NCLEX NGN Pre-Test
A nurse is assigned to care for a client with chronic renal failure who is
undergoing
hemodialysis through an internal AV fistula in the RA. Which intervention
shouldimplement
nurse the in caring for the client?
SATA
a. Assessing the radial pulse in the right
extremity
b. Using the LA ti take BP
readings
c. Drawing pre-dialysis blood specimens from
theAssessing
d. LA the area over the AV fistula for a bruit and three
each
e. shift a pressure dressing over the site after each dialysis
Placing
treatment
f. Administering IV fluids through the venous site of the AV fistula as
needed Correct
answers A, B, C,
D
A nurse is evaluating outcomes for a client with Guillain-Barre
syndrome.
outcome does Whichthe nurse recognize as optimal respiratory outcomes for
theNormal
a. client?deep tendon
reflexes
b. Improved skeletal muscle
tone
c. Absences of paresthesias in the lower
extremities
d. Clear sound in the lower lung fields
bilaterally
e. pO2 of 85 mmHg and pCO2 of 40 mmHg Correct
answers D, E
A nurse of the telemetry unit is caring for a client who has had a MI and is
now
to attached
a cardiac monitor. The nurse is monitoring the client's cardiac
rhythm andfibrillation.
ventricular nots Which nursing intervention should the nurse
take
a. first?the rapid response
Calling
team
b. Preparing the client for
cardioversion
c. Asking the client to bear down and
cough
d. Preparing to administer diltiazem Correct
answers
The patternA of ventricular fibrillation is identified and can be a result after a
patient
an MI. VF with
makes the patient feel faint, then loses consciousness and
becomes
pulseless and apneic (BP and heart sounds absent). Treatment is to
terminate
covert VF a
it into andrhythm via defibrillation-> call a rapid and initiate CPR.
Cardioversion
used is
for ventricular or supraventricular
tachydysrhythmias.
A nurse developing a plan of care for a client with a spinal cord
injury includes
measures to prevent autonomic dysreflexia (hyperreflexia). Which
intervention
nurse does the
incorporate into the plan to prevent this
complication?
a. Keeping the fan running in the client's
room
b. Keeping the linens wrinkle free under
theLimiting
c. client bladder catheterization to once every
12Avoiding
d. hours the administration of enemas and rectal suppositories Correct
answers
The mostBfrequent cause of autonomic dysreflexias are a distended
bladder and
impacted feces. Other causes include stimulation of the skin by tactile,
thermal,stimuli.
painful or The nurse renders care in such a way as to minimize
these risks.
,A nurse provides home care instructions to a client who has been fitted
with a halo
device to treat a cervical fracture. Which statement by the client indicates
the need for
further
teaching?
a. I need to get more fluids and fiber into
myI should
b. diet cut my food into small pieces
before
c. I needI eat
to put powder under the vest twice a day to prevent
sweating
d. I have to check the pin sites everyday and watch for signs of
infection Correct
answers
Cleanse the skin under the wool liner each day to prevent rashes
and soars.
A nurse is caring for a client with increased intracranial pressure. In
which position
should the nurse maintain the
client?
a. Supine with the head
extended
b. Side lying with the neck
flexed
c. Supine with the head turned to
the side midline and elevated 30-45 degrees Correct
d. Head
answers
Proper D
positioning promotes venous drainage from the cranium to
minimize ICP.
A client with a basilar skull fracture has clear fluid leaking from the ears.
The nurse
should take which action
first?
a. Asses the clear fluid for
protein
b. Check the clear fluid for
glucose
c. Place cotton calls or dry gauze loosely in
theUse
d. earsan otoscope to assess the tympanic membrane for rupture Correct
answers
CSF B
contains glucose not
protein.
A nurse is caring for a client who has just undergone cardioversion. Which
intervention
is the nurse's priority after this
procedure.
a. Administer
b. Monitoring the
oxygen
BP
c. Administering antidysrhythmic
medications
d. Monitoring the client's LOC Correct
answers
ABC's A
of nursing. All other choices are correct, but not
priority.
A client with diabetes mellitus who is scheduled to have blood drawn for
of the glycosylated hemoglobin (HbA1c) level asks the nurse why the test is
determination
necessary
if he is performing blood glucose monitoring at home. Which is the best
response
nurse to for the
provide?
a. Detect diabetic
complications
b. Assess long-term glycemic
control
c. Determine whether the client is at risk for
hypoglycemia
d Determine whether the prescribed insulin dosage is correct Correct
answers B
, A nurse caring for a client with acquired immunodeficiency syndrome is
monitoring
client the of complications. Which of the following would cause
for signs
the nurse
suspect to
infection with Pneumocystis jirovec?
