uworld Nclex - pn test 1 Questions and Answers 2023

uworld Nclex - pn test 1 Questions and Answers 2023 The nurse on an inpatient mental health unit is caring for a client with paranoid delusions who is refusing to eat. The client states that all the food and drinks have been poisoned. Which intervention by the nurse is appropriate? provide the client food in unopened, individually packaged food After listening to the parents' reports and seeing the following pediatric clients, the nurse knows that which client demonstrates signs of abuse that may necessitate mandatory reporting? 5- year -old whose x-ray reveals 1 new and 2 healed humerus fractures after falling from a tree. The nurse is discussing the care needs of a client in the last stage of Huntington disease with the family. When the nurse mentions arranging for delivery of a prescribed hospital bed, the client's spouse becomes visibly upset and says, "No hospital bed. I'm just not ready for it yet." What is the best response by the nurse? what upsets you about having a hospital bed? The nurse administers ondansetron to a hospitalized client. Which statement would indicate to the nurse that the ondansetron was effective? The nausea is a lot better The nurse has just received report on 4 clients. Which client should the nurse see first? client receiving Iv normal saline at 250 ml / hr who is reporting puffy legs and a new cough An unaccompanied 16-year-old girl comes to the emergency department with severe abdominal pain and vomiting. The client has a temperature of 102.2 F (39 C) and a pulse of 120/min and is lethargic. The client's parents are out of town, and no guardians can be reached. How should this client's care be handled? Administer care until the parents or guardians can be reached. The nurse reinforces teaching to the parents of a 12-month-old who has begun weaning from breastfeeding. Which statement by the parents indicates that teaching has been effective? I can start substituting breastfeeding sessions with whole cow's milk. The nurse cares for a client with a terminal disease who has an advance directive supporting a do not resuscitate (DNR) code status. The client stops breathing and loses a pulse. The client's adult child states, "I changed my mind. Do whatever you can to save him!" Which intervention is most appropriate at this time? Explain the client's wishes to the client child. The nurse speaks with a client diagnosed with schizophrenia who begins to look away toward the door and grimace. Which statement by the nurse is most therapeutic at this time? what do you see at the door? The nurse reinforces teaching to a 15-year-old primigravid client at 16 weeks gestation during an initial prenatal visit. Which information would be a priority for the nurse to include? stress the importance of consistent prenatal care A female client is visiting the clinic for an annual well-woman examination. The client reports having had sex with women. Which question will help the nurse determine the client's risk for sexually transmitted infections? what barrier methods do you and your partner(s) use? While the nurse is transporting a client to a new unit, the client's chest tube drainage system falls off the bed and the tube becomes dislodged from the chest wall. What is the nurse's priority action? Firmly cover the insertion site with the palm of a clean, gloved hand The nurse cares for a client with a burn on the arm and finds that the area is red, moist, and covered in shiny, fluid-filled vesicles. Which burn stage does the nurse document? Second degree A nurse in the emergency department is caring for 4 clients. Which client should the nurse see first? Client with myasthenia gravis who has a fever and increasing difficulty swallowing The nurse is caring for a client who is being treated for depression and suicidal ideation. Which client statement best indicates that the client is not currently at risk for suicide? I plan to attend my granddaughter's graduation next month. The nurse is caring for a client taking escitalopram who reports no improvement of depressive feelings since starting the medication 2 months ago. What is the best response by the nurse? Let's talk more about how you have taking this medication The nurse removes personal protective equipment (PPE) after completing a wound dressing change for a client in airborne transmission-based precautions. Which PPE should the nurse remove first? Gloves The client admitted to the psychiatric unit with severe anxiety is pacing rapidly in the room, crying, and hyperventilating. The client yells, "I can't believe you took my belongings! Where are you keeping them? This is so frustrating!" What is the appropriate response by the nurse? Your belongings are locked in a safe place to ensure that they are protected while you are here. A client with a history of a seizure disorder has a seizure while sitting in a chair. Which nursing interventions are appropriate during the seizure activity? Select all that apply. Administer oxygen as needed if client becomes cyanotic Move the client from the chair to the floor to prevent a fall Record the duration of seizure activity for documentation A client with type 1 diabetes