passpoint NCLEX question and answers review

Question 1 See full question The nurse is assessing a neonate born to a mother with type 1 diabetes. Which finding is expected? You Selected:  large size Correct response:  large size Explanation: Remediation: Question 2 See full question A client with chest pain, dyspnea, and an irregular heartbeat comes to the emergency department. An electrocardiogram shows a heart rate of 110 beats/minute (sinus tachycardia) with frequent premature ventricular contractions. Shortly after admission, the client has ventricular tachycardia and becomes unresponsive. After successful resuscitation, the client is taken to the intensive care unit (ICU). Which nursing diagnosis is the priority at this time? You Selected:  Fear related to threat of death Correct response:  Ineffective tissue perfusion (cardiopulmonary) related to arrhythmia Explanation: Remediation: Question 3 See full question The nurse is instructing the client on insulin administration. The client is performing a return demonstration for preparing the insulin. The client’s morning dose of insulin is 10 units of regular and 22 units of NPH. The nurse checks the dose accuracy with the client. The nurse determines that the client has prepared the correct dose when the syringe reads how many units? Record your answer using a whole number.Your Response:  32 Correct response:  32 Explanation: Remediation: Question 4 See full question The nurse is assessing a client during a home health visit. The client reports a severe burning on urination. What is the most important action by the nurse? You Selected:  Obtain a urine specimen from the client Correct response:  Obtain a urine specimen from the client Explanation: Remediation: Question 5 See full question A drug must enter the bloodstream before it can act within the body. Which parenteral administration route places a drug directly into the circulation, requiring no absorption? You Selected:  I.V. Correct response:  I.V. Explanation: Remediation: Question 6 See full questionWhen documenting information in a client's medical record, which of the following should the nurse do consistently for each entry? You Selected:  Sign each entry by name and title. Correct response:  Sign each entry by name and title. Explanation: Remediation: Question 7 See full question Which of the following measures should a home healthcare nurse implement to minimize the potential for lawsuits? You Selected:  Perform thorough, accurate, and timely documentation. Correct response:  Perform thorough, accurate, and timely documentation. Explanation: Remediation: Question 8 See full question A nurse manager of the pediatric unit discovers that she is overbudget on supplies. How could each nurse assigned to the unit help with cost containment? You Selected:  Use care pathways to specify care and identify daily outcomes. Correct response:  Use care pathways to specify care and identify daily outcomes. Explanation: Question 9 See full questionA pregnant adolescent admitted with premature uterine contractions was successfully treated with I.V. fluids. She is eager to return to high school to take a math test. The nurse's discharge examination reveals vaginal blood pooling under the adolescent's buttocks that's painless to the client. Which action should the nurse take? You Selected:  Stop the discharge process and notify the physician immediately. Correct response:  Stop the discharge process and notify the physician immediately. Explanation: Remediation: Question 10 See full question The nurse is conducting a routine risk assessment at a prenatal visit. Which question would be the best to screen for intimate partner violence? You Selected:  “How safe do you feel in your home?” Correct response:  “How safe do you feel in your home?” Explanation: Question 11 See full question Following a simple mastectomy, the nurse is totaling the amount of drainage in 24 hours from a suction drain in the incision. The nurse notes there is 200 mL of serosanguinous drainage for the first 24 hours. The nurse should: Correct response:  document the findings. Explanation: Remediation:Question 12 See full question When assessing an 18-year-old primipara who gave birth to a viable neonate under epidural anesthesia 24 hours ago, the nurse determines that the fundus is firm but to the right of midline. Based on this finding, the nurse should further assesses for: You Selected:  urinary retention. Correct response:  urinary retention. Explanation: Remediation: Question 13 See full question Parents of a school-age child with asthma express concern about letting the child participate in sports. What should the nurse tell the parents about the relationship between exercise and asthma? You Selected:  Taking prophylactic drugs before the activity can prevent asthma attacks and enable the child to engage in most sports. Correct response:  Taking prophylactic drugs before the activity can prevent asthma attacks and enable the child to engage in most sports. Explanation: Remediation: Question 14 See full question The nurse is assessing a client who is in her first trimester of pregnancy. The client states that her nausea has been problematic at times, but says that she is able to partially control it using ginger supplements. What is the nurse's best response? You Selected:  "Have you let your care provider know that you are taking ginger?"Correct response:  "Have you let your care provider know that you are taking ginger?" Explanation: Remediation: Question 15 See full question During the immediate postpartum period after giving birth to twins, the client experiences uterine atony. What should the nurse do first? You Selected:  Gently massage the fundus. Correct response:  Gently massage the fundus. Explanation: Remediation: Question 16 See full question A nurse is counseling a client at a crisis center after her house burned down and her daughter was killed. Which action by the nurse is a priority? You Selected:  To assist in psychological resolution of the immediate crisis Correct response:  To assist in psychological resolution of the immediate crisis Explanation: Question 17 See full question A client is suspected of having amyotrophic lateral sclerosis (ALS). To help confirm this disorder, the nurse prepares the client for various diagnostic tests. The nurse expects the physician to order: You Selected: electromyography (EMG). Correct response:  electromyography (EMG). Explanation: Remediation: Question 18 See full question A child with type 1 diabetes is admitted to the emergency department with hot and dry skin, rapid and deep respirations, and a fruity odor to her breath. Which task, when performed by a new-graduate registered nurse (RN), requires the RN preceptor to intervene? You Selected:  Verification of child’s glucose by finger stick. Correct response:  Providing encouragement to the child to drink some orange juice. Explanation: Remediation: Question 19 See full question A client has been hospitalized with pancreatitis for 3 days. The nurse assesses the client and documents the accompanying results. The nurse realizes these findings are a manifestation of what sign? You Selected:  Chvostek's sign Correct response:  Cullen's sign Explanation: Remediation: Question 20 See full questionA nurse is caring for a client who is exhibiting signs and symptoms characteristic of a myocardial infarction (MI). Which statement describes priorities the nurse should establish while performing the physical assessment? You Selected:  Correct response:  Assess the client's level of pain, and administer prescribed analgesics. Explanation: Remediation: Question 21 See full question A physician performs a bone marrow aspiration from the posterior iliac