NCLEX-RN Exam Flash Cards
Which safety measures should be included in the plan of care for a client with an internal
radiation implant? Select all that apply. - ANS * Wear a lead shield when in the client's room.
* Wear a dosimeter badge when entering the client's room.
* Save bed linens and any dressings until the implant is removed.
An adolescent client with a surgically wired jaw has a prescription for a full liquid diet. The nurse
should implement which action to promote the client's compliance with this diet prescription? -
ANS Ask about food preferences and blend these foods into liquids.
The nurse determines that the client understands the elements of follow-up care after a bone
scan if the client states that he or she should perform which actions? Select all that apply. -
ANS *Resume the usual diet.
* Drink plenty of water for a day or 2 following the procedure.
The nurse prepares to bathe and change the bed linens of a client with localized herpes zoster.
The lesions are open and draining a scant amount of serous fluid. Which precaution should the
nurse ensure is followed by all healthcare workers? - ANS Contact
The nurse finds an infant unconscious and suspects a foreign-body airway obstruction (FBAO).
The nurse plans to relieve the obstruction by performing which action? - ANS Delivering 5 back
slaps and 5 chest thrusts.
The nurse is preparing to assist a client who is able to transfer with 2 assistants from the bed to
the chair. The nurse requests assistance from staff members, but no staff members are able to
help at this time. Which action by the nurse is most appropriate at this time? - ANS Use a
mechanical lift to transfer the client from the bed to the chair.
Which client is at greatest risk for fluid volume deficit? - ANS The client on diuretic therapy.
The nurse should take which action to accurately determine the length of a nasogastric tube for
insertion in an adult client? - ANS Place the tube at the tip of the nose and measure by
extending the tube to the earlobe and then down to the xiphoid process.
The nurse auscultates bowel sounds and suspects an intestinal obstruction in a client with a
bowel tumor if which is heard? - ANS High pitched sounds.
The nursing instructor is observing a nursing student transfer a client from the bed to the chair.
The instructor intervenes if the student is observed performing which action? - ANS Positioning
self as far away from the client as possible.
, The pulse point to use when assessing a pulse in an infant is located in which area? - ANS
Brachial
The nurse is caring for an 18-month-old child who has been diagnosed with scabies. The
primary health care provider has prescribed lindane to be applied to the skin to treat the
infection. The nurse should take which most appropriate action at this time? - ANS Contact the
primary health care provider for clarification.
Which communication strategies should the nurse use when working with a client who has
difficulty speaking as a result of weakness? Select all that apply. - ANS * Ask "yes" and "no"
questions when able.
* Have the client use a communication board.
* Repeat what the client said to verify the message.
* Use a pen and paper to communicate client needs.
The nurse is assigned to the following 4 clients for total care during the day shift. Breakfast trays
are arriving, and the common practice on the unit is to assist clients to the bedside chair to eat.
Which client will require the greatest assistance from the nurse? - ANS The client who
underwent right hip replacement.
The nurse is demonstrating adult cardiopulmonary resuscitation (CPR) chest compression
techniques to health care team members. Which action performed by a member on return
demonstration indicates the need for additional teaching in the performance of CPR? - ANS
Lets the fingers rest on the chest.
The nurse is performing catheter care for a client who has an indwelling urinary catheter. Which
action, if performed by the nurse, is indicative of unsafe practice? - ANS The nurse cleans from
the area of most contamination to the area of least contamination.
The prescription for a client reads "cleansing enemas until clear". The nurse has administered a
total of 3 enemas, and the output is liquid brown. The nurse notifies the primary health care
provider, understanding that continued administration can result in which outcome? - ANS
Electrolyte disturbances.
The nurse understands that which identifies a correct principle of surgical sepsis? - ANS A
sterile package that becomes wet is unsterile.
An older client has been lying in bed for 2 hours. The nurse who is repositioning this client
would be most concerned with examining which areas of the client's body? Select all that apply.
