NCLEX RN EXAM 155 Question & Answers Latest Update Graded A 2023

1. 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 2. 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 3. 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 4. 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 5. 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 6. Which complication of cardiac catheterization should the nurse monitor for in the initial 24 hours after the procedure? B.Thrombus formation 7. 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 8. 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 9. 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 10. 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 11. A client with left-sided weakness following a cerebral vascular accident (CVA) is learning to ambulate with a cane. The nurse should teach the client to (b) hold the cane on the right side and move the cane with the left leg 12. 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 13. 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 the level of consciousness 14. 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 D. Meconium ileus 15. 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 B. Send him to the emergency room for evaluation 16. Which of the following should the nurse implement to prepare a client for a KUB (Kidney, Ureter, Bladder) radiography test? D. No special orders are necessary for this examination 17. The nurse is providing information to a client with multiple sclerosis on performing exercises and physical activities. The nurse determines the client needs additional teaching if the client makes which statements? Select all that apply. B. “I should exercise to the point of exhaustion.” E. “I should exercise continuously without rest.” 18. During the evaluation of the quality of home care for a client with Alzheimer’s disease, the priority for the nurse is to reinforce which statement by a family member? C. “We have safety bars installed in the bathroom and have 24-hour alarms on the doors.” 19.A nurse is reviewing a patient’s medication during shift change. Which of the following medications would be contraindicated if the patient were pregnant? Select all that apply. A. Warfarin (Coumadin) 20. A nurse is reviewing a patient’s past medical history (PMH). The history indicates the patient has photosensitive reactions to medications. Which of the following drugs is associated with photosensitive reactions? Select all that apply. A. Ciprofloxacin (Cipro) B. Sulfonamide C. Norfloxacin (Noroxin) D. Sulfamethoxazole and Trimethoprim (Bactrim) E. Isotretinoin (Accutane) 21. A patient tells you that her urine is starting to look discolored. If you believe this change is due to medication, which of the following of the patient’s medication does not cause urine discoloration? D. Aspirin 22. Category: Pharmacological and Parenteral Therapies You are responsible for reviewing the nursing unit’s refrigerator. Which of the following drugs, if found inside the fridge, should be removed? A. Nadolol (Corgard) 23. A 34-year-old female has recently been diagnosed with an autoimmune disease. She has also recently discovered that she is pregnant. Which of the following is the only immunoglobulin that will provide protection to the fetus in the womb? D. IgG 24. A second-year nursing student has just suffered a needlestick while working with a patient that is positive for AIDS. Which of the following is the most significant action that the nursing student should take? B. Start prophylactic AZT treatment 25. 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 26. 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 27. 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 28. 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 29. 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 B.Send him to the emergency room for evaluation 30. Which of the following should the nurse implement to prepare a client for a KUB (Kidney, Ureter, Bladder) radiography test? D.No special orders are necessary for this examination 31. The nurse is giving discharge teaching to a client seven (7) days post myocardial infarction. He asks the nurse why he must wait six (6) weeks before having sexual intercourse. What is the best response by the nurse to this question? B.