crest on a client with a platelet count of 80,000 mm3 . Which intervention should the nurse perform after the procedure? You Selected:  Correct response:  Place pressure over the aspiration site for 5–10 minutes Explanation: Remediation: Question 22 See full question A laboratory assistant who is trying to view the electronic record of a client's personal history gets an error message: "You are not authorized to view this information." What is the reason for this message? You Selected:  The laboratory assistant can retrieve medical records but cannot view the details. Correct response:  The laboratory assistant can retrieve medical records but cannot view the details.Explanation: Question 23 See full question A client is discharged after an aortic aneurysm repair with a synthetic graft to replace part of the aorta. The nurse should instruct the client to notify the health care provider (HCP) before having: You Selected:  major dental work. Correct response:  major dental work. Explanation: Remediation: Question 24 See full question The nurse is teaching a client with multiple sclerosis about prevention of urinary tract infection (UTI) and renal calculi. Which of the following nutrition recommendations by the nurse would be the most likely to reduce the risk of these conditions? You Selected:  Increase fluids (2500 mL/day) and maintain urine acidity by drinking cranberry juice. Correct response:  Increase fluids (2500 mL/day) and maintain urine acidity by drinking cranberry juice. Explanation: Remediation: Question 25 See full question A nurse caring for a client diagnosed with schizophrenia should perform which of the following interventions when the client becomes suspicious and refuses to take his medication? You Selected: Wait for a short time and then attempt to administer the medication Correct response:  Wait for a short time and then attempt to administer the medication Explanation: Remediation: Question 26 See full question A physician admits a client to the health care facility for treatment of an abdominal aortic aneurysm. When planning this client's care, which goal should the nurse keep in mind as she formulates interventions? You Selected:  Stabilizing heart rate and blood pressure and easing anxiety Correct response:  Stabilizing heart rate and blood pressure and easing anxiety Explanation: Remediation: Question 27 See full question A client with alcohol dependency is started on a regimen of disulfiram. Which statement should the nurse include when teaching the client about the intended effects of the drug? You Selected:  Disulfiram acts to deter alcohol consumption. Correct response:  Disulfiram acts to deter alcohol consumption. Explanation: Remediation: Question 28 See full questionWhich statement reflects appropriate documentation in the medical record of a hospitalized client? You Selected:  "Client's skin is moist and cool." Correct response:  "Client's skin is moist and cool." Explanation: Remediation: Question 29 See full question A nurse is caring for a client with a fresh postoperative wound following a femoral– popliteal revascularization procedure. The nurse fails to routinely assess the pedal pulses on the affected leg, and missed the warning sign that the blood vessel was becoming occluded. The nurse manager is made aware of the complication and the nurse’s failure to assess the client properly. What action should be taken by the nurse manager? You Selected:  Address the nurse’s omissions as negligent behavior. Correct response:  Address the nurse’s omissions as negligent behavior. Explanation: Remediation: Question 30 See full question A nurse suspects that a child, age 4, is being neglected physically. To best assess the child's nutritional status, the nurse should ask the parents which question? You Selected:  "What did your child eat for breakfast?" Correct response: "What did your child eat for breakfast?" Explanation: Remediation: Question 31 See full question An adolescent is diagnosed with iron deficiency anemia. After emphasizing the importance of consuming dietary iron, the nurse asks him to select iron-rich breakfast items from a sample menu. Which selection demonstrates knowledge of dietary iron sources? You Selected:  Ham and eggs Correct response:  Ham and eggs Explanation: Remediation: Question 32 See full question The health care provider (HCP) prescribes IV cefazolin 1 g for a client. In preparing to administer the cefazolin, the nurse notes that the client is allergic to penicillin. Based on this information, what is an appropriate action for the nurse to take? You Selected:  Notify the HCP of the client’s allergy to penicillin. Correct response:  Notify the HCP of the client’s allergy to penicillin. Explanation: Remediation: Question 33 See full question A primigravida, currently about 8 weeks pregnant, and her husband ask when they should begin the preparation for childbirth classes that discuss maternal nutrition during pregnancy. Which time would be most appropriate for the nurse to suggest that they begin the classes? You Selected:  as soon as the client experiences lightening Correct response:  now during the first trimester of pregnancy Explanation: Remediation: Question 34 See full question An elderly client asks the nurse how to treat chronic constipation. What is the best recommendation the nurse can make? You Selected:  Take a stool softener such as docusate sodium daily. Correct response:  Take a stool softener such as docusate sodium daily. Explanation: Remediation: Question 35 See full question The nurse is caring for a client with an order for an intravenous infusion of dextrose with 5% normal saline at 1500 mL over 8 hrs. The drip administration is set at 10 drops/mL. How fast will the IV infuse (drops/minute)? Record your answer using a whole number. Your Response:  31 Correct response:  31Explanation: Question 36 See full question A toddler has a temperature above 101° F (38.3° C). The physician orders acetaminophen, 120 mg suppository, to be administered rectally every 4 to 6 hours. The nurse should question an order to administer the medication rectally if the child has a diagnosis of: You Selected:  thrombocytopenia. Correct response:  thrombocytopenia. Explanation: Remediation: Question 37 See full question The nurse is evaluating a parent’s understanding of measuring one tablespoon of medication in a medicine cup. At which level on the medicine cup would the nurse confirm an appropriate dose? You Selected: Your selection and the correct area, market by the green box. Explanation: Question 38 See full questionA client at 36 weeks’ gestation with type 1 diabetes is scheduled for a contraction stress test. After explaining the purpose of the test, the nurse determines that the client understands the instruction when she states that the test is done to detect which problem? You Selected:  uteroplacental sufficiency Correct response:  uteroplacental sufficiency Explanation: Remediation: Question 39 See full question A new nurse has transferred to the chemical dependency rehabilitation unit. Which action if performed by the new nurse would warrant the change nurse to intervene? You Selected:  calling the Narcotics Anonymous group for the client Correct response:  calling the Narcotics Anonymous group for the client Explanation: Remediation: Question 40 See full question When developing a teaching plan for a client about the medications prescribed for depression, which component is most important for the nurse to include? Correct response:  management of common adverse effects Explanation: Remediation:Question 41 See full question A new nurse is asked to start an I.V. on an antepartum client. The new nurse has performed the procedure only once and isn't