NCLEX RN Quiz - NCLEX Academy

Question 1 of 99

The nurse manager has implemented a change in the method of the nursing delivery system from functional to team nursing. An assistive personnel (AP) is resistant to the change and is not taking an active part in facilitating the process of change. Which is the best approach in dealing with the AP?

Exert coercion on the AP.

Confront the AP to encourage verbalization of feelings regarding the change.

Ignore the resistance.

Provide a positive reward system for the AP.

Question 1 of 99

Question 2 of 99

Which teaching method is most effective when providing instruction to members of special populations?

Teach-back

Verbal explanation

Written materials

Video instruction

Question 2 of 99

Question 3 of 99

The nurse reviews the blood gas results of a client with atelectasis. The nurse analyzes the results and determines that the client is experiencing respiratory acidosis. Which result validates the nurses findings?

pH 7.52, Paco₂ 28 mm Hg

pH 7.35, Paco₂ 40 mm Hg

pH 7.25, Paco₂ 50 mm Hg

pH 7.50, Paco₂ 52 mm Hg

Question 3 of 99

Question 4 of 99

The nurse reviews a clients record and determines that the client is at risk for developing a potassium deficit if which situation is documented?

Has a history of Addisons disease

Sustained tissue damage

Uric acid level of 9.4 mg/dL (557 mcmol/L)

Requires nasogastric suction

Question 4 of 99

Question 5 of 99

The nurse is planning care for a client of Native Hawaiian descent who recently had a baby. The nurse develops a teaching plan and includes information about which measure that is related to a newborn complication within this ethnic group?

Baby-proofing

Safe sleeping

Breast-feeding

Car seat safety

Question 5 of 99

Question 6 of 99

The nurse is caring for a client with several broken ribs. The client is most likely to experience what type of acid-base imbalance?

Metabolic acidosis from calcium loss due to broken bones

Metabolic alkalosis from taking analgesics containing base products

Respiratory alkalosis from anxiety and hyperventilation

Respiratory acidosis from inadequate ventilation

Question 6 of 99

Question 7 of 99

Which identifies accurate nursing documentation notation(s)? Select all that apply.

The client seemed angry when awakened for vital sign measurement.

The clients left lower medial leg wound is 3 cm in length without redness, drainage, or edema.

Abdominal wound dressing is dry and intact without drainage.

The client appears to become anxious when it is time for respiratory treatments.

The client slept through the night.

Question 7 of 99

Question 8 of 99

Which client is at risk for the development of a sodium level at 130 mEq/L (130 mmol/L)?

The client who is taking diuretics

The client with hyperaldosteronism

The client who is taking corticosteroids

The client with Cushings syndrome

Question 8 of 99

Question 9 of 99

The nurse employed in an emergency department is assigned to triage clients coming to the emergency department for treatment on the evening shift. The nurse should assign priority to which client?

A client with a minor laceration on the index finger sustained while cutting an eggplant

A client who twisted her ankle when rollerblading and is requesting medication for pain

A client complaining of muscle aches, a headache, and history of seizures

A client with chest pain who states that he just ate pizza that was made with a very spicy sauce

Question 9 of 99

Question 10 of 99

10.

Which client is at risk for the development of a potassium level of 5.5 mEq/L (5.5 mmol/L)?

The client with Cushings syndrome

The client who has been overusing laxatives

The client with colitis

The client who has sustained a traumatic burn

Question 10 of 99

Question 11 of 99

11.

The nurse is assessing a client suspected of having meningitis for meningeal irritation and elicits a positive Brudzinskis sign. Which finding did the nurse observe?

The clients upper arms are flexed and held tightly to the sides of the body and the legs are extended and internally rotated.

The client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column.

The client flexes a leg at the hip and knee and reports pain in the vertebral column when the leg is extended.

The client rigidly extends the arms with pronated forearms and plantar flexion of the feet.

Question 11 of 99

Question 12 of 99

12.

A client is recovering from abdominal surgery and has a large abdominal wound. The nurse should encourage the client to eat which food item that is naturally high in vitamin C to promote wound healing?

Bananas

Chicken

Oranges

Milk

Question 12 of 99

Question 13 of 99

13.

The nurse caring for a client who has been receiving intravenous (IV) diuretics suspects that the client is experiencing a fluid volume deficit. Which assessment finding would the nurse note in a client with this condition?

Decreased hematocrit and increased urine output

Increased respirations and increased blood pressure

Lung congestion and increased heart rate

Weight loss and poor skin turgor

Question 13 of 99

Question 14 of 99

14.

The nurse is planning to teach a client with malabsorption syndrome about the necessity of following a low-fat diet. The nurse develops a list of high-fat foods to avoid and should include which food items on the list? Select all that apply.

Margarine

Broccoli

Oranges

Luncheon meats

Cream cheese

Broiled haddock

Question 14 of 99

Question 15 of 99

15.

