NCLEX DEC FILE 2

NCLEX DEC FILE 2 1. Potential Which individual is at greatest risk for developing hypertension? A. 45-year-old African-American attorney 2. A 15-year-old female who ingested 15 tablets of maximum strength acetaminophen 45 minutes ago is rushed to the emergency department. Which of these orders should the nurse do first? A. Gastric lavage 3. Which complication of cardiac catheterization should the nurse monitor for in the initial 24 hours after the procedure? B. Thrombus formation 4. A client is admitted to the emergency room with renal calculi and is complaining of moderate to severe flank pain and nausea. The client’s temperature is 100.8 degrees Fahrenheit. The priority nursing goal for this client is: C.Manage pain 5. What would the nurse expect to see while assessing the growth of children during their school age years? D.Yearly weight gain of about 5.5 pounds per year 6. At a community health fair, the blood pressure of a 62-year-old client is 160/96 mmHg. The client states “My blood pressure is usually much lower.” The nurse should tell the client to: A. Go get a blood pressure check within the next 15 minutes 7. The hospital has sounded the call for a disaster drill on the evening shift. Which of these clients would the nurse put first on the list to be discharged in order to make a room available for a new admission? A. A middle-aged client with a history of being ventilator dependent for over Seven (7) years and admitted with bacterial pneumonia five days ago. 8. A 25-year-old male client has been newly diagnosed with hypothyroidism and will take levothyroxine (Synthroid) 50 mcg/day by mouth. As part of the teaching plan, the nurse emphasizes that this medication: A. Should be taken in the morning 9. A 3-year-old child was brought to the pediatric clinic after the sudden onset of findings that include irritability, thick muffled voice, croaking on inspiration, hot to touch, sit leaning forward, tongue protruding, drooling and suprasternal retractions. What should the nurse do first? D.Notify the healthcare provider of the child’s status 10. In children suspected to have a diagnosis of diabetes, which one of the following complaints would be most likely to prompt parents to take their school-age child for evaluation? C.Bedwetting 11. A client comes to the clinic for treatment of recurrent pelvic inflammatory disease. The nurse recognizes that this condition most frequently follows which type of infection? B.Chlamydia 12. A registered nurse who usually works in a spinal rehabilitation unit is floated to the emergency department. Which of these clients should the charge nurse assign to this RN? C.An adolescent who has been on pain medications terminal cancer with an initial assessment finding pupils and a relaxed respiratory rate of 11, 13. When teaching a client with coronary artery disease about nutrition, the nurse should emphasize: C.Avoiding very heavy meals 14. Which of these findings indicate that a pump to deliver a basal rate of 10 ml per hour plus PRN for pain breakthrough for morphine drip is not working? C.The level of drug is 100 ml at 8 AM and is 80 ml at noon 15. The nurse is speaking at a community meeting about personal responsibility for health promotion. A participant asks about chiropractic treatment for illnesses. What should be the focus of the nurse’s response? B.Spinal column manipulation 16. The nurse is performing a neurological assessment on a client post right cerebrovascular accident. Which finding, if observed by the nurse, would warrant immediate attention ? A. Decrease in level of consciousness 17. A child who has recently been diagnosed with cystic fibrosis is in a pediatric clinic where a nurse is performing an assessment. Which later finding of this disease would the nurse not expect to see at this time? C.Moist, productive cough 18. The home health nurse visits a male client to provide wound care and finds the client lethargic and confused. His wife states he fell down the stairs two (2) hours ago. The nurse should