familiar with the I.V. pumps used in this facility. The new nurse should: You Selected:  review the unit's procedure manual. Correct response:  review the unit's procedure manual. Explanation: Remediation: Question 42 See full question A postpartum client has a nursing diagnosis of risk for impaired urinary elimination related to loss of bladder sensation after childbirth. Which of the following priorities outcome criteria should the client achieve? You Selected:  The client will drink 6 to 8 glasses of fluids in a 24-hour period of time. Correct response:  Client voids more than 30 mL/hour without urinary retention beginning 1 hour after birth. Explanation: Remediation: Question 43 See full question A scrub nurse in the operating room has which responsibility? You Selected:  Handing surgical instruments to the surgeon Correct response: Handing surgical instruments to the surgeon Explanation: Question 44 See full question A client with manic episodes is taking lithium. Which electrolyte level should the nurse check before administering this medication? Correct response:  Sodium Explanation: Remediation: Question 45 See full question The nurse is admitting a hospital client who does not speak English and who is accompanied by the client's school-aged child. The client appears to be in pain, but the nurse is unable to assess the character or history of the client's pain. How should the nurse best communicate with the client? You Selected:  Enlist the help of a hospital interpreter; ask the son to translate if none is readily available. Correct response:  Enlist the help of a hospital interpreter; ask the son to translate if none is readily available. Explanation: Remediation: Question 46 See full question The nurse should instruct the client to avoid which drug while taking metoclopramide hydrochloride? You Selected:  alcohol Correct response: alcohol Explanation: Remediation: Question 47 See full question The risk for injury during an attack of Ménière's disease is high. The nurse should instruct the client to take which immediate action when experiencing vertigo? You Selected:  "Assume a reclining or flat position." Correct response:  "Assume a reclining or flat position." Explanation: Remediation: Question 48 See full question A nurse is caring for a child with intussusception. What is an expected outcome for a goal to relieve acute pain from abdominal cramping? You Selected:  The child exhibits no manifestations of discomfort. Correct response:  The child exhibits no manifestations of discomfort. Explanation: Remediation: Question 49 See full question A client reports difficulty breathing and a sharp pain in the right side of his chest. The respiratory rate measures 40 breaths/minute. The nurse should assign highest priority to which care goal? You Selected:  Maintaining effective respirationsCorrect response:  Maintaining effective respirations Explanation: Remediation: Question 50 See full question A client with chronic sinusitis comes to the outpatient department complaining of headache, malaise, and a nonproductive cough. When examining the client's paranasal sinuses, the nurse detects tenderness. To evaluate this finding further, the nurse should transilluminate the: You Selected:  frontal and maxillary sinuses. Correct response:  frontal and maxillary sinuses. Explanation: Remediation: Question 51 See full question When teaching a client with newly diagnosed hypertension about the pathophysiology of this disease, the nurse states that arterial baroreceptors, which monitor arterial pressure, are located in the carotid sinus. Which other area should the nurse mention as a site of arterial baroreceptors? You Selected:  Aorta Correct response:  Aorta Explanation: Question 52 See full questionA pregnant client calls the nurse at 22 weeks gestation to report that she is experiencing some edema of her face and hands, with puffiness in her eyelids in the morning. What is the priority action by the nurse? You Selected:  Tell the client to monitor her symptoms for 24 hours. Correct response:  Refer the client to her physician. Explanation: Remediation: Question 53 See full question A client with acute asthma is prescribed short-term corticosteroid therapy. Which is the expected outcome for the use of steroids in clients with asthma? You Selected:  Have an anti-inflammatory effect. Correct response:  Have an anti-inflammatory effect. Explanation: Remediation: Question 54 See full question In the hospital setting, the daughter of a man who is dying tells the nurse, “It is hard to just sit with my father for hours and not say or do anything.” As the nurse responds to the daughter’s statement, what issue is most important for the nurse to focus on during their discussion? You Selected:  Correct response:  Know that being present with the person is important.Explanation: Remediation: Question 55 See full question A school nurse assesses that an 8-year-old child is preoccupied with sexual comments and activities. The nurse is concerned that the child may have been sexually abused at home. What is the nurse’s best response to this situation? You Selected:  Notify the local Child Protective Services. Correct response:  Notify the local Child Protective Services. Explanation: Remediation: Question 56 See full question The mother of a client who has a radium implant asks why so many nurses are involved in her daughter’s care. She states, “The doctor said I can be in the room for up to 2 hours each day, but the nurses say they are restricted to 30 minutes.” The nurse explains that this variation is based on the fact that nurses: You Selected:  work with radiation on an ongoing basis, while visitors have infrequent exposure to radiation. Correct response:  work with radiation on an ongoing basis, while visitors have infrequent exposure to radiation. Explanation: Remediation: Question 57 See full question A client admitted to the alcohol detoxification program asks the nurse if there's anything he can take to "stop me from wanting a drink so badly." The nurse should teach the client about:You Selected:  naltrexone. Correct response:  naltrexone. Explanation: Remediation: Question 58 See full question A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). The nurse informs the client that the physician will order diuretic therapy and restrict fluid and sodium intake to treat the disorder. If the client doesn't comply with the recommended treatment, which complication may arise? You Selected:  Cerebral edema Correct response:  Cerebral edema Explanation: Remediation: Question 59 See full question The nurse is performing an assessment in the nursery on an infant with a developmental hip dysplasia. Which of the following findings should the nurse anticipate? You Selected:  Femoral lengthening Correct response:  Ortolani’s sign Explanation:Remediation: Question 60 See full question A couple admitted to the labor and birth unit show the nurse their birth plan. The nurse inquires about their specific choices and wishes for the birth of their first baby. Which of the following best describes why the nurse is asking questions about the family’s birth plan? You Selected:  Recognizing the family as active participants in their care Correct response:  Recognizing the family as active participants in their care Explanation: Question 61 See full question A client is receiving streptomycin for the treatment of tuberculosis. The nurse should assess the client for eighth cranial nerve damage by observing the client for: Correct response:  Vertigo. Explanation: Remediation: Question 62 See full question A pregnant client’s labor is progressing, but her cervix is still only 5 cm dilated and 100% effaced. Although she appears relaxed, she is aware of labor contractions. At this time, which suggestion would be most helpful for the client’s partner? You Selected:  “Encourage her to rest between contractions." Correct response:  “Encourage her to rest between contractions." Explanation:Remediation: Question 63 See full question Which is the correct technique when the nurse is instilling eye drops for an adult who is alert? Select all that apply. You Selected:  Have the client tilt the head back and look up.  