“When you can climb 2 flights of stairs without problems, it is generally safe.” 32. A post-operative client is admitted to the post-anesthesia recovery room. The anesthetist reports that malignant hyperthermia occurred during surgery. You recognize that this complication is related to: C) A genetic predisposition 33. A newly admitted client has a diagnosis of depression. She complains of "twitching muscles “and a "racing heart", and states she stopped taking Zoloft a few days ago because it was not helping her depression. Instead, she began to take her husband's Parnate. The nurse should immediately assess for: C) Mental status changes 34. You are caring for a client with a diagnosis of schizophrenia who has been treated with Quetiapine (Seroquel) for one month. Today the client is increasingly agitated and complains of muscle stiffness. Critical assessments to report are: A) Elevated temperature and sweating. 35. A 55 year-old woman is taking Prednisone and Aspirin as part of her treatment for rheumatoid arthritis. Which one of the following would be an appropriate intervention for the nurse? C) Test her stools for occult blood. 36. A nurse has been named in a lawsuit. The BEST evidence a nurse can use to protect herself in a court of law is B) Documentation of nursing actions on client record 37. The nurse is caring for a client with a new order for Bupropion (Wellbutrin) for treatment of depression. The physician's order reads "175 mg. BID x 4 days". What is the appropriate action? B) Question this medication dose. 38. A nurse is assessing a client who has a rash on his left lower thigh and left foot. Which questions should the nurse ask in order to gain further information about the client’s rash? Select all that apply. A. When did the rash start? D. Do you have allergies? E. Have you traveled outside the country? 39. A nurse is caring for a client who recently had a cystoscopy to remove the bladder. The client now has an ileal conduit. What assessment by the nurse would indicate the client is developing complications? Select all that apply. A. Sharp abdominal pain with rigidity B. Dusky appearance of the stoma 40. The nurse delegates an unlicensed assistive person (UAP) to assist a client with a clean urinary catheterization procedure. The client had formerly been able to do the procedure but because of arthritis, he has been unable to perform the catheterization. Although the UAP has done this procedure before, which of the following must the nurse emphasize to the UAP? 2.‐ Report immediately any unusual observations, such as bleeding. 41. Decreased excretion of bilirubin would probably be attributed to which of the following? 3.‐ An obstructed common bile duct 42. The doctor has ordered oral administration of lactulose (Chronulac) for a client with esophageal bleeding from esophageal varices. The nurse knows that the reason for administration of this drug is to: 4.‐ Promote excretion of ammonia. 43. When admitting a client with a diagnosis of cirrhosis, the nurse assesses the medications ordered. She should question the administration of which of the following? 4.‐ Acetaminophen (Tylenol) 44 A client with cirrhosis of the liver and esophageal varices suddenly begins vomiting copious amount of dark‐colored blood. The sign/symptom that is least expected would be which of the following: 2.‐ Pain. 45. A client on the unit with hepatitis B suddenly develops anorexia, vomiting, abdominal pain, progressive jaundice, lethargy, and disorientation. The nurse knows that these indicate which of the following? 2.‐ Fulminant hepatitis 46. A client had a ruptured abdominal aortic aneurysm that was repaired surgically. Her postoperative recovery progressed without complications, and she is ready for discharge. Client education in preparation for discharge began 7 days ago on her admission to the nursing unit. Evaluation of nursing care related to client education is based on evaluation of expected outcomes. Which statement made by the client would indicate that she is ready for discharge? C. "I am allowed to exercise by walking for short periods." 47. A 67-year-old man had a physical examination prior to beginning volunteer work at the hospital. A routine chest x- ray demonstrated left ventricular hypertrophy. His blood pressure was 180/110. He is 45 lb overweight. His diet is high in sodium and fat. He has a strong family history of hypertension. The client is placed on antihypertensive medication; a low-sodium, low-fat diet; and an exercise regimen. On his next visit, compliance would best be determined by: A. A blood pressure reading of 130/70 with a 5-lb weight loss 48. A 55-year-old woman entered the emergency room by ambulance. Her primary complaint is chest pain. She is receiving O2 via nasal cannula at 2 L/min for dyspnea. Which of the following findings in the client’s nursing assessment demand immediate nursing action? B. Restlessness and apprehensiveness 49. A 48-year-old client is in the surgical intensive care unit after having had three-vessel coronary artery bypass surgery yesterday. She is extubated, awake, alert and talking. She is receiving digitalis for atrial arrhythmias. This Nmorning serum electrolytes were drawn. Which abnormality would require immediate intervention by the nurse after contacting the physician? D. Serum potassium is low. The nurse should administer KCl as ordered. 