A client brought to the emergency department states that he has accidentally been taking 2 times his prescribed dose of warfarin for the past week. After noting that the client has no evidence of obvious bleeding, the nurse plans to take which action?

Draw a sample for type and crossmatch and transfuse the client.

Draw a sample for prothrombin time (PT) and international normalized ratio (INR).

Draw a sample for an activated partial thromboplastin time (aPTT) level.

Prepare to administer an antidote.

Question 15 of 99

Question 16 of 99

16.

The nurse is volunteering with an outreach program to provide basic health care for homeless people. Which finding, if noted, should be addressed first?

Random blood glucose level of 206 mg/dL (11.47 mmol/L)

Complaints of pain associated with numbness and tingling in both feet

Visual acuity of 20/200 in both eyes

Blood pressure 154/72 mm Hg

Question 16 of 99

Question 17 of 99

17.

The nurse reviews the electrolyte results of a client with chronic kidney disease and notes that the potassium level is 5.7 mEq/L (5.7 mmol/L). Which patterns would the nurse watch for on the cardiac monitor as a result of the laboratory value? Select all that apply.

ST depression

Tall peaked T waves

Prominent U wave

Prolonged ST segment

Widened QRS complexes

Question 17 of 99

Question 18 of 99

18.

The nurse is testing the extraocular movements in a client to assess for muscle weakness in the eyes. The nurse should implement which assessment technique to assess for muscle weakness in the eye?

Test the 6 cardinal positions of gaze.

Test sensory function by asking the client to close the eyes and then lightly touching the forehead, cheeks, and chin.

Test the corneal reflexes.

Test visual acuity, using a Snellen eye chart.

Question 18 of 99

Question 19 of 99

19.

The nurse is caring for a client having respiratory distress related to an anxiety attack. Recent arterial blood gas values are pH = 7.53, Pao₂ = 72 mm (72 mmol/L), and HCO₃⁻ = 28 mEq/L (28 mmol/L). Which conclusion about the client should the nurse make?

The client has acidotic blood.

The client is fluid volume overloaded.

The client is probably overreacting.

The client is probably hyperventilating.

Question 19 of 99

Question 20 of 99

20.

Which health concern(s) should the nurse be aware of as risk factors when caring for clients of African American descent? Select all that apply.

Cancer

Heart disease

Hypertension

Hypothyroidism

Obesity

Diabetes mellitus

Question 20 of 99

Question 21 of 99

21.

The nurse is caring for a client who is on a mechanical ventilator. Blood gas results indicate a pH of 7.50 and a Paco₂ of 30 mm Hg (30 mm Hg). The nurse has determined that the client is experiencing respiratory alkalosis. Which laboratory value would most likely be noted in this condition?

Magnesium level of 1.8 (0.74 mmol/L)

Phosphorus level of 3.0 mg/dL (0.97 mmol/L)

Potassium level of 3.0 mEq/L (3.0 mmol/L)

Sodium level of 145 mEq/L (145 mmol/L)

Question 21 of 99

Question 22 of 99

22.

Which action by the nurse will best facilitate adherence to the treatment regimen for a client with a chronic illness?

Communicating with one provider only to avoid confusion for the client

Arranging for home health care

Focusing on managing a single illness at a time

Allowing the client to teach a support person about their treatment regimen

Question 22 of 99

Question 23 of 99

23.

The nurse is reading a primary health care providers (PHCPs) progress notes in the clients record and reads that the PHCP has documented "insensible fluid loss of approximately 800 mL daily." The nurse makes a notation that insensible fluid loss occurs through which type of excretion?

Integumentary output

Wound drainage

Urinary output

The gastrointestinal tract

Question 23 of 99

Question 24 of 99

24.

A Spanish-speaking client arrives at the triage desk in the emergency department and states to the nurse that an interpreter is needed. Which is the best action for the nurse to take?

Page an interpreter from the hospitals interpreter services.

Have the Spanish-speaking triage receptionist interpret.

Have one of the clients family members interpret.

Obtain a Spanish-English dictionary and attempt to triage the client.

Question 24 of 99

Question 25 of 99

25.

The nurse is teaching a client who has iron deficiency anemia about foods she should include in the diet. The nurse determines that the client understands the dietary modifications if which items are selected from the menu?

Oranges and dark green leafy vegetables

Coffee and tea

Cooked rolled oats and fish

Nuts and milk

Question 25 of 99

Question 26 of 99

26.

The nurse has made an error in documentation of the dose administered of an opioid pain medication in the clients record. The nurse draws 1 mg from the vial and another registered nurse (RN) witnesses wasting of the remaining 1 mg. When scanning the medication, the nurse entered into the medication administration record (MAR) that 2 mg of hydromorphone was administered instead of the actual dose administered, which was 1 mg. The nurse should take which action(s) to correct the error in the MAR? Select all that apply.