Hold the dropper over the eye, and instill the drops into the lower lid.  Blot excess drops from the client’s face. Correct response:  Hold the dropper over the eye, and instill the drops into the lower lid.  Have the client tilt the head back and look up.  Blot excess drops from the client’s face. Explanation: Remediation: Question 64 See full question A client’s partner uses the call bell to tell the nurse that the client’s membranes have ruptured and “something is hanging out on the bed!” The nurse visualizes an overt prolapsed umbilical cord. What is the priority nursing action? You Selected:  Place the mother in a knee-to-chest position. Correct response:  Place the mother in a knee-to-chest position. Explanation: Remediation: Question 65 See full questionImmediately after birth, a nurse assesses the neonate’s respiratory effort as slow. The neonate is actively moving but grimaces in response to stimulation. His fingers and toes are bluish, and his heart rate is 130 bpm. Which step should the nurse take next? You Selected:  Provide oxygen and stimulate the baby to cry Correct response:  Provide oxygen and stimulate the baby to cry Explanation: Remediation: Question 66 See full question Lorazepam is commonly given along with a neuroleptic agent. What is the purpose of administering the drugs together? You Selected:  To reduce anxiety and potentiate the neuroleptic's sedative action Correct response:  To reduce anxiety and potentiate the neuroleptic's sedative action Explanation: Remediation: Question 67 See full question A client develops a facial rash and urticaria after receiving penicillin. Which laboratory value does the nurse expect to be elevated? You Selected:  IgE Correct response:  IgEExplanation: Remediation: Question 68 See full question When making rounds on the pediatric neurology unit, the nurse manager notes that, when giving IV medications, many of the staff nurses are disconnecting the flush syringe first and then clamping the intermittent infusion device. The nurse manager is concerned that the nurses do not understand the benefits of positive pressure technique and turbulence flow flush in preventing clots. After discussing the problem with the staff educator, which intervention would be the mosteffective way to improve the nursing practice? You Selected:  Send a group email discussing the importance of clamping the device first. Correct response:  Create a poster presentation on the topic with a required posttest. Explanation: Question 69 See full question A 15-year-old unmarried primiparous client is being cared for in the hospital’s birthing center after vaginal birth of a viable neonate. The neonate is being placed for adoption through a social service agency. Four hours postpartum, the client asks if she can feed her baby. Which response would be most appropriate? You Selected:  “I will bring the baby to you for feeding.” Correct response:  “I will bring the baby to you for feeding.” Explanation: Remediation: Question 70 See full question A nurse is caring for a client receiving chemotherapy. Which nursing action is most appropriate for handling chemotherapeutic agents?You Selected:  Wear protective clothing. Correct response:  Wear protective clothing. Explanation: Remediation: Question 71 See full question The nurse is admitting a child who has been diagnosed with bacterial meningitis to the pediatric unit. The nurse should implement which type of isolation? You Selected:  droplet precautions Correct response:  droplet precautions Explanation: Remediation: Question 72 See full question A 39-year-old client tells the nurse that he wants to undergo gender reassignment surgery because he feels trapped in his male body. What is the priority intervention for this client? You Selected:  Participating in psychotherapy Correct response:  Participating in psychotherapy Explanation: Question 73 See full questionOn her third postpartum day, a client complains of chills and aches. Her chart shows that she has had a temperature of 100.6° F (38.1° C) for the past 2 days. The nurse assesses foul-smelling, yellow lochia. What should the nurse do next? You Selected:  Anticipate that the physician will order laboratory tests and cultures. Correct response:  Anticipate that the physician will order laboratory tests and cultures. Explanation: Remediation: Question 74 See full question After teaching a primiparous client about treatment and self-care of infectious mastitis of the right breast, the nurse determines that the client needs further instruction when she makes which statement? You Selected:  “I should begin breastfeeding on the right side to decrease the pain.” Correct response:  “I should begin breastfeeding on the right side to decrease the pain.” Explanation: Remediation: Question 75 See full question A client tells the nurse about having numbness from the back of the left buttock to the dorsum of the foot and big toe. The client is scheduled to undergo a laminectomy, and the operative consent form states “a left lumbar laminectomy of L3–L4.” What should the nurse do next? You Selected:  Call the surgeon. Correct response: Call the surgeon. Explanation: Remediation: Question 1 See full question A priority in the first 24 hours after a bilateral adrenalectomy is: You Selected:  preventing adrenal crisis. Correct response:  preventing adrenal crisis. Explanation: Remediation: Question 2 See full question The terms "judgment" and "insight" are sometimes used incorrectly. Insight is the ability to: You Selected:  understand the nature of one's problem or situation. Correct response:  understand the nature of one's problem or situation. Explanation: Question 3 See full question A client is recovering from an attack of gout. Client teaching should include the need to lose weight because: You Selected:  weight loss will reduce uric acid levels and reduce stress on joints. Correct response: weight loss will reduce uric acid levels and reduce stress on joints. Explanation: Remediation: Question 4 See full question An elderly client has been admitted to the medical-surgical unit from the postanesthesia care unit. While the nurse is off the floor, the client falls out of bed and fractures his right leg and right wrist. The nurse finding him states, "The side rails were down and the bed was in the high position." The client's family files legal charges against the nurse and the hospital. Which charge most accurately reflects the nurse's actions? You Selected:  Negligence Correct response:  Negligence Explanation: Remediation: Question 5 See full question When performing routine health evaluations in school-age children, which finding would alert the school nurse to pediculosis capitis (head lice)? You Selected:  frequent scalp scratching Correct response:  frequent scalp scratching Explanation: Remediation: Question 6 See full questionA child, age 15 months, is admitted to the health care facility. During the initial nursing assessment, which statement by the mother most strongly suggests that the child has a Wilms' tumor? You Selected: Correct response:  "My child's abdomen seems bigger, and his diapers are much tighter." Explanation: Remediation: Question 7 See full question A client is scheduled for a prostatectomy, and the anesthetist plans to use a