has prescriptions for NPH insulin and regular insulin. At 7:30 AM, the client's blood glucose level is 322 mg/dL. The nurse expects the client's breakfast to arrive before 8 AM. What action should the nurse take? Click on the exhibit button for additional information. Administer 37 units of insulin: 25 units of NPH insulin mixed with 12 units of regular insulin in the same syringe, drawing up the regular insulin first The new nurse is reinforcing teaching to a client scheduled for electroconvulsive therapy (ECT). What information given by the new nurse would cause the charge nurse to intervene? be sure to take your valproic acid prior to the procedure The nurse is participating in a community health presentation about prevention of tick bites and Lyme disease. Which instructions should the nurse include? Select all that apply. apply a tick repellent spray before outdoor activities avoid hiking through areas of tall grass and thick under brush report bull's- eye rash or flu-like symptoms to the healthcare provider Wear a long sleeve shirt tucked into pants and clothes till shoes while hiking The nurse is caring for a new mother whose infant has been diagnosed with Down syndrome. The client says to the nurse, "I'm so worried. My husband is so devastated that he won't even look at the baby." What is the best response by the nurse? how are you feeling about your baby The nurse is reinforcing self-care and medication teaching for a client diagnosed with vaginal candidiasis who has been prescribed miconazole vaginal cream. Which statement by the client indicates that further teaching is needed? I will refrain from having sex until my partner is also tested and treated for the infection. A 4-year-old boy is diagnosed with Duchenne muscular dystrophy. Which nursing teaching is most appropriate to reinforce for this child's parents? remove throw rugs from the home The nurse checks a client's blood pressure using an automatic, noninvasive machine. The nurse notes that the machine inflates for an unusually long amount of time, and the client reports intense pain in the arm with the cuff. The device suddenly stops inflation and displays an error message. Which action by the nurse is appropriate? send the machine for maintenance and repeat the measurement manually The charge nurse assists a student nurse preparing to apply knee-length compression stockings onto a client with chronic venous insufficiency. Which actions by the student nurse would cause the charge nurse to intervene? Select all that apply. instructs client that stockings will be worn only at night rolls down any excess length at the top of the stocking selects size larger to avoid friction against a leg laceration The nurse is reinforcing teaching to the caregiver of a client with a new prescription for risperidone. Which statement indicates that the caregiver needs further instruction? it is normal for the client to become shaky and restless when agitated The nurse is reviewing a client's preoperative questionnaire, which indicates a religious preference with spiritual needs concerning surgery scheduled later today. Which action is most appropriate at this time? follow up with the client regarding the nature of the spiritual needs or religious practices The new nurse, caring for a 3-month-old client who is sedated in the intensive care unit following surgery, needs to prevent skin breakdown. Which action performed by the new nurse would cause the charge nurse to intervene? placing a donut pillow under the head The nurse is preparing to administer Edison to a 4-year-old client weighing 43 lb. based on the prescription, what is the volume of the medication in milliliters that the child should receive with each dose? 9 An elderly client with diabetes comes to the clinic in winter reporting numbness of the feet. After removing the client's shoes and socks, the nurse notes that the feet are ice cold to the touch and appear waxy and pale. What is the appropriate nursing action? soak the client's lower legs in a warm water bath The home health nurse visits a client with inflammatory bowel disease who recently underwent a total colectomy with ileostomy creation. Which statement by the client indicates that the client understands ileostomy care? I cut the appliance opening slightly larger than my stoma The staff nurse is preparing a presentation about strategies to reduce horizontal violence. The nurse educator is reviewing the presentation beforehand. Which recommendation included in the presentation indicates a need for further teaching? working toward diversification of staff age and gender For which client is it most important for the nurse to reinforce teaching regarding ways to prevent the spread of the condition? client with tinea corporis The nurses on a medical-surgical unit maintain a shared social media page. Which social media posts written by nurses breach client confidentiality? Select all that apply. I'm going to private message everyone a cute story about our sweet client with dementia it breaks my heart that are paraplegic client was so neglected by her husband The client in room five is positive for influenza so please remember your flu vaccines Wash your hands well if you had room for this week! cultures are now positive for clostridium difficile The nurse assists with medication reconciliation for a client visiting the clinic for a follow-up appointment. Which medication reported by the client requires further investigation? Click the exhibit button for additional information. 