Complete and file an occurrence report.

Document in a nurses note in the clients record detailing the corrected information.

Document the correct information and end with the nurses signature and title.

Obtain a cosignature from the RN who witnessed the waste of the remaining 1 mg.

Right-click on the entry and modify it to reflect the correct information.

Question 26 of 99

Question 27 of 99

27.

Potassium chloride intravenously is prescribed for a client with heart failure experiencing hypokalemia. Which actions should the nurse take to plan for preparation and administration of the potassium? Select all that apply.

Obtain an intravenous (IV) infusion pump.

Monitor the IV site for signs of infiltration or phlebitis.

Ensure that the medication is diluted in the appropriate volume of fluid.

Monitor urine output during administration.

Prepare the medication for bolus administration.

Ensure that the bag is labeled so that it reads the volume of potassium in the solution.

Question 27 of 99

Question 28 of 99

28.

The registered nurse is planning the client assignments for the day. Which is the most appropriate assignment for an assistive personnel (AP)?

A client who requires urine specimen collections

A client with difficulty swallowing food and fluids

A client requiring a colostomy irrigation

A client receiving continuous tube feedings

Question 28 of 99

Question 29 of 99

29.

On review of the clients medical records, the nurse determines that which client is at risk for fluid volume excess?

The client with kidney disease and a 12-year history of diabetes mellitus

The client who requires intermittent gastrointestinal suctioning

The client with an ileostomy from a recent abdominal surgery

The client taking diuretics who has tenting of the skin

Question 29 of 99

Question 30 of 99

30.

A client with hypertension has been told to maintain a diet low in sodium. The nurse who is teaching this client about foods that are allowed should include which food item in a list provided to the client?

Tomato soup

Boiled shrimp

Instant oatmeal

Summer squash

Question 30 of 99

Question 31 of 99

31.

The nurse is preparing discharge resources for a client being discharged to the homeless shelter. When looking at the discharge medication reconciliation form, the nurse determines there is a need for follow-up if which medication was prescribed?

Glipizide

Beclomethasone

Metformin

Lisinopril

Question 31 of 99

Question 32 of 99

32.

The nurse manager is discussing the facility protocol in the event of a tornado with the staff. Which instructions should the nurse manager include in the discussion? Select all that apply.

Move beds away from windows.

Close window shades and curtains.

Open doors to client rooms.

Relocate ambulatory clients from the hallways back into their rooms.

Place blankets over clients who are confined to bed.

Question 32 of 99

Question 33 of 99

33.

The nurse notes that a clients arterial blood gas (ABG) results reveal a pH of 7.50 and a Paco₂ of 30 mm Hg (30 mm Hg). The nurse monitors the client for which clinical manifestations associated with these ABG results? Select all that apply.

Nausea

Hyperkalemia

Tachycardia

Confusion

Lightheadedness

Bradypnea

Question 33 of 99

Question 34 of 99

34.

The nurse is caring for a client with cirrhosis of the liver. To minimize the effects of the disorder, the nurse teaches the client about foods that are high in thiamine. The nurse determines that the client has the best understanding of the dietary measures to follow if the client states an intention to increase the intake of which food?

Broccoli

Chicken

Milk

Legumes

Question 34 of 99

Question 35 of 99

35.

The nurse has received the assignment for the day shift. After making initial rounds and checking all of the assigned clients, which client should the nurse plan to care for first?

A client scheduled for physical therapy for the first crutch-walking session

A client with a white blood cell count of 14,000 mm³ (14 x 10⁹/L) and a temperature of 38.4° C

A client who is ambulatory demonstrating steady gait

A postoperative client who has just received an opioid pain medication

Question 35 of 99

Question 36 of 99

36.

A client with diabetes mellitus has a glycosylated hemoglobin A_1c level of 8%. On the basis of this test result, the nurse plans to teach the client about the need for which measure?

Preventing and recognizing hyperglycemia

Preventing and recognizing hypoglycemia

Avoiding infection

Taking in adequate fluids

Question 36 of 99

Question 37 of 99

37.

The nurse notes documentation that a client is exhibiting Cheyne-Stokes respirations. On assessment of the client, the nurse should expect to note which finding?

Rhythmic respirations with periods of apnea

Regular rapid and deep, sustained respirations

Totally irregular respiration in rhythm and depth

Irregular respirations with pauses at the end of inspiration and expiration

Question 37 of 99

Question 38 of 99

38.

A client with a history of upper gastrointestinal bleeding has a platelet count of 300,000 mm³ (300 × 10⁹/L). The nurse should take which action after seeing the laboratory results?

Report the abnormally high count.

Place the normal report in the clients medical record.

Place the client on bleeding precautions.

Report the abnormally low count.

Question 38 of 99

Question 39 of 99

39.

