective measures for communicating with a hearing-impaired client. The nurse instructs the UAP to:

21 / 96

A nurse provides instructions to a client about measures to prevent an acute attack of gout. The nurse determines that the client needs additional instructions if the client states:

22 / 96

A nurse provides instructions to a client with rheumatoid arthritis about joint exercises that are important to prevent deformity and reduce pain. Which statement by the client indicates the need for further instruction?

23 / 96

A nurse provides home care instructions to a client with a below-the-knee amputation (BKA) about residual limb and prosthesis care. Which statement by the client indicates a need for further instruction?

24 / 96

Buck extension traction is applied to the right leg of a client who sustained a right hip fracture. Which intervention should the nurse include in the plan of care?

25 / 96

A client with a leg fracture who has been placed in skeletal traction is transported to the orthopedic unit after surgery. Which finding would indicate the need to contact the orthopedic specialist?

26 / 96

A client has just had a plaster leg cast applied, and the nurse has given the client instructions on cast care. Which statement by the client indicates the need for further instruction?

27 / 96

A client who sustained a fracture of the left arm requires the application of a plaster cast. The nurse tells the client that the procedure for applying the cast involves:

28 / 96

A client is found to have AIDS. What is the nurse’s highest priority in providing care to this client?

29 / 96

A client arrives at the emergency department with reports of a headache, hives, itching, and difficulty swallowing. The client states that he took ibuprofen (Motrin) 1 hour earlier and believes that he is experiencing an allergic reaction to this medication. After ensuring that the client has a patent airway, which intervention does the nurse prepare the client for first?

30 / 96

A nurse is assessing a client with AIDS for signs of Pneumocystis jiroveci infection. Which sign of the infection is the earliest manifestation?

31 / 96

An emergency department (ED) nurse receives a telephone call from emergency medical services and is told that a client who has sustained severe burns of the face and upper arms is being transported to the ED. Which action does the nurse, preparing for the arrival of the client, plan to implement first?

32 / 96

A nurse is monitoring a client who has just undergone radical neck dissection. The nurse notes that the client’s blood pressure has dropped from 132/84 to 90/50 mm Hg and that the pulse has increased from 78 to 96 beats/min. On the basis of these findings, the nurse immediately:

33 / 96

A client with a spinal cord injury suddenly complains of a pounding headache. The nurse quickly assesses the client and notes that the client is diaphoretic, that his blood pressure has increased, and that his heart rate has slowed. Suspecting that the client is experiencing autonomic dysreflexia, the nurse elevates the head of the client’s bed and immediately:

34 / 96

A nurse is providing home care instructions to a client with Parkinson disease about measures to avoid rigidity and to overcome tremor and bradykinesia. The nurse tells the client to:

35 / 96

A nurse is teaching a client who is experiencing homonymous hemianopsia after a brain attack (stroke) about measures to overcome the deficit. The nurse tells the client to:

36 / 96

A client who is recovering from a brain attack (stroke) has residual dysphagia. Which measure does the nurse plan to implement at mealtimes?

37 / 96

A client who experienced a brain attack (stroke) exhibits right-sided unilateral neglect. The nurse caring for this client plans to place the client’s personal care items:

38 / 96

A nurse answers the call bell of a client who has been fitted with an internal cervical radiation implant, and the client states that she thinks that the implant has fallen out. The nurse checks the client and sees the implant lying in the bed. Which action should the nurse take first?

39 / 96

A female client who has undergone placement of a sealed radiation implant asks the nurse whether she can take a walk around the nursing unit. How should the nurse respond to the client’s request?

40 / 96

A nurse develops a nursing care plan for a client with a sealed radiation implant. Which stipulation does the nurse include in the plan?

41 / 96

The nurse has instructed a client who is about to begin external radiation therapy in how to maintain optimal skin integrity during therapy. Which statement by the client indicates a need for further instruction?

42 / 96

A client with cancer of the larynx is receiving external radiation therapy of the neck. Which side effect related specifically to the site of irradiation does the nurse tell the client to expect?

43 / 96

A nurse is having dinner at a restaurant when a man sitting at the next table collapses and falls to the floor. The nurse yells for help and quickly assesses the client, noting that the client is not breathing and does not have a pulse. The nurse initiates cardiopulmonary resuscitation (CPR) immediately, and the restaurant manager rushes to the scene with an automatic external defibrillator (AED). What should the nurse do next?

44 / 96

A nurse is working in the emergency department. Which client should be assessed first?

45 / 96

A nurse attending a recertification course in basic life support (BLS) for healthcare professionals is practicing BLS on an infant mannequin. Where does the nurse place the fingers to assess the infant’s pulse?

46 / 96

A pediatric nurse finds a hospitalized child unresponsive. A quick assessment reveals that the child is not breathing and does not have a pulse. The nurse initiates cardiopulmonary resuscitation (CPR). How many chest compressions per minute does the nurse deliver?