50. A male client received a heart-lung transplant 1 month ago at a local transplant center. While visiting the nursing center to have his blood pressure taken, he complains of recent weakness and fatigue. He also tells the nurse that he is considering stopping his cyclosporine because it is expensive and is causing his face to become round. He fears he will catch viruses and be more susceptible to infections. The nurse responds to this last statement by explaining that cyclosporine: A. Is given to prevent rejection and makes him less susceptible to infection than other oral corticosteroids 51. A 68-year-old client developed acute respiratory distress syndrome while hospitalized for pneumonia. After a respiratory arrest, an endotracheal tube was inserted. Several days later, numerous attempts to wean him from mechanical ventilation were ineffective, and a tracheostomy was created. For the first 24 hours following tracheostomy, it is important to minimize bleeding around the insertion site. The nurse can accomplish this by: B. Avoiding manipulation of the tracheostomy including cuff deflation 52. A 43-year-old client is admitted to the hospital with a diagnosis of peripheral vascular disorder. She arrives in her room via stretcher and requires assistance to move to her bed. The nurse notes that her left leg is cold to touch. She complains of having recently experienced muscle spasms in that leg. To determine if these muscle spasms are indicative of intermittent claudication, the nurse would begin her assessment with the following question: D. "Do your muscle spasms occur following rest, walking, or exercising?" 53. A 42-year-old client presents with a diagnosis of paranoid schizophrenia. She has become increasingly restless and verbally argumentative, and her speech has become pressured. She is exhibiting signs of: B. Agitation 54. A 50-year-old depressed client has recently lost his job. He has been reluctant to leave his hospital room. Nursing care would include: C. Monitoring elimination patterns 55. A client was admitted to the hospital for a TURP. Within 48 hours of admission and 12 hours postoperatively, both the blood pressure and pulse increased. He became agitated, thought snakes were crawling on his arms and legs, and generally became unmanageable. He pulled out his IV and urinary catheter in attempt to rid himself of the snakes. He was sweating profusely. The admission nurse’s notes indicated that the client admitted to "having a few drinks now and then." He is probably experiencing which of the following? B. Delirium tremens 56. A depressed client is seen at the mental health center for follow-up after an attempted suicide 1 week ago. She has taken phenelzine sulfate (Nardil), a monoamine oxidase (MAO) inhibitor, for 7 straight days. She states that she is not feeling any better. The nurse explains that the drug must accumulate to an effective level before symptoms are totally relieved. Symptom relief is expected to occur within: B. 24 weeks 57. Because a client is taking an MAO inhibitor, it is necessary to discuss the need for adherence to a lowtyramine diet. Which of the following are foods that she should avoid? A. Pickled, aged, smoked, and fermented foods 58. In working with mental health clients who are prescribed medication that must be taken on a routine basis, it is important for education to begin when the drug therapy is initiated. One of the first steps in the teaching process is to: D. Explore the client’s perception regarding medication therapy 59. A 29-year-old client is diagnosed with borderline personality disorder. He has aroused the nurse’s anger by using a condescending tone of voice with other clients and staff persons. Which of the following statements from the nurse would be most appropriate in acknowledging feelings regarding the client’s behavior? A. "I feel angry when I hear that tone of voice." 60. A 14-year-old client has a history of lying, stealing, and destruction of property. Personal items of peers have been found missing. After group therapy, a peer approaches the nurse to report that he has seen the 14-year-old with some of the missing items. The best response of the nurse is to: B. Approach him when he is alone to inquire about his involvement in the incident 61. A 15-year-old client is admitted to the adolescent unit. The nurse recognizes that encouraging a client to speak openly depends on how clearly questions are phrased. Which of the following statements is most desirable in eliciting information from an adolescent client? D. "What is it like between you and your family?" 