NCLEX Review Study Guide
Comprehensive Exam With Verified
Answers.
A client with diabetes mellitus calls the clinic nurse and reports that she has been
vomiting during the night and now has diarrhea. Which question does the nurse make a
priority of asking the client? - ANS "Have you tested your blood glucose?"
A client with heart failure suddenly experiences profound dyspnea, pallor, audible
wheezing, and cyanosis, and the nurse suspects pulmonary edema. The nurse would
first: - ANS Raise the head of the client's bed
A client with cervical cancer who is undergoing chemotherapy with cisplatin (Platinol).
For which adverse effect of cisplatin will the nurse assess the client? - ANS Hearing
loss
Alendronate (Fosamax) is prescribed for a client with postmenopausal osteoporosis.
The nurse provides information on the medication to the client. When does the nurse tell
the client to take the alendronate? - ANS Every morning before breakfast, with a full
glass of water
A client with emphysema is receiving theophylline (Theo-24). While providing dietary
instructions, the nurse tells the client that it is acceptable to consume: - ANS Apple
juice
A nurse is reviewing the record of a client scheduled for electroconvulsive therapy
(ECT). Which of the following diagnoses, if noted on the client's record, would indicate a
need to contact the physician who is scheduled to perform the ECT? - ANS Recent
stroke
An emergency department nurse is assessing a client with acute closed-angle
glaucoma. Which of the following characteristics of the disorder does the nurse expect
the client to exhibit? Select all that apply. - ANS Nausea
Eye pain
Vomiting
Headache
The nurse administers intravenous morphine sulfate to a client in pulmonary edema. For
which intended effect of the medication does the nurse monitor the client? - ANS Relief
of anxiety
,An emergency department nurse is told that a client with carbon monoxide poisoning
resulting from a suicide attempt is being brought to the hospital by emergency medical
services. Which intervention will the nurse carry out as a priority upon arrival of the
client? - ANS Administering 100% oxygen
A client with agoraphobia will undergo systematic desensitization through graduated
exposure. In explaining the treatment to the client, the nurse tells the client that this
technique involves: - ANS Gradually introducing the client to a phobic object or
situation in a predetermined sequence of least to most frightening
A client with a medical history of diabetes mellitus is found to have sarcoidosis, and oral
prednisone is prescribed. The nurse provides instructions to the client about the
medication and tells the client to: - ANS Closely monitor the blood glucose level
Enalapril maleate (Vasotec) is prescribed for a hospitalized client. Which assessment
does the nurse perform as a priority before administering the medication? - ANS
Checking the client's blood pressure
A client who has undergone abdominal hysterectomy asks the nurse when she will be
able to resume sexual intercourse. The nurse tells the client that sexual intercourse may
be resumed: - ANS In about 6 weeks, when the vaginal vault is satisfactorily
healed
A nurse on the evening shift checks a physician's prescriptions and notes that the dose
of a prescribed medication is higher than the normal dose. The nurse calls the
physician's answering service and is told that the physician is off for the night and will be
available in the morning. The nurse should: - ANS Ask the answering service to
contact the on-call physician
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? - ANS "Don't say that. If you
can't control yourself, we'll help you."
A client with HIV infection who has been found to have histoplasmosis is being treated
with intravenous amphotericin B (Fungizone). Which parameter does the nurse check to
detect the most common adverse effect of this medication? - ANS Intake and output
A nurse is gathering subjective and objective data from a client with suspected
rheumatoid arthritis (RA). Which early manifestations of RA would the nurse expect to
note? Select all that apply. - ANS Fatigue
Low-grade fever
Phenelzine sulfate (Nardil) is prescribed for a client with depression. The nurse provides
information to the client about the adverse effects of the medication and tells the client
to contact the physician immediately if she experiences: - ANS Neck stiffness or
soreness
, A client is receiving an intravenous infusion of oxytocin (Pitocin) to stimulate labor. The
nurse monitoring the client notes uterine hypertonicity and immediately: - ANS Stops
the oxytocin infusion
A nurse is assessing a pregnant woman for the presence of edema. The nurse places a
thumb on the top of the client's foot, then exerts pressure and releases it and notes that
the thumb has left a persistent depression. On the basis of this finding, the nurse
concludes that: - ANS Pitting edema is present
A nurse is caring for a client with community-acquired pneumonia who is being treated
with levofloxacin (Levaquin). For which of the following findings, indicating an adverse
reaction to the medication, does the nurse monitor the client? - ANS Fever
A client receiving parenteral nutrition (PN) suddenly experiences chest pain and
dyspnea, and the nurse suspects an air embolism. The nurse immediately places the
client in a lateral Trendelenburg position, on the left side. What action does the nurse
take next? - ANS Clamping the intravenous catheter
A nurse is preparing a poster for a health fair booth promoting primary prevention of
skin cancer. Which of the following recommendations does the nurse include on the
poster? Select all that apply. - ANS Seek medical advice if you find a skin lesion.