47 / 96

The nurse is administering cardiopulmonary resuscitation (CPR) to an adult client. Which compression-ventilation ratio is correct?

48 / 96

A nurse arrives at the scene of a code and begins to assist with cardiopulmonary resuscitation (CPR) of an adult. The nurse delivers compressions by pushing down on the chest to a depth of:

49 / 96

A nurse enters a client’s room and finds the client unconscious. The nurse quickly performs an assessment and determines that the client is not breathing. Which action does the nurse take first?

50 / 96

A nurse notes that a client’s serum potassium level is 5.8 mEq/L(5.8 mmol/L). The nurse interprets this as an expected finding in the client with:

51 / 96

The client rings the call bell and complains of pain at the site of an IV infusion. The nurse assesses the site and determines that phlebitis has developed. Which actions should the nurse take? Select all that apply.

52 / 96

A client is receiving total parenteral nutrition (TPN) with fat emulsion (lipids) piggybacked to the TPN solution. For which signs of an adverse reaction to the fat emulsion should the nurse monitor the client? Select all that apply.

53 / 96

A nurse is caring for a group of adult clients on an acute care nursing unit. Which clients does the nurse recognize as the most likely candidates for total parenteral nutrition (TPN)? Select all that apply.

54 / 96

A home care nurse has been assigned a client who has been discharged home with a prescription for total parenteral nutrition (TPN). Which parameters does the nurse plan to check at each visit as a means of identifying complications of the TPN therapy? Select all that apply.

55 / 96

How does a client who has lost a spouse show that she is successfully completing the tasks of mourning? Select all that apply.

56 / 96

At 1300, the nurse is documenting the receipt of a unit of packed blood cells at the hospital blood bank. The nurse calculates that the transfusion must be started by which time?

57 / 96

Packed red blood cells have been prescribed for a client with low hemoglobin and hematocrit values. The nurse takes the client’s temperature orally before hanging the blood transfusion and notes that it is 100.0° F (37.7 C). What should the nurse do next?

58 / 96

A nurse discontinues an infusion of a unit of blood after the client experiences a transfusion reaction. Once the incident has been documented appropriately, where does the nurse send the blood transfusion bag?

59 / 96

A client has a prescription for a unit of packed red blood cells (RBCs). Which IV solution should the nurse obtain to hang with the blood product at the client’s bedside?

60 / 96

A nurse has just received a prescription to transfuse a unit of packed red blood cells for an assigned client. For how long does the nurse plan to stay with the client after the unit of blood is hung?

61 / 96

A nurse has obtained a unit of blood from the blood bank and properly checked the blood bag with another nurse. Which parameter should the nurse assess just before hanging the transfusion?

62 / 96

A client has just undergone insertion of a central venous catheter by the health care provider at the bedside. Which result would the nurse be sure to check before initiating infusion of the IV solution that the health care provider has prescribed?

63 / 96

A nurse has a written prescription to remove an intravenous (IV) line. Which item should the nurse obtain from the unit supply area for use in applying pressure to the site after removing the IV catheter?

64 / 96

A nurse notes that the site of a client’s peripheral IV catheter is reddened, warm, painful, and slightly edematous in the area of the insertion site. After taking appropriate steps to care for the client, the nurse documents in the medical record that the client has experienced which problem?

65 / 96

A client with schizophrenia who has been taking an antipsychotic medication calls the clinic nurse and says, “I need to cancel my appointment with the psychiatrist again, because I still have this awful sore throat. It’s so bad that my mouth has a sore.” How does the nurse respond to the client?

66 / 96

A client with schizophrenia has been taking an antipsychotic medication for 2 months. For which adverse effect should the nurse monitor the client closely?

67 / 96

A young female client with schizophrenia says to the nurse, “Since I started on olanzapine last year, I’m doing well in school and all, but I’ve gained so much weight, and it’s really bothering me. What can I do about this?” Which response by the nurse would be therapeutic?

68 / 96

A nurse answers a call bell and finds that the total parenteral nutrition (TPN) solution bag of an assigned client is empty. The new prescription was written for a new bag at the beginning of the shift, but it has not yet arrived from the pharmacy. Which action should the nurse take first?

69 / 96

 

A nurse is making initial rounds on a group of assigned clients. Which client should the nurse see first?

70 / 96

A nurse suspects that a client receiving total parenteral nutrition (TPN) through a central line has an air embolism. The nurse immediately places the client in which position?

71 / 96

The nurse is preparing to change the solution bag and intravenous tubing of a client receiving total parenteral nutrition (TPN) through a left subclavian central venous line. Which essential action does the nurse ask the client to perform just before switching the tubing?

72 / 96

A nurse is preparing a client for the insertion of a central intravenous line into the subclavian vein by the health care provider. The nurse gathers the equipment, places it at the bedside, and prepares to assist the health care provider with the procedure. As further preparation for the procedure, the nurse places the client in which position?