62. A 37-year-old client has been taking antipsychotic medication for the past 10 days. The nurse observes her walking with a shuffling gait and postural rigidity and notes a masklike expression on her face. Which side effect is this client exhibiting? B. Parkinsonism 63. Clients receiving antipsychotic drug therapy will often exhibit extrapyramidal side effects that are reversible with which of the following agents ordered by the physician? B. Anticholinergics 64. A client who was started on antipsychotic medication 2 weeks ago is preparing for discharge from the hospital. Compliance with the medication regimen is important despite the mild side effects encountered. In order to increase the likelihood of medication compliance, the nurse would: A. Discuss the disease process and the importance of the medication in prevention of symptoms. 65. A 25-year-old outpatient presents with a diagnosis of compulsive personality disorder. His coworkers become annoyed with his rigid, perfectionistic manner and preoccupation with trivial details and schedules. A nursing intervention appropriate for this client would include: D. Contracting with him for the amount of time he will spend on the compulsive behaviors 66. The nurse would formulate which of the following as an appropriate nursing diagnosis for a child receiving peritoneal dialysis? Select all that apply. 3.‐ Risk for infection related to invasive procedures and diminished immune functioning 5.‐ Ineffective health maintenance related to chronic condition 67. A child is admitted to the nursing unit with acute renal failure (ARF). When reviewing the nursing history, the nurse notes a history of all of the following diseases. The nurse concludes that which most likely precipitated the onset of ARF? 3.‐ Dehydration 68. A child has been admitted in renal failure. The nurse would expect to find which of the following laboratory values? Select all that apply. 3.‐ Oliguria 5.‐ Azotemi 69. The nurse admits children with the following diseases to the unit. The nurse determines that the children with which diseases are at risk for the development of acute renal failure (ARF)? (Select all that apply.) 3.‐ Nephrotic syndrome 5.‐ Urinary tract infection 70. 7 The Emergency Department nurse is educating a parent on safety measures for a child who has been treated for accidental ingestion of acetaminophen (Tylenol). The nurse concludes that the parent has understood the teaching instructions when the parent makes which statements? Select all that apply. 1.‐ “I will use warning stickers like Mr. Yuk on all medicine containers.” 2.‐ “I will buy products with childproof caps 4.‐ “I will put the Poison Control Center phone number by every phone in the house.” 71. Which of the following are finding common in neonates born with esophageal atresia? Select all that apply. B. Cyanosis C. Coughing E. Choking 72. The client with Crohn's disease has a nursing diagnosis of acute pain. Which of the following should the nurse expect to be part of the care plan? Select all that apply D. Corticosteroid therapy E. Antidiarrheal medications 73. A nurse is caring for a client with a stage 3 pressure ulcer on the back of the right thigh. Which of the following are characteristics of a stage 3 pressure? Select all that apply. C. Sinus tracts have developed D. There is full thickness skin loss 74. The medical surgical nurse is working with an unlicensed assistive personnel (UAP). The nurse has delegated the UAP to care for a client with human immunodeficiency virus (HIV). Which statement by the UAP indicates a correct understanding of the HIV transmission process? Select all that apply. C. “I will wash my hands after toileting the client.” E. “I will wear a mask, gown, and gloves if I will come in contact with splattering blood or body fluids.” 75. The nurse has identified what appears to be ventricular tachycardia on the cardiac monitor of a client being evaluated for possible myocardial infarction. The FIRST action the nurse would perform is to A) Begin cardiopulmonary resuscitation B) Prepare for immediate defibrillation C) Notify the "Code" team and physician 76. A client has had his entire stomach removed surgically. Which of the following assessment would the nurse anticipate finding? A) Complaints of fatigue 77. A client with acute asthma has been admitted to the hospital. The client's pulse oximeter reading is 89%. Which of the following nursing diagnoses would be MOST appropriate for this client based on this assessment data? D) Impaired gas exchange related to bronchoconstriction and mucosal edema 78. A 6 year-old female is diagnosed with recurrent urinary tract infections (UTI). Which one of the following instructions would be BEST for the nurse to tell the caregiver? C) Use plain water for the bath, shampooing hair last 79. A female client diagnosed with genital herpes simplex virus 2 complains of dysuria, dyspareunia and leukorrhea and lesions on the labia and perianal skin. A PRIMARY nursing action should be to A) Encourage 3-4 warm sitz baths per day 80. Which of the following medications reported by a client during a nursing history could be associated with the development of hypocalcemia? 