The nurse provides instructions to a client with a low potassium level about the foods that are high in potassium and tells the client to consume which foods? Select all that apply.

Cantaloupe

Strawberries

Peas

Raisins

Potatoes

Cauliflower

Question 39 of 99

Question 40 of 99

40.

The nurse is caring for a client who takes ibuprofen for pain. The nurse is gathering information on the clients medication history and determines it is necessary to contact the primary health care provider (PHCP) if the client is also taking which medications? Select all that apply.

Glimepiride

Atorvastatin

Simvastatin

Warfarin

Amlodipine

Question 40 of 99

Question 41 of 99

41.

The nurse is caring for a client with diabetic ketoacidosis and documents that the client is experiencing Kussmauls respirations. Which patterns did the nurse observe? Select all that apply.

Respirations that are abnormally deep

Respirations that are shallow

Respirations that are abnormally slow

Respirations that cease for several seconds

Respirations that are increased in rate

Question 41 of 99

Question 42 of 99

42.

The nurse is caring for a client with heart failure. On assessment, the nurse notes that the client is dyspneic, and crackles are audible on auscultation. What additional manifestations would the nurse expect to note in this client if excess fluid volume is present?

Flat neck and hand veins and decreased urinary output

Weakness and decreased central venous pressure (CVP)

Weight loss and dry skin

An increase in blood pressure and increased respirations

Question 42 of 99

Question 43 of 99

43.

A client has been admitted to the hospital for gastroenteritis and dehydration. The nurse determines that the client has received adequate volume replacement if the blood urea nitrogen (BUN) level drops to which value?

15 mg/dL (5.4 mmol/L)

29 mg/dL (10.44 mmol/L)

3 mg/dL (1.08 mmol/L)

35 mg/dL (12.6 mmol/L)

Question 43 of 99

Question 44 of 99

44.

The nurse who works on the night shift enters the medication room and finds a coworker with a tourniquet wrapped around the upper arm. The coworker is about to insert a needle, attached to a syringe containing a clear liquid, into the antecubital area. Which is the most appropriate action by the nurse?

Call the nursing supervisor.

Call security.

Call the police.

Lock the coworker in the medication room until help is obtained.

Question 44 of 99

Question 45 of 99

45.

The nurse hears a client calling out for help, hurries down the hallway to the clients room, and finds the client lying on the floor. The nurse performs an assessment, assists the client back to bed, notifies the primary health care provider, and completes an occurrence report. Which statement should the nurse document on the occurrence report?

The client climbed over the side rails.

The client became restless and tried to get out of bed.

The client was found lying on the floor.

The client fell out of bed.

Question 45 of 99

Question 46 of 99

46.

The nurse reviews a clients laboratory report and notes that the client’s serum phosphorus (phosphate) level is 1.8 mg/dL (0.58 mmol/L). Which condition most likely caused this serum phosphorus level?

Hypoparathyroidism

Renal insufficiency

Malnutrition

Tumor lysis syndrome

Question 46 of 99

Question 47 of 99

47.

A client who is found unresponsive has arterial blood gases drawn and the results indicate the following: pH is 7.12, Paco₂ is 90 mm Hg (90 mmol/L), and HCO₃^- is 22 mEq/L (22 mmol/L). The nurse interprets the results as indicating which condition?

Respiratory acidosis with compensation

Metabolic acidosis with compensation

Respiratory acidosis without compensation

Metabolic acidosis without compensation

Question 47 of 99

Question 48 of 99

48.

The nurse is instructing a client how to perform a testicular self-examination (TSE). The nurse should explain that which is the best time to perform this exam?

After a shower or bath

While lying in bed before arising

While standing to void

After having a bowel movement

Question 48 of 99

Question 49 of 99

49.

An adult female client has a hemoglobin level of 10.8 g/dL (108 mmol/L). The nurse interprets that this result is most likely caused by which condition noted in the clients history?

Dehydration

Chronic obstructive pulmonary disease

Heart failure

Iron deficiency anemia

Question 49 of 99

Question 50 of 99

50.

A postoperative client has been placed on a clear liquid diet. The nurse should provide the client with which items that are allowed to be consumed on this diet? Select all that apply.

Pudding

Broth

Coffee

Pureed vegetables

Gelatin

Vegetable juice

Question 50 of 99

Question 51 of 99

51.

The nurse is assigned to care for four clients. In planning client rounds, which client should the nurse assess first?

A client requiring daily dressing changes of a recent surgical incision

A client scheduled for a chest x-ray after insertion of a nasogastric tube

A postoperative client preparing for discharge with a new medication

A client with asthma who requested a breathing treatment during the previous shift

Question 51 of 99

Question 52 of 99

52.

The nurse is planning care for an assigned client. The nurse should include information in the plan of care about prevention of human immunodeficiency virus (HIV) for which individuals specifically at risk?