spinal (subarachnoid) block during surgery. In the operating room, the nurse positions the client according to the anesthetist's instructions. Why does the client require special positioning for this type of anesthesia? Correct response:  To prevent cerebrospinal fluid (CSF) leakage Explanation: Remediation: Question 8 See full question The nurse should inform a young female client that the barrier method providing the best protection against sexually transmitted infections (STIs) is: You Selected:  Condoms. Correct response:  Condoms. Explanation: Question 9 See full questionA primigravid client asks the nurse if she can continue to have a glass of wine with dinner during her pregnancy. Which statement would be the nurse's best response? You Selected:  "You should abstain from drinking alcoholic beverages." Correct response:  "You should abstain from drinking alcoholic beverages." Explanation: Remediation: Question 10 See full question The nurse is reflecting on the evaluation step of the nursing process. Which documentation would indicate nursing actions were effective in reducing breathing problems for a client? Select all that apply. You Selected: Correct response:  Anxiety decreased, oxygen saturation levels at 94%, nonproductive cough, respirations at 22 breaths/min  Lung sounds clear bilaterally with non-labored respirations noted Explanation: Remediation: Question 11 See full question Which observation by the nurse indicates that the mother of a child receiving home IV nafcillin therapy requires further teaching? The mother: You Selected: Correct response:  flushes the venous access site with heparin 20 minutes after giving the antibiotic. Explanation:Remediation: Question 12 See full question A client with diabetes is taking insulin lispro injections. The nurse should advise the client to eat: You Selected:  within 10 to 15 minutes after the injection. Correct response:  within 10 to 15 minutes after the injection. Explanation: Remediation: Question 13 See full question The charge nurse in an acute care setting assigns a client who is on one-on-one suicide precautions to a psychiatric aide. This assignment is considered: You Selected:  reasonable nursing practice because one-on-one requires the total attention of a staff member. Correct response:  reasonable nursing practice because one-on-one requires the total attention of a staff member. Explanation: Question 14 See full question The nurse should suspect that the client taking disulfiram has ingested alcohol when the client exhibits which symptom? You Selected:  nausea and flushing of the face and neck Correct response: nausea and flushing of the face and neck Explanation: Remediation: Question 15 See full question After a total hip replacement, the client tells the nurse that the pain in the operative hip has increased. Assessing the hip and leg, the nurse notes that the leg is internally rotated and shorter than the other leg and that the client has difficulty moving the leg. Based on this information, the nurse determines that the client: You Selected:  has experienced a dislocation of the hip prosthesis. Correct response:  has experienced a dislocation of the hip prosthesis. Explanation: Remediation: Question 16 See full question A 10-year-old child presents to the emergency department with dehydration. A physician orders 1 L of normal saline solution be administered at a rate of 60 ml/hour. While preparing the infusion, a nurse notices that the I.V. pump's safety inspection sticker has expired. Which action sCorrect response:  Take the pump out of commission and locate a pump with a valid inspection sticker. Explanation: Remediation: Question 17 See full question A nurse implements a health care facility's disaster plan. Which action should she perform first? You Selected: Correct response:  Identify a command center at which activities are coordinated. Explanation: Question 18 See full question A client with early dementia exhibits disturbances in mental awareness and orientation to reality. The nurse should expect to assess a loss of ability in which other area? You Selected:  judgment Correct response:  judgment Explanation: Remediation: Question 19 See full question After a stroke, a client develops aphasia. The nurse expects to see which assessment finding? You Selected:  Inability to speak clearly Correct response:  Inability to speak clearly Explanation: Remediation: Question 20 See full question When preparing to administer a chemotherapeutic agent to a client, the nurse should: You Selected: use gloves and disposable long-sleeved gowns when handling agents. Correct response:  use gloves and disposable long-sleeved gowns when handling agents. Explanation: Remediation: Question 21 See full question A client returned to the recovery room after a dilatation and curettage has the postoperative medication prescriptions shown in the medical record. What should the nurse do next?  . Correct response:  Ask the client to rate the intensity of her pain on a scale of 1 to 10, and administer the analgesia according to the intensity of the pain. Explanation: Remediation: Question 22 See full question What should a male client older than age 50 do to help ensure early identification of prostate cancer? You Selected:  Have a digital rectal examination and prostate-specific antigen (PSA) test done yearly. Correct response:  Have a digital rectal examination and prostate-specific antigen (PSA) test done yearly. Explanation: Remediation: Question 23 See full questionThe nurse is caring for a group of clients on a pulmonary unit. The nurse can delegate which task to unlicensed assistive personnel (UAP)? You Selected:  Assisting a client with adjusting his or her nasal cannula Correct response:  Assisting a client with adjusting his or her nasal cannula Explanation: Question 24 See full question A nurse is explaining medication benefits and adverse effects to a client with a history of psychosis. The client's brother tells the nurse that she's wasting her time explaining things to the client. What information about informed consent should the nurse use to respond to the brother's negative statement? You Selected:  Informed consent is an important part of effective client care that helps accomplish treatment goals. Correct response:  Informed consent is an important part of effective client care that helps accomplish treatment goals. Explanation: Remediation: Question 25 See full question A client is scheduled for an intravenous pyelogram (IVP). In preparation for the procedure, what should the nurse ask the client? You Selected:  "Do you have any allergies?" Correct response:  "Do you have any allergies?"Explanation: Remediation: Question 26 See full question A registered nurse (RN) is working with the licensed practical nurse (LPN) to care for a group of clients in a nursing home. How should the RN expect the LPN to communicate changes in the clients' wound status? You Selected:  The RN communicates daily with the LPN about the condition of each resident. Correct response:  The RN communicates daily with the LPN about the condition of each resident. Explanation: Question 27 See full question A client is receiving chemotherapy to treat breast cancer. Which assessment finding indicates a chemotherapy-induced complication? You Selected:  Serum potassium level of [2.6 mEq/L (2.6 mmol/L)} Correct response:  Serum potassium level of [2.6 mEq/L (2.6 mmol/L)} Explanation: Remediation: Question 28 See full question A woman brings her 6-year-old daughter to the pediatrician's office for evaluation. The child recently started wetting the bed and running a low-grade fever. A urinalysis is positive for bacteria and protein. A urinary tract infection (UTI) is diagnosed, and the child is prescribed antibiotics. Which nursing interventions are appropriate? Select all that apply. You Selected: Assess the mother's understanding of UTI and its causes.  