1.‐ Phenytoin (Dilantin) 81. The family of a client with hypercalcemia states that the client is “not acting like himself.” The nurse focuses assessment on which of the following symptoms? 1.‐ Personality change 82. The nurse who is assessing the client for signs of hypocalcaemia would conclude that this electrolyte imbalance exists after noting which of the following? 2.‐ Positive Trousseau’s sign 83. The nurse would review a client’s electrolyte levels to detect a possible increase in magnesium if the client had which of the following conditions? 3.‐ Addison’s disease 84. The nurse concludes that a client does not have an increased magnesium level based on which of the following findings? 3.‐ Supraventricular tachycardia (SVT) 85. A client with renal failure is experiencing hypomagnesaemia. The nurse explains that which of 1.‐ Dialysis 86. The nurse reviews the laboratory test results for a client with pre‐eclampsia, expecting to find which of the following values? 4.‐ Magnesium 1.2 mEq/L 87. A client was admitted to the hospital with a weight gain of 30 pounds over the past month. Upon assessment, the client was noted to have a moon face and a “buffalo hump.” On admission, lab results indicated decreased serum potassium and magnesium, and elevated serum chloride and sodium levels. The nurse interprets that which of the following disorders is consistent with these manifestations? 2.‐ Cushing’s syndrome 88. A home health nurse is making a visit to an elderly client who has a history of heart failure (CHF). The client was prescribed diuretics twice a day and a low‐ sodium diet. The nurse should be most concerned about which of the following laboratory results? 2.‐ Cl‐ 90 mEq/L 89. Which of the following findings in a client’s history would alert the nurse to assess for signs and symptoms of hypophosphatemia? 1.‐ Withdrawal from alcohol 90. The nurse is caring for a client with emphysema. Which of the following nursing interventions are most appropriate? Select all that apply. B. Teach client pursed –lip breathing. C. Administer low flow oxygen. 91. The nurse caring for a newborn 30 minutes after birth would do which of the following when preparing to give a prescribed dose of ophthalmic erythromycin? 2.‐ Administer the dose into each lower conjunctival sac. 92. A female client comes for her 24‐week prenatal visit. The nurse midwife tells her, “Your blood tests reveal that you do not show immunity to the German measles.” Which notation will the nurse include in the plan of care for the client? “Client will need: 4.‐ "Rubella vaccine after delivery on the day of discharge.” 93. A client who is breastfeeding her newborn is to be discharged from the postpartum unit. She has been found to have no immunity to rubella, and has orders to receive rubella vaccine on the day of discharge. What is the most important instruction for the nurse to include in the discharge plan? 1.‐ Practice contraception and avoid conception for at least 2–3 months. 94. A primigravida with blood type A‐negative is at 28 weeks gestation. Today, her physician has ordered a RhoGAM injection. Which statement by the client demonstrates that more teaching is needed related to this therapy? 1.‐ “I’m getting this shot so that my baby won’t develop antibodies against my blood, right?” 95. The nurse explains to a new nurse orientee that phytonadione (AquMEPHYTON) needs to be administered to the neonate for which of the following reasons? 3.‐ The neonate lacks the intestinal flora for vitamin K production. 96. A pregnant client is receiving magnesium sulfate. The nurse evaluates which of the following as a sign of excessive blood levels of the drug? 2.‐ Disappearance of the knee‐jerk reflex 97. After receiving magnesium sulfate, a client develops signs of toxicity. The nurse should be prepared to administer which of the following? 4.‐ Calcium gluconate 98. While a client is receiving magnesium sulfate for severe pre‐eclampsia, the nurse would carry out which of the following appropriate nursing interventions? Select all that apply. 3.‐ Restrict visitors and keep the room darkened and quiet. 4.‐ Obtain calcium gluconate for use as an antagonist if necessary. 5.‐ Assess for patellar reflexes. 99. After consulting with the health care provider, the nurse explains to a woman who has just found out she is pregnant that which of the following common drugsmay be taken if needed during pregnancy? 