A nurse is providing instructions to a client with glaucoma who will be using
acetazolamide (Diamox) daily. Which of the following findings, an adverse effect, does
the nurse instruct the client to report to the physician? - ANS Dark urine
A nurse is providing morning care to a client who has undergone surgery to repair a
fractured left hip. Which item is most important for the nurse to use in turning the client
from side to side to change the bed linens? - ANS Abduction device
A nurse administers nitroglycerin sublingually to a client with angina pectoris who
complains of chest pain. The medication is ineffective, so the nurse prepares to
administer a second dose. Before administering the nitroglycerin, which action does the
nurse make a priority? - ANS Checking the client's blood pressure
A nurse provides information to a client with coronary artery disease (CAD) about
smoking-cessation measures. Which statement by the client indicates a need for further
information? - ANS "I should drink a cup of coffee if I feel the urge to smoke."
A client with myasthenia gravis who has been taking pyridostigmine bromide (Mestinon)
for the treatment of the disorder comes to the emergency department complaining of
severe muscle weakness, and cholinergic crisis is diagnosed. Which medication does
the nurse prepare for immediate use in treating the crisis? - ANS Atropine sulfate
A rape victim being treated in the emergency department says to the nurse, "I'm really
worried that I've got HIV now." What is the appropriate response by the nurse? - ANS
"Let's talk about the information that you need to determine your risk of
contracting HIV."
Comprehensive Exam With Verified
Answers.
A client with diabetes mellitus calls the clinic nurse and reports that she has been
vomiting during the night and now has diarrhea. Which question does the nurse make a
priority of asking the client? - ANS "Have you tested your blood glucose?"
A client with heart failure suddenly experiences profound dyspnea, pallor, audible
wheezing, and cyanosis, and the nurse suspects pulmonary edema. The nurse would
first: - ANS Raise the head of the client's bed
A client with cervical cancer who is undergoing chemotherapy with cisplatin (Platinol).
For which adverse effect of cisplatin will the nurse assess the client? - ANS Hearing
loss
Alendronate (Fosamax) is prescribed for a client with postmenopausal osteoporosis.
The nurse provides information on the medication to the client. When does the nurse tell
the client to take the alendronate? - ANS Every morning before breakfast, with a full
glass of water
A client with emphysema is receiving theophylline (Theo-24). While providing dietary
instructions, the nurse tells the client that it is acceptable to consume: - ANS Apple
juice
A nurse is reviewing the record of a client scheduled for electroconvulsive therapy
(ECT). Which of the following diagnoses, if noted on the client's record, would indicate a
need to contact the physician who is scheduled to perform the ECT? - ANS Recent
stroke
An emergency department nurse is assessing a client with acute closed-angle
glaucoma. Which of the following characteristics of the disorder does the nurse expect
the client to exhibit? Select all that apply. - ANS Nausea
Eye pain
Vomiting
Headache
The nurse administers intravenous morphine sulfate to a client in pulmonary edema. For
which intended effect of the medication does the nurse monitor the client? - ANS Relief
of anxiety
,An emergency department nurse is told that a client with carbon monoxide poisoning
resulting from a suicide attempt is being brought to the hospital by emergency medical
services. Which intervention will the nurse carry out as a priority upon arrival of the
client? - ANS Administering 100% oxygen
A client with agoraphobia will undergo systematic desensitization through graduated
exposure. In explaining the treatment to the client, the nurse tells the client that this
technique involves: - ANS Gradually introducing the client to a phobic object or
situation in a predetermined sequence of least to most frightening
A client with a medical history of diabetes mellitus is found to have sarcoidosis, and oral
prednisone is prescribed. The nurse provides instructions to the client about the
medication and tells the client to: - ANS Closely monitor the blood glucose level
Enalapril maleate (Vasotec) is prescribed for a hospitalized client. Which assessment
does the nurse perform as a priority before administering the medication? - ANS
Checking the client's blood pressure
A client who has undergone abdominal hysterectomy asks the nurse when she will be
able to resume sexual intercourse. The nurse tells the client that sexual intercourse may
be resumed: - ANS In about 6 weeks, when the vaginal vault is satisfactorily
healed
A nurse on the evening shift checks a physician's prescriptions and notes that the dose
of a prescribed medication is higher than the normal dose. The nurse calls the
physician's answering service and is told that the physician is off for the night and will be
available in the morning. The nurse should: - ANS Ask the answering service to
contact the on-call physician
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? - ANS "Don't say that. If you
can't control yourself, we'll help you."