200 mg of celecoxib PO once daily A client is in cardiac arrest, and resuscitation efforts are in progress when the client's spouse arrives. The client's spouse insists on coming into the room. How should the nurse respond? Allow the spouse into the room and provide a chair The clinic nurse instructs a female client on how to collect a clean-catch urine specimen for culture and sensitivity. Which of the following client statements indicate that teaching has been effective? Select all that apply. I will be very careful not to touch the inside or rim of the container I will begin to urinate before passing the container into the stream for collection I will cleanse the area with single use antiseptic wipes prior to urinating The nurse in a psychiatric unit is approached by an aggressive client who grabs the nurse's stethoscope and attempts to strangle the nurse with it. The nurse is able to escape the client's grasp unharmed. Which action should the nurse take first? Beginning scoring other clients out of the room A client comes to the emergency department after being bitten by a bat. The nurse observes 2 small, nondraining puncture wounds resembling pinpricks on the fingertip. Which action should the nurse implement first? scrub the wound with povidone iodine solution or soap and water The nurse on a medical-surgical unit prepares scheduled daily medications for a client and places them in a pill cup. After receiving the pill cup, the client states, "I take a whole tablet of metoprolol at home. Why did you cut this one in half?" What is the best response by the nurse? show me which pill you're talking about so I can verify the prescriptions again A 10-year-old client with autism spectrum disorder is hospitalized for a diagnostic workup. Which is the most appropriate nursing action? Give the client a schedule of daily activities The charge nurse is educating a new nurse on intramuscular injection technique for a 6-year-old with autism spectrum disorder. Which statement by the new nurse indicates that further teaching is required? I will hold the child's hand as a soothing measure The nurse is reinforcing client teaching about newly prescribed cyclosporine. Which client statement indicates a need for further teaching? I am going to a concert with my friends this weekend The nurse is caring for a client who reports severe abdominal pain and vaginal spotting. The client had a positive urine pregnancy test at home, and her last menstrual period was 8 weeks ago. Which client report to the nurse is most concerning? Right shoulder pain and dizziness A nurse is reinforcing teaching to a client newly prescribed verapamil for chronic migraine headaches. Which statement by the client indicates the need for further teaching? I will take this medication at the first sign of a migraine The nurse is reviewing the medical history of a client who has sustained a right tibia/fibula fracture from a fall. The nurse identifies which finding as most likely to hinder healing? peripheral arterial disease The student nurse assists in caring for a client who is scheduled for electroconvulsive therapy for the treatment of depression. Which statement by the student indicates a need for further teaching? Because this client has a mental illness, the agent with medical power of attorney should sign the informed consent document The nurse is reinforcing discharge teaching for a client who is hearing impaired. Which of the following actions should the nurse implement? Select all that apply. Encourage the client to repeat back teaching Ensure adequate lighting in the client's room Said directly in front of the client while speaking Use printed materials with pictures and illustrations A student nurse is accompanying the charge nurse when conducting daily rounds. Which personal protective measure by the charge nurse does the student nurse question? Wears two pairs of gloves when emptying the urinary catheter collection bag of a client with HIV The nurse helps a client with end-stage renal disease and a serum potassium level of 5.2 mEq/L to plan menu choices. Which items would be best to include in the meal plan? Grilled chicken sandwich on white bread, applesauce The nurse receives handoff of care report on four clients. Which client should the nurse see first? client who has a urinary tract infection, temperature of 102° F, and respiratory rate of 25 beats a minute The nurse is reinforcing education about lifestyle choices to help reduce symptoms for a client with gastroesophageal reflux disease. Which of the following statements by the client indicate a correct understanding? Select all that apply. I have switched from coffee to decaffeinated herbal tea in the morning I plan to join a smoking cessation program I brought myself up on a couple of pillows when I go to sleep I will switch to low-fat dairy product and avoid high-fat foods