1.‐ Cough and cold products 100. Which statement by the nurse to a group of pregnant women who plan to breastfeed best reflects the need for cautious medication use during lactation? 4.‐ "Most drugs that enter the mother's bloodstream can be readily transferred to the breast milk." 101. The neonatal nurse assigned to work with a newborn interprets that which infant‐related factor adversely affects the neonate with respect to pharmacokinetics? 3.‐ Immature kidney function 102. A 20-year-old male client is being treated for protein deficiency. If he likes all of the following foods, which one would the nurse recommend to increase in the diet? C. Chicken 103. The nurse is interviewing a client with a diagnosis of possible abdominal aortic aneurysm. Which of the following statements will be reflected in the client’s chief complaint? D. "I don’t remember anything in particular, I just haven’t felt well." 104. A client admitted with a diagnosis of possible myocardial infarction is admitted to the unit from the emergency room. The nurse’s first action when admitting the client will be to: B. Connect the client to the cardiac monitor 105. The nurse discovers that a 78-year-old client who received hydralazine (Apresoline) 20 mg 45 minutes ago has a blood pressure of 70/40 mm Hg. The client has been on this dose of the medication for 3 years. Which of the following data is most likely significant in relation to the cause of the low blood pressure? B. Twenty-four-hour intake 1000 mL/day for past 2 days 106. 2. A client confides in the RN that a friend has told her the medication she takes for depression, Wellbutrin, was taken off the market because it caused seizures. An appropriate response would be to tell the client C) There were problems, but the recommended dose is changed. 107. Which nursing interventions will assist in reducing pressure points that may lead to pressure ulcers?Check all that apply: Avoid use of donut type devices. When the client is side lying, use the 30 degree lateral inclined position. Avoid uninterrupted sitting in a chair or wheelchair. 108. The nurse is preparing discharge for a patient with GERD. What would be important for the nurse toinclude in this teaching plan? Select all that apply: Elevate the HOB. Decrease intake of caffeine. Discuss strategies for weight loss if overweight. Take ranitidine (Zantac) at hs. 109. The nurse is preparing a client for cardiac catheterization. Which nursing interventions are necessary inpreparing the client for this procedure. Select all that apply: Verify consent has been signed. Explain procedure to client. Obtain a 12 lead ECG Obtain history ofshellfish allergy. 110. The nurse has been assigned a group of cardiac clients. What would be the most important informationfor the nurse to check on the initial evaluation of each client? Select all that apply: Presence of cardiac pain. Presence of jugular vein distention. Heart sounds and apical rate. Presence of diaphoresis. 111. The nurse is teaching a client about home care and treatment of venous stasis ulcers in his leg. Whatshould be included in the nurse’s instructions? Select all that apply: Healing will be facilitated by wearing leg compression devices. When the client is in sitting position, he should keep his legs elevated. Avoid standing for long periods of time. 112. A nurse knows the clinical manifestations of a client with Addison’s disease include which of the following? Select all that apply: Nausea Hyperpigmentation Hypotension 113. A licensed practical nurse is attending an agency orientation meeting about the nursing model of practice implemented in the facility. The nurse is told that the nursing model is a team nursing approach.The nurse understands that which of the following is a characteristic of this type of nursing model of practice? Nursing staff are led by a nurse when providing care to a group of clients. 114. A male client is admitted to the psychiatric unit after experiencing severe depression. He states that he intends to kill himself, but he asks the nurse not to repeat his intentions to other staff members. Which response demonstrates understanding and appropriate action on the part of the nurse? D. "This is very serious. I do not want any harm to come to you. I will have to report this to the rest of the staff." 