- ANS * Heels
* Sacrum
* Back of the head
* Greater trochanter
Which safety measures should be included in the plan of care for a client with an internal
radiation implant? Select all that apply. - ANS * Wear a lead shield when in the client's room.
* Wear a dosimeter badge when entering the client's room.
* Save bed linens and any dressings until the implant is removed.
An adolescent client with a surgically wired jaw has a prescription for a full liquid diet. The nurse
should implement which action to promote the client's compliance with this diet prescription? -
ANS Ask about food preferences and blend these foods into liquids.
The nurse determines that the client understands the elements of follow-up care after a bone
scan if the client states that he or she should perform which actions? Select all that apply. -
ANS *Resume the usual diet.
* Drink plenty of water for a day or 2 following the procedure.
The nurse prepares to bathe and change the bed linens of a client with localized herpes zoster.
The lesions are open and draining a scant amount of serous fluid. Which precaution should the
nurse ensure is followed by all healthcare workers? - ANS Contact
The nurse finds an infant unconscious and suspects a foreign-body airway obstruction (FBAO).
The nurse plans to relieve the obstruction by performing which action? - ANS Delivering 5 back
slaps and 5 chest thrusts.
The nurse is preparing to assist a client who is able to transfer with 2 assistants from the bed to
the chair. The nurse requests assistance from staff members, but no staff members are able to
help at this time. Which action by the nurse is most appropriate at this time? - ANS Use a
mechanical lift to transfer the client from the bed to the chair.
Which client is at greatest risk for fluid volume deficit? - ANS The client on diuretic therapy.
The nurse should take which action to accurately determine the length of a nasogastric tube for
insertion in an adult client? - ANS Place the tube at the tip of the nose and measure by
extending the tube to the earlobe and then down to the xiphoid process.
The nurse auscultates bowel sounds and suspects an intestinal obstruction in a client with a
bowel tumor if which is heard? - ANS High pitched sounds.
The nursing instructor is observing a nursing student transfer a client from the bed to the chair.
The instructor intervenes if the student is observed performing which action? - ANS Positioning
self as far away from the client as possible.
, The pulse point to use when assessing a pulse in an infant is located in which area? - ANS
Brachial
The nurse is caring for an 18-month-old child who has been diagnosed with scabies. The
primary health care provider has prescribed lindane to be applied to the skin to treat the
infection. The nurse should take which most appropriate action at this time? - ANS Contact the
primary health care provider for clarification.
Which communication strategies should the nurse use when working with a client who has
difficulty speaking as a result of weakness? Select all that apply. - ANS * Ask "yes" and "no"
questions when able.
* Have the client use a communication board.
* Repeat what the client said to verify the message.
* Use a pen and paper to communicate client needs.
The nurse is assigned to the following 4 clients for total care during the day shift. Breakfast trays
are arriving, and the common practice on the unit is to assist clients to the bedside chair to eat.
Which client will require the greatest assistance from the nurse? - ANS The client who
underwent right hip replacement.
The nurse is demonstrating adult cardiopulmonary resuscitation (CPR) chest compression
techniques to health care team members. Which action performed by a member on return
demonstration indicates the need for additional teaching in the performance of CPR? - ANS
Lets the fingers rest on the chest.
The nurse is performing catheter care for a client who has an indwelling urinary catheter. Which
action, if performed by the nurse, is indicative of unsafe practice? - ANS The nurse cleans from
the area of most contamination to the area of least contamination.
The prescription for a client reads "cleansing enemas until clear". The nurse has administered a
total of 3 enemas, and the output is liquid brown. The nurse notifies the primary health care
provider, understanding that continued administration can result in which outcome? - ANS
Electrolyte disturbances.
The nurse understands that which identifies a correct principle of surgical sepsis? - ANS A
sterile package that becomes wet is unsterile.
An older client has been lying in bed for 2 hours. The nurse who is repositioning this client
would be most concerned with examining which areas of the client's body? Select all that apply.
- ANS * Heels
* Sacrum
* Back of the head
* Greater trochanter