Women-who-have-sex-with-women (WSW)

Female-to-male (FTM) transgender persons

Men-who-have-sex-with-men (MSM)

Lesbian persons

Question 52 of 99

Question 53 of 99

53.

The nurse employed in a hospital is waiting to receive a report from the laboratory via the facsimile (fax) machine. The fax machine activates and the nurse expects the report, but instead receives a sexually oriented photograph. Which is the most appropriate initial nursing action?

Call the laboratory and ask for the name of the individual who sent the photograph.

Call the nursing supervisor and report the occurrence.

Call the police.

Cut up the photograph and throw it away.

Question 53 of 99

Question 54 of 99

54.

A nursing instructor delivers a lecture to nursing students regarding the issue of clients rights and asks a nursing student to identify a situation that represents an example of invasion of client privacy. Which situation, if identified by the student, indicates an understanding of a violation of this client right?

Performing a procedure without consent

Observing care provided to the client without the clients permission

Telling the client that he or she cannot leave the hospital

Threatening to give a client a medication

Question 54 of 99

Question 55 of 99

55.

The nurse caring for a refugee considers which health care need a priority for this client?

Access to clean water

Access to mental health care services

Access to housing

Access to transportation

Question 55 of 99

Question 56 of 99

56.

The nurse reviews the arterial blood gas results of a client and notes the following: pH 7.45, Paco₂ of 30 mm Hg (30 mmol/L), and HCO_3^– of 20 mEq/L (20 mmol/L). The nurse analyzes these results as indicating which condition?

Respiratory acidosis, uncompensated

Respiratory alkalosis, compensated

Metabolic alkalosis, uncompensated

Metabolic acidosis, compensated

Question 56 of 99

Question 57 of 99

57.

A client with atrial fibrillation who is receiving maintenance therapy of warfarin sodium has a prothrombin time (PT) of 35 seconds. On the basis of these laboratory values, the nurse anticipates which prescription?

Holding the next dose of warfarin

Adding a dose of heparin sodium

Administering the next dose of warfarin

Increasing the next dose of warfarin

Question 57 of 99

Question 58 of 99

58.

The nurse is giving a bed bath to an assigned client when an assistive personnel (AP) enters the clients room and tells the nurse that another assigned client is in pain and needs pain medication. Which is the most appropriate nursing action?

Cover the client, raise the side rails, tell the client that you will return shortly, and administer the pain medication to the other client.

Finish the bed bath and then administer the pain medication to the other client.

Ask the AP to find out when the last pain medication was given to the client.

Ask the AP to tell the client in pain that medication will be administered as soon as the bed bath is complete.

Question 58 of 99

Question 59 of 99

59.

The nurse is performing a neurological assessment on a client and notes a positive Rombergs test. The nurse makes this determination based on which observation?

An involuntary rhythmic, rapid, twitching of the eyeballs

A lack of normal sense of position when the client is unable to return extended fingers to a point of reference

A dorsiflexion of the great toe with fanning of the other toes

A significant sway when the client stands erect with feet together, arms at the side, and the eyes closed

Question 59 of 99

Question 60 of 99

60.

The nurse is caring for a client with a diagnosis of breast cancer who is immunosuppressed. The nurse would consider implementing neutropenic precautions if the clients white blood cell count was which value?

11,500 mm³ (11.5 × 10⁹/L)

2000 mm³ (2.0 × 10⁹/L)

5800 mm³ (5.8 × 10⁹/L)

8400 mm³ (8.4 × 10⁹/L)

Question 60 of 99

Question 61 of 99

61.

The nurse is caring for a client with Crohns disease who has a calcium level of 8 mg/dL (2 mmol/L). Which patterns would the nurse watch for on the electrocardiogram? Select all that apply.

Prominent U wave

Widened T wave

Prolonged QT interval

U waves

Prolonged ST segment

Question 61 of 99

Question 62 of 99

62.

The nurse is assessing a client with a lactose intolerance disorder for a suspected diagnosis of hypocalcemia. Which clinical manifestation would the nurse expect to note in the client?

Negative Trousseaus sign

Twitching

Hypoactive bowel sounds

Hypoactive deep tendon reflexes

Question 62 of 99

Question 63 of 99

63.

A client is brought to the emergency department by emergency medical services (EMS) after being hit by a car. The name of the client is unknown, and the client has sustained a severe head injury and multiple fractures and is unconscious. An emergency craniotomy is required. Regarding informed consent for the surgical procedure, which is the best action?

Transport the victim to the operating room for surgery.

Obtain a court order for the surgical procedure.

Call the police to identify the client and locate the family.

Ask the EMS team to sign the informed consent.

Question 63 of 99

Question 64 of 99

64.

A client is receiving a continuous intravenous infusion of heparin sodium to treat deep vein thrombosis. The clients activated partial thromboplastin time (aPTT) is 65 seconds. The nurse anticipates that which action is needed?