Instruct the mother to administer the antibiotic as prescribed, even if the symptoms diminish. Correct response:  Assess the mother's understanding of UTI and its causes.  Instruct the mother to administer the antibiotic as prescribed, even if the symptoms diminish. Explanation: Remediation: Question 29 See full question Before a transesophageal echocardiogram, a nurse gives a client an oral topical anesthetic spray. When the client returns from the procedure, the nurse observes that he has no active gag reflex. In response, the nurse should: You Selected:  withhold food and fluids. Correct response:  withhold food and fluids. Explanation: Remediation: Question 30 See full question A nurse is caring for a client with hyperemesis gravidarum who will need close monitoring at home. When should the nurse begin discharge planning? Correct response:  On admission to the facility Explanation: Remediation:Question 31 See full question A client, 11 weeks pregnant, is admitted to the facility with hyperemesis gravidarum. She tells the nurse she has never known anyone who had such severe morning sickness. The nurse understands that hyperemesis gravidarum results from: You Selected:  an unknown cause. Correct response:  an unknown cause. Explanation: Remediation: Question 32 See full question For the client who is receiving intravenous magnesium sulfate for severe preeclampsia, which assessment findings would alert the nurse to suspect hypermagnesemia? You Selected:  decreased deep tendon reflexes Correct response:  decreased deep tendon reflexes Explanation: Remediation: Question 33 See full question A client with end-stage pulmonary hypertension tells the physician he doesn't want any heroic measures should his heart stop, and he doesn't want to be placed on a ventilator. The physician enters a do-not-resuscitate order into the hospital's computer system. Which ethical principle is the nurse upholding by supporting the client's decision? You Selected: Autonomy Correct response:  Autonomy Explanation: Question 34 See full question The selection of a nursing care delivery system (NCDS) is critical to the success of client care in a nursing area. Which factor is essential to the evaluation of an NCDS? You Selected:  Identifying who will be responsible for making client care decisions Correct response:  Identifying who will be responsible for making client care decisions Explanation: Question 35 See full question A child, age 2, with a history of recurrent ear infections is brought to the clinic with a fever and irritability. To elicit the most pertinent information about the child's ear problems, the nurse should ask the parent: Correct response:  "Does your child tug at either ear?" Explanation: Remediation: Question 36 See full question A client is admitted to the psychiatric unit exhibiting extreme agitation, disorientation, and incoherence of speech with frantic and aimless physical activity and grandiose delusions. Which of the following would the highest priority goal in planning nursing interventions? You Selected:  The client will show no self-harm or harm to staff.Correct response:  The client will show no self-harm or harm to staff. Explanation: Remediation: Question 37 See full question An adult male client with lymphoma reports cough, difficulty swallowing, and shortness of breath. On physical exam his face and neck are swollen and his upper extremities are cyanotic. Which of the following is the nurse’s best course of action? You Selected:  Monitor the respiratory pattern of the client continually Correct response:  Monitor the respiratory pattern of the client continually Explanation: Remediation: Question 38 See full question A 70-year-old client asks the nurse if she needs to have a mammogram. Which is the nurse's bestresponse? You Selected:  Correct response:  "The incidence of breast cancer increases with age." Explanation: Remediation: Question 39 See full question The client with tuberculosis is to be discharged home with nursing follow-up. Which aspect of nursing care will have the highest priority? Correct response: teaching the client about the disease and its treatment Explanation: Remediation: Question 40 See full question Which indicator is the best for determining whether a client with Addison's disease is receiving the correct amount of glucocorticoid replacement? You Selected:  daily weight Correct response:  daily weight Explanation: Remediation: Question 41 See full question A nurse is preparing a client for bronchoscopy. Which of the following instructions is appropriate for the nurse to give to the client? You Selected:  "Don't eat for 6 hours prior to the procedure." Correct response:  "Don't eat for 6 hours prior to the procedure." Explanation: Remediation: Question 42 See full question A client is prescribed an intravenous solution of 1,000 ml to be infused from 0800 to 2000. The nurse will use an infusion pump that delivers the solution in milliliters per hour. At what rate would the nurse set the pump to deliver the solution? Record your answer using a whole number. (For example: 62) Your Response: 83 Correct response:  83 Explanation: Question 43 See full question The nurse administers a tap water enema to a client. While the solution is being infused, the client has abdominal cramping. What should the nurse do first? You Selected: Correct response:  Temporarily stop the infusion, and have the client take deep breaths. Explanation: Remediation: Question 44 See full question When developing a teaching plan for the parents of a 1 1/2-month-old infant about how to administer levothyroxine, what should the nurse suggest as most appropriate for dissolving and mixing the medication? You Selected:  small amount of formula or breast milk Correct response:  small amount of formula or breast milk Explanation: Remediation: Question 45 See full question A physician has ordered a heating pad for an elderly client's lower back pain. Which item would be most important for a nurse to assess before applying the heating pad? You Selected: Client's level of consciousness Correct response:  Client's level of consciousness Explanation: Remediation: Question 46 See full question The client with rapid-cycling bipolar disorder who is about to receive his 1700 hours dose of carbamazepine tells the nurse he has a sore throat and chills. What should the nurse do next? You Selected:  Call the health care provider (HCP) to report changes. Correct response:  Call the health care provider (HCP) to report changes. Explanation: Remediation: Question 47 See full question A graduate nurse is reviewing the procedure for removing a peripherally inserted central catheter (PICC) with her preceptor. Which planned action by the graduate nurse should the preceptor correct? You Selected:  Discarding the catheter in a trash container Correct response:  Discarding the catheter in a trash container Explanation: Remediation: Question 48 See full questionA 15-year-old client gives birth to a healthy neonate. The neonate's adolescent father arrives on the unit demanding to see his baby. Both sets of grandparents are also present and asking to see their grandchild. The newly hired nurse assigned to the nursery should take which action? You Selected:  Discuss the unit's policy with the charge nurse. Correct response:  Discuss the unit's policy with the charge nurse. Explanation: Remediation: Question 49 See full question A male neonate underwent circumcision. What nursing intervention is part of the initial care of a circumcised neonate? You Selected:  Apply petroleum gauze to the site for 24 hours. Correct response:  Apply petroleum gauze to the site for 24 hours. Explanation: Remediation: Question 50 See full question Bacterial conjunctivitis has affected several children at a local day care center. A nurse should advise which measure to minimize the risk of infection? You Selected:  Perform thorough hand washing before and after touching any child in the day care center. Correct response: Perform thorough hand washing before and after touching any child in the day care center. Explanation: Remediation: Question 51 See full question The nurse sees a client walking in the hallway who begins to have a seizure. What should the nurse do in order of priority from first to last? All options must be used. You Selected:  Ease the client to the floor.  