73 / 96

A client receiving total parenteral nutrition (TPN) requires fat emulsion (lipids), which will be piggybacked to the TPN solution. On obtaining a bottle of fat emulsion, the nurse notes that fat globules are floating at the top of the solution. Which action should the nurse take?

 

74 / 96

A nurse is changing the central line dressing of a client receiving total parenteral nutrition (TPN). The nurse notes moisture under the dressing covering the catheter insertion site. What should the nurse assess next?

75 / 96

At 1600 the nurse checks a client’s total parenteral nutrition (TPN) infusion bag and notes that the solution is running at a rate of 100 mL/hr. The bag was hung the previous day at 1800. The nurse plans to change the infusion bag and tubing this evening at what time?

76 / 96

A nurse is monitoring a client who is receiving total parenteral nutrition (TPN). Which t signs and symptoms causes the nurse to suspect that the client is experiencing hyperglycemia as a complication?

77 / 96

The first bag of total parenteral nutrition (TPN) solution has arrived on the clinical unit for a client beginning this nutritional therapy. The solution is to be infused by way of a central line. Which essential piece of equipment should the nurse obtain before hanging the solution?

78 / 96

A client with a peripheral intravenous (IV) line in place has a new prescription for infusion of total parenteral nutrition (TPN), a solution containing 25% glucose. Which action should be taken by the nurse?

79 / 96

A nurse is assessing a peripheral intravenous (IV) site and notes blanching, coolness, and edema at the insertion site. What should the nurse do first?

80 / 96

The health care provider (HCP)prescribes the administration of totalparenteral nutrition (TPN), to be started at a rate of 50 mL/hr by way of infusion pump through an established subclavian central line. After the first 2 hours of the TPN infusion, the client suddenly complains of difficulty breathing and chest pain. The nurse should take which immediate action?

81 / 96

A client with heart failure is being given furosemide and digoxin. The client calls the nurse and complains of anorexia and nausea. Which action should the nurse take first?

82 / 96

A nurse discontinues an infusion of a unit of packed red blood cells (RBCs) because the client is experiencing a transfusion reaction. After discontinuing the transfusion, which action should the nurse take next?

83 / 96

A nurse hangs a 500-mL bag of intravenous (IV) fluid for an assigned client. One hour later the client complains of chest tightness, is dyspneic and apprehensive, and has an irregular pulse. The IV bag has 100 mL remaining. Which action should the nurse take first?

84 / 96

A nurse notes that the site of a client’s peripheral intravenous (IV) catheter is reddened, warm, painful, and slightly edematous near the insertion point of the catheter. On the basis of this assessment, the nurse should take which action first?

85 / 96

A 24-year-old schizophrenic client says, “I was in college and suddenly I was hearing voices telling me I was no good and that I should jump off the bridge by our college. My parents came and got me when I called them. We thought that I had inadvertently taken drugs at a party or something. My psychiatrist says that if I can improve, I can return to college next semester.” Which guideline does the nurse plan to incorporate into teaching of the client and family about self-care on the client’s return to college?

86 / 96

A schizophrenic client is admitted to the inpatient psychiatric unit. The client is exhibiting clang associations, word salad, and loose associations. Which problem does the nurse recognize that the client is experiencing?

87 / 96

The nurse plans outcomes for a client who is being treated for psychosis. Which step would be included during the stable or discharge phase of treatment?

88 / 96

A schizophrenic client says to the nurse, “I keep getting these thoughts and hearing voices. They worry and consume me so that I can’t always stop myself like my health care provider told me to.” Which intervention would the nurse suggest as a distraction technique?

89 / 96

A schizophrenic client exhibits confused and unintelligible speech. Which nursing statement would be most therapeutic?

90 / 96

A nurse educator describes the standards of care formulated by the American Nurses Association to a group of new nursing graduates hired by the hospital. Which of the following options are accurate descriptions of these standards of care? Select all that apply.

91 / 96

A nursing instructor asks a nursing student to describe accountability. Which statement(s) by the student indicate(s) an accurate description of accountability? Select all that apply.

92 / 96

A registered nurse (RN) is planning assignments for five clients on the nursing unit. The team includes a licensed practical nurse (LPN) and a nursing assistant. Which clients should the nurse assign to the LPN? Select all that apply.

93 / 96

A registered nurse (RN) is planning client assignments for the day. Which clients should the nurse assign to a nursing assistant (unlicensed assistive personnel)? Select all that apply.

94 / 96

A nurse is providing a change-of-shift report on his assigned clients, using an audiotape. Which of the following pieces of information should the nurse include in the report about each assigned client? Select all that apply.

95 / 96

A registered nurse (RN) in charge of a long-term care facility who is working with a nursing assistant on the night shift prepares to take her break. To ensure client safety during her break, which of the following actions should the nurse take? Select all that apply.

96 / 96

The registered nurse has accepted a new position as case manager in a hospital. Which responsibilities are part of the nurse’s new role? Select all that apply.

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