Increasing the rate of the heparin infusion

Decreasing the rate of the heparin infusion

Leaving the rate of the heparin infusion as is

Discontinuing the heparin infusion

Question 64 of 99

Question 65 of 99

65.

Nursing staff members are sitting in the lounge taking their morning break. An assistive personnel (AP) tells the group that she thinks that the unit secretary has acquired immunodeficiency syndrome (AIDS) and proceeds to tell the nursing staff that the secretary probably contracted the disease from her husband, who is supposedly a drug addict. The registered nurse should inform the AP that making this accusation has violated which legal tort?

Negligence

Slander

Assault

Libel

Question 65 of 99

Question 66 of 99

66.

Which therapeutic communication technique is most helpful when working with transgender persons?

Using pronouns associated with birth sex

Anticipating the clients needs and making suggestions

Using open-ended questions

Using their first name to address them

Question 66 of 99

Question 67 of 99

67.

A nursing graduate is attending an agency orientation regarding the nursing model of practice implemented in the health care facility. The nurse is told that the nursing model is a team nursing approach. The nurse determines that which scenario is characteristic of the team-based model of nursing practice?

Each staff member is assigned a specific task for a group of clients.

A staff member is assigned to determine the clients needs at home and begin discharge planning.

A single registered nurse (RN) is responsible for providing care to a group of 6 clients with the aid of an assistive personnel (AP).

An RN leads 2 licensed practical nurses (LPNs) and 3 APs in providing care to a group of 12 clients.

Question 67 of 99

Question 68 of 99

68.

The charge nurse is planning the assignment for the day. Which factors should the nurse remain mindful of when planning the assignment? Select all that apply.

Client needs and workers needs and abilities

The number of anticipated client discharges

Specific requests from the staff

The acuity level of the clients

The clustering of the rooms on the unit

Question 68 of 99

Question 69 of 99

69.

The nurse employed in a long-term care facility is planning assignments for the clients on a nursing unit. The nurse needs to assign four clients and has a licensed practical nurse and 3 assistive personnel (APs) on a nursing team. Which client would the nurse most appropriately assign to the licensed practical nurse?

An older client requiring frequent ambulation

A client requiring abdominal wound irrigations and dressing changes every 3 hours

A client who requires hourly vital sign measurements

A client who requires a bed bath

Question 69 of 99

Question 70 of 99

70.

The nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client for manifestations of which disorder that the client is at risk for?

Respiratory acidosis

Metabolic alkalosis

Metabolic acidosis

Respiratory alkalosis

Question 70 of 99

Question 71 of 99

71.

A hospitalized client tells the nurse that an instructional directive is being prepared and that the lawyer will be bringing the document to the hospital today for witness signatures. The client asks the nurse for assistance in obtaining a witness to the will. Which is the most appropriate response to the client?

"You will need to find a witness on your own."

"I will sign as a witness to your signature."

"I will call the nursing supervisor to seek assistance regarding your request."

"Whoever is available at the time will sign as a witness for you."

Question 71 of 99

Question 72 of 99

72.

The nurse is caring for a client with heart failure who is receiving high doses of a diuretic. On assessment, the nurse notes that the client has flat neck veins, generalized muscle weakness, and diminished deep tendon reflexes. The nurse suspects hyponatremia. What additional signs would the nurse expect to note in a client with hyponatremia?

Increased specific gravity of the urine

Hyperactive bowel sounds

Decreased urinary output

Muscle twitches

Question 72 of 99

Question 73 of 99

73.

A client who is recovering from surgery has been advanced from a clear liquid diet to a full liquid diet. The client is looking forward to the diet change because he has been "bored" with the clear liquid diet. The nurse should offer which full liquid item to the client?

Gelatin

Custard

Tea

Ice pop

Question 73 of 99

Question 74 of 99

74.

The nurse is assigned to care for a group of clients. On review of the clients medical records, the nurse determines that which client is most likely at risk for a fluid volume deficit?

A client with heart failure

A client receiving frequent wound irrigations

A client on long-term corticosteroid therapy

A client with an ileostomy

Question 74 of 99

Question 75 of 99

75.

An older woman is brought to the emergency department for treatment of a fractured arm. On physical assessment, the nurse notes old and new ecchymotic areas on the clients chest and legs and asks the client how the bruises were sustained. The client, although reluctant, tells the nurse in confidence that her son frequently hits her if supper is not prepared on time when he arrives home from work. Which is the most appropriate nursing response?

"As a nurse, I am legally bound to report abuse. I will stay with you while you give the report and help find a safe place for you to stay."

"Lets talk about the ways you can manage your time to prevent this from happening."

"Oh, really? I will discuss this situation with your son."

"Do you have any friends who can help you out until you resolve these important issues with your son?"

Question 75 of 99

Question 76 of 99

76.