Maintain a patent airway.  Obtain vital signs.  Record the seizure activity observed. Correct response:  Ease the client to the floor.  Maintain a patent airway.  Obtain vital signs.  Record the seizure activity observed. Explanation: Remediation: Question 52 See full question A nurse is teaching a client about tricyclic antidepressants. The nurse determines that teaching has been effective when the client states: You Selected:  “Improvement in my mood will take up to 28 days.” Correct response: “Improvement in my mood will take up to 28 days.” Explanation: Remediation: Question 53 See full question A mother is visiting her neonate in the neonatal intensive care unit. Her baby is fussy and the mother wants to know what to do. In order to quiet a sick neonate, what can the nurse teach the mother to do? Correct response:  Use constant, gentle touch. Explanation: Remediation: Question 54 See full question For a client with newly diagnosed cancer, the nurse formulates a nursing diagnosis of Anxiety related to the threat of death secondary to cancer diagnosis. Which expected outcome is appropriate for this client? You Selected:  "Client verbalizes feelings of anxiety." Correct response:  "Client verbalizes feelings of anxiety." Explanation: Remediation: Question 55 See full question The nurse is administering penicillian V potasium to a child with cellulitis. The child weighs 27.5 lb (12.5 kg). The order reads penicillian V potasium 40 mg/kg/day po divided every six hours. How many milligrams of antibiotics should this child receive with each dose? Record your answer using a whole number. Your Response:  125Correct response:  125 Explanation: Question 56 See full question The fire alarm sounds on the maternal-neonatal unit at 0200. How can a nurse best care for her clients during a fire alarm? You Selected:  Close all of the doors on the unit. Correct response:  Close all of the doors on the unit. Explanation: Remediation: Question 57 See full question A 10-year-old child hospitalized with acute poststreptococcal glomerulonephritis during the acute stage has elevated blood pressure and low urine output for 14 hours. The nurse should next: You Selected:  assess the child's neurologic status. Correct response:  assess the child's neurologic status. Explanation: Remediation: Question 58 See full question To prevent development of peripheral neuropathies associated with isoniazid administration, the nurse should teach the client to: Correct response: supplement the diet with pyridoxine (vitamin B6). Explanation: Remediation: Question 59 See full question The nurse is caring for a young child on the oncology unit who has developed thrombocytopenia after cancer treatment. What is the priority action for the nurse to implement when caring for this client? You Selected: Correct response:  Ensure a safe environment. Explanation: Remediation: Question 60 See full question During a preparation for parenting class, one of the participants asks the nurse, “How will I know if I am really in labor?” What should the nurse tell the participant about true labor contractions? You Selected:  "True labor contractions are felt first in the lower back, then the abdomen." Correct response:  "True labor contractions are felt first in the lower back, then the abdomen." Explanation: Remediation: Question 61 See full question A client with thrombocytopenia has developed a hemorrhage. The nurse should assess the client for which finding? You Selected:  tachycardiaCorrect response:  tachycardia Explanation: Remediation: Question 62 See full question An adult with appendicitis has severe abdominal pain. Which action will be the most effective to assist the client to manage pain prior to surgery? You Selected:  Place the client in semi-Fowler’s position with the knees to the chest. Correct response:  Place the client in semi-Fowler’s position with the knees to the chest. Explanation: Remediation: Question 63 See full question On a crisis shelter hotline, the nurse talks to two 11-year-old boys who think a friend sniffs glue. They say his breath sometimes smells like glue and he acts drunk. They say they are afraid to tell their parents about the friend. When formulating a reply, what is the most important factor for the nurse to consider? You Selected:  The boys probably fear punishment. Correct response:  The boys probably fear punishment. Explanation: Remediation: Question 64 See full question The parents of a child with rheumatic fever express concern that their other children will develop the disease. Which response from the nurse is best?Correct response:  "This disease is not contagious." Explanation: Remediation: Question 65 See full question The nurse enters the nondiabetic client’s room shortly after a group of health care providers has made rounds. The client asks, “Why did the doctor tell the others that I am not compliant with my diabetes regimen?” The nurse is aware that which ethical principle has been violated? You Selected:  confidentiality Correct response:  confidentiality Explanation: Question 66 See full question A parent calls the pediatric clinic to express concern over her child's eating habits. She says the child eats very little and consumes only a single type of food for weeks on end. The nurse knows that this behavior is characteristic of: You Selected:  toddlers. Correct response:  toddlers. Explanation: Remediation: Question 67 See full questionA client with diabetes mellitus has had declining renal function over the past several years. Which diet regimen should the nurse recommend to the client on days between dialysis? Correct response:  A low-protein diet with a prescribed amount of water Explanation: Remediation: Question 68 See full question Which has the highest priority in the care of a client with chronic renal failure? You Selected:  Maintain a low-sodium diet. Correct response:  Maintain a low-sodium diet. Explanation: Remediation: Question 69 See full question On a medical-surgical floor, a nurse is caring for a cluster of clients with diabetes mellitus. Which client should the nurse assess first? You Selected:  A 55-year-old complaining of chest pressure Correct response:  A 55-year-old complaining of chest pressure Explanation: Remediation: Question 70 See full question On the second day after surgery, the nurse assesses an elderly client and finds the following:• blood pressure, 148/92 mm Hg; heart rate, 98 bpm; respirations 32 breaths/min • O2 saturation of 88 on 4 L/min of oxygen administered by nasal cannula • breath sounds are coarse and wet bilaterally with a loose, productive cough • client voided 100 mL very dark, concentrated urine during the last 4 hours • bilateral pitting pedal edema Using the SBAR method to notify the health care provider (HCP) of current assessment findings, the nurse should recommend that the HCP write a prescription for a(n): You Selected:  Correct response:  diuretic medication. Explanation: Question 