A client with HIV infection who has been found to have histoplasmosis is being treated
with intravenous amphotericin B (Fungizone). Which parameter does the nurse check to
detect the most common adverse effect of this medication? - ANS Intake and output
A nurse is gathering subjective and objective data from a client with suspected
rheumatoid arthritis (RA). Which early manifestations of RA would the nurse expect to
note? Select all that apply. - ANS Fatigue
Low-grade fever
Phenelzine sulfate (Nardil) is prescribed for a client with depression. The nurse provides
information to the client about the adverse effects of the medication and tells the client
to contact the physician immediately if she experiences: - ANS Neck stiffness or
soreness
, A client is receiving an intravenous infusion of oxytocin (Pitocin) to stimulate labor. The
nurse monitoring the client notes uterine hypertonicity and immediately: - ANS Stops
the oxytocin infusion
A nurse is assessing a pregnant woman for the presence of edema. The nurse places a
thumb on the top of the client's foot, then exerts pressure and releases it and notes that
the thumb has left a persistent depression. On the basis of this finding, the nurse
concludes that: - ANS Pitting edema is present
A nurse is caring for a client with community-acquired pneumonia who is being treated
with levofloxacin (Levaquin). For which of the following findings, indicating an adverse
reaction to the medication, does the nurse monitor the client? - ANS Fever
A client receiving parenteral nutrition (PN) suddenly experiences chest pain and
dyspnea, and the nurse suspects an air embolism. The nurse immediately places the
client in a lateral Trendelenburg position, on the left side. What action does the nurse
take next? - ANS Clamping the intravenous catheter
A nurse is preparing a poster for a health fair booth promoting primary prevention of
skin cancer. Which of the following recommendations does the nurse include on the
poster? Select all that apply. - ANS Seek medical advice if you find a skin lesion.
A nurse is providing instructions to a client with glaucoma who will be using
acetazolamide (Diamox) daily. Which of the following findings, an adverse effect, does
the nurse instruct the client to report to the physician? - ANS Dark urine
A nurse is providing morning care to a client who has undergone surgery to repair a
fractured left hip. Which item is most important for the nurse to use in turning the client
from side to side to change the bed linens? - ANS Abduction device
A nurse administers nitroglycerin sublingually to a client with angina pectoris who
complains of chest pain. The medication is ineffective, so the nurse prepares to
administer a second dose. Before administering the nitroglycerin, which action does the
nurse make a priority? - ANS Checking the client's blood pressure
A nurse provides information to a client with coronary artery disease (CAD) about
smoking-cessation measures. Which statement by the client indicates a need for further
information? - ANS "I should drink a cup of coffee if I feel the urge to smoke."
A client with myasthenia gravis who has been taking pyridostigmine bromide (Mestinon)
for the treatment of the disorder comes to the emergency department complaining of
severe muscle weakness, and cholinergic crisis is diagnosed. Which medication does
the nurse prepare for immediate use in treating the crisis? - ANS Atropine sulfate
A rape victim being treated in the emergency department says to the nurse, "I'm really
worried that I've got HIV now." What is the appropriate response by the nurse? - ANS
"Let's talk about the information that you need to determine your risk of
contracting HIV."