The nurse calls the primary health care provider (PHCP) regarding a new medication prescription, because the dosage prescribed is higher than the recommended dosage. The nurse is unable to locate the PHCP, and the medication is due to be administered. Which action should the nurse take?

Contact the nursing supervisor.

Hold the medication until the PHCP can be contacted.

Administer the recommended dose until the PHCP can be located.

Administer the dose prescribed.

Question 76 of 99

Question 77 of 99

77.

The nurse is caring for a postoperative client who is receiving demand-dose hydromorphone via a patient-controlled analgesia (PCA) pump for pain control. The nurse enters the clients room and finds the client drowsy and records the following vital signs: temperature 97.2° F (36.2° C) orally, pulse 52 beats per minute, blood pressure 101/58 mm Hg, respiratory rate 11 breaths per minute, and SpO₂ of 93% on 3 liters of oxygen via nasal cannula. Which action should the nurse take next?

Contact the primary health care provider (PHCP) immediately.

Document the findings.

Check the medication administration history on the PCA pump.

Attempt to arouse the client.

Question 77 of 99

Question 78 of 99

78.

The nurse is explaining the appropriate methods for measuring an accurate temperature to an assistive personnel (AP). Which method, if noted by the UAP as being an appropriate method, indicates the need for further teaching?

Taking a temperature on the neck behind the ear using an electronic device for a client who is diaphoretic

Taking a rectal temperature for a client who has undergone nasal surgery

Taking an axillary temperature for a client who has just consumed hot coffee

Taking an oral temperature for a client with a cough and nasal congestion

Question 78 of 99

Question 79 of 99

79.

While performing a cardiac assessment on a client with an incompetent heart valve, the nurse auscultates a murmur. The nurse documents the finding and describes the sound as which?

Lub-dub sounds

Abrupt, high-pitched snapping noise

A blowing or swooshing noise

Scratchy, leathery heart noise

Question 79 of 99

Question 80 of 99

80.

A client with a diagnosis of asthma is admitted to the hospital with respiratory distress. Which type of adventitious lung sounds should the nurse expect to hear when performing a respiratory assessment on this client?

Crackles

Wheezes

Diminished

Stridor

Question 80 of 99

Question 81 of 99

81.

A staff nurse is precepting a new graduate nurse and the new graduate is assigned to care for a client with chronic pain. Which statement, if made by the new graduate nurse, indicates the need for further teaching regarding pain management?

"I will be sure to ask my client what his pain level is on a scale of 0 to 10."

"I will be sure to cue in to any indicators that the client may be exaggerating their pain."

"I know that pain in the older client might manifest as sleep disturbances or depression."

"I know that I should follow up after giving medication to make sure it is effective."

Question 81 of 99

Question 82 of 99

82.

Which special population should be targeted for breast cancer screening by way of mammography? Select all that apply.

Women-who-have-sex-with-women (WSW)

Female-to-male (FTM)

Men-who-have-sex-with-men (MSM)

Male-to-female (MTF)

Women-who-have-sex-with-men (WSM)

Question 82 of 99

Question 83 of 99

83.

The nurse instructs a client with chronic kidney disease who is receiving hemodialysis about dietary modifications. The nurse determines that the client understands these dietary modifications if the client selects which items from the dietary menu?

Cured pork, grits, strawberries, orange juice

Cream of wheat, blueberries, coffee

Bacon, cantaloupe melon, tomato juice

Sausage and eggs, banana, orange juice

Question 83 of 99

Question 84 of 99

84.

Several laboratory tests are prescribed for a client, and the nurse reviews the results of the tests. Which laboratory test results should the nurse report? Select all that apply.

Sodium 150 mEq/L (150 mmol/L)

Platelets 35,000 mm³ (35 × 10⁹/L)

Potassium 5.0 mEq/L (5.0 mmol/L)

Segmented neutrophils 40% (0.40)

White blood cells, 3000 mm³ (3.0 × 10⁹/L)

Serum creatinine, 1 mg/dL (88.3 mcmol/L)

Question 84 of 99

Question 85 of 99

85.

The nurse reviews a clients electrolyte laboratory report and notes that the potassium level is 2.5 mmol/L). Which patterns should the nurse watch for on the electrocardiogram (ECG) as a result of the laboratory value? Select all that apply.

Absent P waves

Inverted T waves

Widened QRS complex

Depressed ST segment

U waves

Question 85 of 99

Question 86 of 99

86.

The nurse is reviewing laboratory results and notes that a clients serum sodium level is 150 mEq/L (150 mmol/L). The nurse reports the serum sodium level to the primary health care provider (PHCP), and the PHCP prescribes dietary instructions based on the sodium level. Which acceptable food items does the nurse instruct the client to consume? Select all that apply.

Cauliflower

Peas

Nuts

Cheese

Processed oat cereals

Question 86 of 99

Question 87 of 99

87.