71 See full question What question would the nurse ask to assess coping abilities of a family dealing with a chronic illness? You Selected:  How is your condition affecting your family members and their usual roles? Correct response:  How is your condition affecting your family members and their usual roles? Explanation: Remediation: Question 72 See full question Two hours ago, a multigravid client was admitted in active labor with her cervix dilated at 5 cm and completely effaced and the fetus at 0 station. Currently, the client is experiencing nausea and vomiting, a slight chill with perspiration beads on her lip, and extreme irritability. The nurse should first: You Selected: assess the client's cervical dilation and station. Correct response:  assess the client's cervical dilation and station. Explanation: Remediation: Question 73 See full question A client on short-term mental health disability leave undergoes required psychiatric evaluation and counseling. He requests that his evaluation and counseling records be e-mailed to his Human Resources representative. How should the nurse respond? You Selected:  "It's best not to e-mail your personal records because doing so might jeopardize your right to privacy." Correct response:  "It's best not to e-mail your personal records because doing so might jeopardize your right to privacy." Explanation: Question 74 See full question When a client has a tearing of tissue with irregular wound edges, the nurse should document this as: You Selected:  laceration. Correct response:  laceration. Explanation: Remediation: Question 75 See full questionThe client with acute renal failure asks the nurse for a snack. Because the client's potassium level is elevated, which snack is most appropriate? You Selected:  yogurt Correct response:  a gelatin dessert Explanation: Question 1 See full question When assessing a neonate 1 hour after delivery, the nurse measures an axillary temperature of 95.6° F (35.3° C), an apical pulse of 110 beats/minute, and a respiratory rate of 64 breaths/minute. Which nursing diagnosis is the priority at this time? You Selected:  Hypothermia related to heat loss Correct response:  Hypothermia related to heat loss Explanation: Remediation: Question 2 See full question A hospitalized client with a fracture of the tibia and fibula of the left leg is reporting increased pain at the site. What signs must the nurse be alert to that would indicate compromised circulation to the leg? You Selected:  Increased swelling of the toes and decreased distal pulses Correct response:  Increased swelling of the toes and decreased distal pulses Explanation:Remediation: Question 3 See full question For almost an hour after birth, a neonate was awake, alert, and startled and cried easily. Respirations rose to 70 breaths/minute, and heart rate on two occasions was 160 beats/minute. After sleeping quietly for about 2 hours, the neonate then awoke with a start, cried, extended and flexed all four extremities, and then choked, gagged, and regurgitated some thick mucus. What should the nurse do next? You Selected:  Change the neonate's position and aspirate mucus as necessary. Correct response:  Change the neonate's position and aspirate mucus as necessary. Explanation: Remediation: Question 4 See full question A 57-year-old woman with breast cancer who does not speak English is admitted for a lumpectomy. Her daughter, who speaks English, accompanies her. In order to obtain admission information from the client, what should the nurse do? You Selected:  Obtain a trained medical interpreter. Correct response:  Obtain a trained medical interpreter. Explanation: Remediation: Question 5 See full question A nurse is assessing a 10-year-old girl. The girl's mother informs the nurse that she's concerned about her daughter's breasts. The nurse assesses the breasts and notes the areola and nipple protrude slightly. Which statement by the nurse is an appropriate response? You Selected: "The changes in your daughter's breasts are the first signs of puberty." Correct response:  "The changes in your daughter's breasts are the first signs of puberty." Explanation: Remediation: Question 6 See full question Which item in the care plan for a toddler with a seizure disorder should a nurse revise? You Selected:  Arm restraints while asleep Correct response:  Arm restraints while asleep Explanation: Remediation: Question 7 See full question A nurse is teaching a client with type 1 diabetes how to treat adverse reactions to insulin. To reverse hypoglycemia, the client ideally should ingest an oral carbohydrate. However, this treatment isn't always possible or safe. Therefore, the nurse should advise the client to keep which alternate treatment on hand? You Selected:  Glucagon Correct response:  Glucagon Explanation: Remediation: Question 8 See full questionWhich statement indicates that a client with diabetes mellitus understands proper foot care? You Selected:  "I'll wear cotton socks with well-fitting shoes." Correct response:  "I'll wear cotton socks with well-fitting shoes." Explanation: Remediation: Question 9 See full question After a plane crash, a client is brought to the emergency department with severe burns and respiratory difficulty. The nurse helps to secure a patent airway and attends to the client's immediate needs, then prepares to perform an initial neurologic assessment. The nurse should perform an: You Selected:  evaluation of the corneal reflex response. Correct response:  evaluation of the corneal reflex response. Explanation: Remediation: Question 10 See full question When assessing a client's I.V. insertion site, a nurse notes normal color and temperature at the site and no swelling. However, the I.V. solutions haven't infused at the ordered rate; the flow rate is slow even with the roller clamp wide open. When the nurse lowers the I.V. fluid bag, no blood returns to the tubing. What should the nurse do first? You Selected:  Check the tubing for kinks and reposition the client's wrist and elbow. Correct response: Check the tubing for kinks and reposition the client's wrist and elbow. Explanation: Remediation: Question 11 See full question A nurse is providing health teaching focusing on urinary tract infections to a group of adolescent girls. One of the girls tells the nurse that she has heard of a condition called honeymoon cystitis and wants to know what it is. Which statement by the nurse is the most appropriate response? You Selected:  “This condition results from irritation and inflammation from sexual activity.” Correct response:  “This condition results from irritation and inflammation from sexual activity.” Explanation: Remediation: Question 12 See full question A nurse is planning postoperative care for a client who has received a general anesthetic. During the immediate postoperative period, which nursing assessment should the nurse be most concerned about? Correct response:  Heart rate of 130 bpm, blood pressure of 98/56 mm Hg, and inspirations of 24 Explanation: Remediation: Question 13 See full question When bandaging a client's ankle, the nurse should use which technique? You Selected:  Figure-eightCorrect response:  Figure-eight Explanation: Remediation: Question 14 See full question During hospitalization, a client with bulimia stops purging but becomes fearful that she will gain weight. She tells the nurse, “I cannot gain weight. I am fat enough as it is. I will be really disgusting if I get fatter.” When responding to this client, which response by the nurse would be mosttherapeutic? You Selected:  Use nonjudgmental and realistic comments. Correct response:  Use nonjudgmental and realistic comments. Explanation: Remediation: Question 15 See full question A 16-year-o