115. A 45-year-old male client experiences a sense of depression because he has not yet achieved his life’s goals. His career has not been satisfying. He is still looking for the right job. His wife spends too much money, and his children seem to ignore him while being very selfish. He is tired of all of their attitudes and is considering buying a red Corvette convertible. While obtaining these data concerning the client’s feelings about his life, the nurse is able to determine he is experiencing what psychological crisis according to Erikson’s stages? D. Generativity versus self-absorption 116. A female client is anticipating a visit with her parents over the Thanksgiving holidays. She has recently begun experiencing periods of extreme shortness of breath, which her physician has labeled as panic attacks. Which of the following statements by the nurse would enhance therapeutic communication? D. "Perhaps you and I can discover what produces your anxiety." 117. An alcoholic client who is completing the inpatient segment of a substance abuse program was placed on disulfiram (Antabuse) drug therapy. What should the nurse include in the discharge instructions? D. The effects of disulfiram can be triggered by alcohol 5 days to 2 weeks after the drug is discontinued. 118.An 82-year-old former restaurant owner walks to the nursing station and states, "I have to go. The restaurant opens at 11 am." Which response by the nurse is the most appropriate? C. "You once owned a restaurant. Tell me about it." 119.A 15-year-old female adolescent is frequently breaking the rules of the unit. She has left the unit and was found smoking in the bathroom and spending a large amount of time in the male ward. Which statement by the nurse would best explain to the teenager why she must follow the rules of the unit? A. "It is not easy, but the rules must be followed so that everyone can get a fair chance." 120. A 15-year-old child is admitted to the pediatric unit with a diagnosis of thalassemia. Which of the following would be included in educating the mother and child as part of discharge planning? C. Know the signs and symptoms of iron overload. 121.An 8-year-old boy has been diagnosed with hemophilia. Which of the following diagnostic blood studies is characteristically abnormal in this disorder? A. Partial thromboplastin time 122. A murmur has been discovered during the routine physical examination of a 1-year-old child. The parent is extremely concerned about this diagnosis. Which of the following explanations by the nurse indicates understanding of this dysfunction? B. Surgical closure by suture or patch is recommended before school age 123. The nurse is evaluating a client recently diagnosed with primary open angle glaucoma (POAG). What willan important nursing action be? Select all that apply: Review meds the client is currently on to determine whether any of them cause an increased intraocular pressure as aside effect. Have the client demonstrate the use of eye drops. Assessthe clientfor chronic diseasessuch as diabetes. 124. A nurse understands that a patient may experience pain during peritoneal dialysis because of which ofthe following? Select allthat apply: Too rapid installation Accumulation of dialysate solution under the diaphragm 125. The nurse is evaluating a client’s response to hemodialysis. Which lab results will indicate the dialysiswas effective? Select all that apply: Serumpotassiumlevel decreasesfrom5.4 to 4.6mEq/L Cr decreases from 1.6 to 0.8 mg/dLBUN decreasesfrom 110 to 90 mg/dL The nurse understands that the following clinical findings are indications for dialysis. Select all thatapply: Volume overload K 5.2 mEq/L Metabolic acidosis Cr 5.0 mg/Dl 126. The grandmother of a young adult male admitted to the psychiatric unit yesterday requests information about her grandson’s treatment plan. Before answering the family member’s question, what action should the nurse take? Ensure that the signed release of info includes thegrandmother 127. When providing health teaching to elderly clients, what action is most important for the nurse to implement? Use everyday language when explaining issue 128. A male client presents to the clinic stating that he has a high stress job and is having difficulty falling asleep at night. The client complains of a constant headache and is seeking medication to help him sleep. Which intervention should the nurse implement? Determine the client's sleep andactivity pattern 129. To assess the quality of an adult client’s pain. What approach should the nurse use? Ask the pt to describe pain 130. The nurse is planning a weight reduction teaching program to be implemented at a community health center. Which goal is best for clients who are approximately fifteen percent over their ideal wight and wish to participate in the weight loss program? Fat intake between 20 to 30 percent of total daily intake 131. The nurse prepares to irrigate the ear of an adult client. The client is positioned with the head tilted slightly toward the affected side and the emesis basin positioned under the ear. What actionshould the nurse take next? confirm the temperature of the irrigation solution 132. The home health nurse visits a client who has a serum sodium level of 123 mEq/L. To explore possible etiologies for this value, what questions should the nurse ask the client? How much waterand ice chips do you have each day? 133. The healthcare provider prescribes hydroxyzine (Vistaril) 35 mg IM for a client who is vomiting. The available drug is labeled, 50 mg/ml. How many ml should the nurse administer? 