The nurse is instructing a client with hypertension on the importance of choosing foods low in sodium. The nurse should teach the client to limit intake of which food?

Smoked salami

Apples

Bananas

Steamed vegetables

Question 87 of 99

Question 88 of 99

88.

A client with a 3-day history of nausea and vomiting presents to the emergency department. The client is hypoventilating and has a respiratory rate of 10 breaths per minute. The electrocardiogram (ECG) monitor displays tachycardia, with a heart rate of 120 beats per minute. Arterial blood gases are drawn and the nurse reviews the results, expecting to note which finding?

A decreased pH and an increased Paco₂

An increased pH and a decreased Paco₂

An increased pH and an increased HCO_3^–

A decreased pH and a decreased HCO_3^–

Question 88 of 99

Question 89 of 99

89.

The nurse arrives at work and is told to report (float) to the intensive care unit (ICU) for the day because the ICU is understaffed and needs additional nurses to care for the clients. The nurse has never worked in the ICU. The nurse should take which best action?

Ask the nursing supervisor to review the hospital policy on floating.

Clarify the ICU client assignment with the team leader to ensure that it is a safe assignment.

Refuse to float to the ICU based on lack of unit orientation.

Submit a written protest to nursing administration, and then call the hospital lawyer.

Question 89 of 99

Question 90 of 99

90.

The nurse planning care for a military veteran should prioritize nursing interventions targeted at managing which condition, if present, that commonly occurs in this population?

Post-traumatic stress disorder

Hyperlipidemia

Substance abuse disorder

Hypertension

Question 90 of 99

Question 91 of 99

91.

The nurse working in a community outreach program for foster children plans care knowing that which health conditions are common in this population? Select all that apply.

Attention-deficit hyperactivity disorder (ADHD)

Sleep problems

Bipolar disorder

Aggressive behavior

Claustrophobia

Asthma

Question 91 of 99

Question 92 of 99

92.

The clinic nurse prepares to perform a focused assessment on a client who is complaining of symptoms of a cold, a cough, and lung congestion. Which should the nurse include for this type of assessment? Select all that apply.

Asking the client about a family history of any illness or disease

Obtaining information about the clients respirations

Performing a musculoskeletal and neurological examination

Assessing the strength of peripheral pulses

Auscultating lung sounds

Obtaining the clients temperature

Question 92 of 99

Question 93 of 99

93.

The nurse is completing the admission assessment for a client who is intellectually disabled. Which part of the client encounter may require more time to complete?

The readmission risk assessment

The history

The nursing plan of care

The physical assessment

Question 93 of 99

Question 94 of 99

94.

The nurse working in a correctional facility is caring for a new prisoner. The client asks about health risks associated with living in a prison. How should the nurse respond?

"Living in a prison is similar to living in a condominium complex or dormitory."

"Living in a prison can predispose a person to different health conditions."

"Living in a prison isnt different than living at home."

"Health care is very limited in the prison setting."

Question 94 of 99

Question 95 of 99

95.

The nurse is caring for a female client in the emergency department who presents with a complaint of fatigue and shortness of breath. Which physical assessment findings, if noted by the nurse, warrant a need for follow-up?

A reddish-purple mark on the neck

Dry flaking noted on the scalp

A scaly rash noted on the elbows and knees

Reddened sclera of the eyes

Question 95 of 99

Question 96 of 99

96.

The nurse is conducting a dietary assessment on a client who is on a vegan diet. The nurse provides dietary teaching and should focus on foods high in which vitamin that may be lacking in a vegan diet?

Vitamin C

Vitamin E

Vitamin A

Vitamin B₁₂

Question 96 of 99

Question 97 of 99

97.

A client with a history of heart failure is due for a morning dose of furosemide. Which serum potassium level, if noted in the clients laboratory report, should be reported before administering the dose of furosemide?

3.8 mEq/L (3.8 mmol/L)

4.8 mEq/L (4.8 mmol/L)

3.2 mEq/L (3.2 mmol/L)

4.2 mEq/L (4.2 mmol/L)

Question 97 of 99

Question 98 of 99

98.

A client diagnosed with conductive hearing loss asks the nurse to explain the cause of the hearing problem. The nurse plans to explain to the client that this condition is caused by which problem?

A defect in cranial nerve VIII

A physical obstruction to the transmission of sound waves

A defect in the cochlea

A defect in the sensory fibers that lead to the cerebral cortex

Question 98 of 99

Question 99 of 99

99.

The nurse has just assisted a client back to bed after a fall. The nurse and primary health care provider have assessed the client and have determined that the client is not injured. After completing the occurrence report, the nurse should implement which action next?

Reassess the client.

Contact the nursing supervisor to update information regarding the fall.

Document in the nurses notes that an occurrence report was completed.

Conduct a staff meeting to describe the fall.

Question 99 of 99