0.7ml 134. The nurse finds a confused female client wandering in the hallway during the night. What actionshould the nurse implement? (Select all that apply) Raise the side rails of bed Escort her back to room Secure bed alarm on mattress 135. A client in the outpatient clinic complains of experiencing hard, infrequent stools. Which instruction should the nurse provide this client? Drink 6-8 large glasses of water daily 136. The nurse reviews discharge instructions for a male client with obstructive sleep apnea syndrome (OSAS). The client tells the nurse that he likes to drink a glass of wine before going to bed. How should the nurse respond? Offer to contact healthcare provider about a prescription for a sleepingaid 137. A client with hepatitis A (HAV) is newly admitted to the unit. Which action would be the priority to include in the plan of care within the initial 24 hours for this client? Wear gown and gloves during client contact 138. The nurse is providing diet instruction to the parents of a child with cystic fibrosis. The nurse would emphasize that the diet should be: High protein, high calorie, unrestricted fat 139. A client with multiple sclerosis plans to begin an exercise program. In addition to discussing the benefits of regular exercise, the nurse should caution the client to avoid activities which: Lead to dehydration 140. A newborn has hyperbilirubinemia and is undergoing phototherapy with a blanket. Which safety measure is most important during this process? Provide water feedings at least every 2 hours 140. The nurse has admitted a 4 year-old with the diagnosis of possible rheumatic fever. Which statement by the parent would cause the nurse to suspect an association with this disease? Strep throat went through all the children at the day care last month 141. A client expresses anger when the call light is not answered within 5 minutes. The client demanded a blanket. The best response for the nurse to make is: "I see this is frustrating for you. I have a few minutes so let's talk." 142. Upon completing the admission documents, the nurse learns that the87 year-old client does not have an advance directive. What action should the nurse take? Give information about advance directives 143. A client with Guillain Barre is in a non-responsive state, yet vital signs are stable and breathing is independent. What should the nurse document to most accurately describe the client's condition? Glascow Coma Scale 8, respirations regular 144. A hospitalized female client with mania enters the unit community room and says to a client who is wearing a blue shirt, "Boys in blue are fun to do! Boys in blue are fun to do!" What is the appropriate response by the nurse? "Don’t say that. If you can’t control yourself, we’ll help you." 145. A nurse reviews the laboratory results of a hospitalized pregnant client with a diagnosis of sepsis who is at risk for disseminated intravascular coagulopathy (DIC). Which laboratory finding would indicate to the nurse that DIC has developed in the client? Positive result on d-dimer study 146. A nurse has given a client with viral hepatitis instructions about home care. Which of the following statements by the client indicates to the nurse that the client needs further teaching? “I need to eat three meals a day with foods high in protein, fat, and carbs’ 147. A client who is to have antineoplastic chemotherapy tells the nurses of a fear of being sick all the time and wishes to try acupuncture. Which of these beliefs stated by the client would be incorrect about acupuncture? The flow of life is believed to flow through major pathways or nerve clusters in your body. 148. A middle aged woman talks to the nurse in the health care provider’s office about uterine fibroids also called leiomyomas or myomas. What statement by the woman indicates more education is needed? Fibroids that cause no problems still need to be taken out 149. A client with heart failure has Lanoxin (digoxin) ordered. What would the nurse expect to find when evaluating for the therapeutic effectiveness of this drug? Improved respiratory status and increased urinary output 150. The nurse is caring for a client with hypothyroidism. Expected fi ndings for this disorder include: Select all that apply. (a) Constipation (b) Dry skin (c) Anorexia (e) Bradycardia