SATA
a.
Diarrhea
b.
Tachypnea
c. Pedal
edema
d. Intermittent
fever
e. Dyspnea with
ambulating
f. Expectoration of frothy mucus Correct answers
B,opportunistic
A D, E respiratory infection associated with AIDs that causes,
dyspnea
nonproductive cough, intermittent fever, fatigue, anorexia,
tachypnea, wt. loss.
Zidovudine is prescribed for a client with AIDS. The nurse tells the
client that to
important it is
report back to the clinic as scheduled for which follow-up
diagnostic?
a. Blood glucose
checks
b. Blood pressure
checks
c. Complete blood counts
(CBC)
d. Electrocradiographic studies Correct
answers C is an antiviral medication that cause cause agranulocytosis
Zidovudine
and anemia.
After a non-immunocompromised client undergoes a Mantoux test for TB
infection,
area an
of induration 6 mm wide developed. The client asks the nurse what
this result
means. Which is the best
response?
a. We'll have to repeat the test because the result was
inconclusive
b. The swollen area is small, so that means your test result is
negative
c. You've been exposed to TB so you will need to have a
chest
d. Youx-ray
need to get started on medication right away because you have
TB Correct
answers
B
Indurations less than 10 mm (non-immunocompromised)
and 5 mm
(immunocompromised) is considered a negative result after 48-72 hrs.
Results greater
indicate exposure and possible TB infection. Morse testing (x-ray) will
be needed.
A clients arterial blood gases are analyzed; pH 1.49, paO2 97 mmHg, HCO3-
22 mEq/L.
Which acid base balance disturbance does the nurse identify from
these
a. results?
Metabolic
acidosis
b. Metabolic
c. Respiratory
alkalosis
acidosis
d. Respiratory alkalosis Correct
answers D paCo2 >45 mmHg and RAlkalosis is paCo2 <35 mmHg. MAcidosis
RAcidosis:
HCO3-
is less than 22 mEq/L and MAlkalosis is HCO3- greater than 26
mEq/L.
A client has recently been diagnosed with deep vein thrombosis of the right
leg.
of Which
the following interventions of the nurse immediately
implement?
a. Elevating the foot of the bed 6
inches
b. Placing ice packs on and under the
right
c. leg
Documenting the need for hourly calf
measurements
A nurse is assigned to care for a client with chronic renal failure who is
undergoing
hemodialysis through an internal AV fistula in the RA. Which intervention
shouldimplement
nurse the in caring for the client?
SATA
a. Assessing the radial pulse in the right
extremity
b. Using the LA ti take BP
readings
c. Drawing pre-dialysis blood specimens from
theAssessing
d. LA the area over the AV fistula for a bruit and three
each
e. shift a pressure dressing over the site after each dialysis
Placing
treatment
f. Administering IV fluids through the venous site of the AV fistula as
needed Correct
answers A, B, C,
D
A nurse is evaluating outcomes for a client with Guillain-Barre
syndrome.
outcome does Whichthe nurse recognize as optimal respiratory outcomes for
theNormal
a. client?deep tendon
reflexes
b. Improved skeletal muscle
tone
c. Absences of paresthesias in the lower
extremities
d. Clear sound in the lower lung fields
bilaterally
e. pO2 of 85 mmHg and pCO2 of 40 mmHg Correct
answers D, E
A nurse of the telemetry unit is caring for a client who has had a MI and is
now
to attached
a cardiac monitor. The nurse is monitoring the client's cardiac
rhythm andfibrillation.
ventricular nots Which nursing intervention should the nurse
take
a. first?the rapid response
Calling
team
b. Preparing the client for
cardioversion
c. Asking the client to bear down and
cough
d. Preparing to administer diltiazem Correct
answers
The patternA of ventricular fibrillation is identified and can be a result after a
patient
an MI. VF with
makes the patient feel faint, then loses consciousness and
becomes
pulseless and apneic (BP and heart sounds absent). Treatment is to
terminate
covert VF a
it into andrhythm via defibrillation-> call a rapid and initiate CPR.
Cardioversion
used is
for ventricular or supraventricular
tachydysrhythmias.
A nurse developing a plan of care for a client with a spinal cord
injury includes
measures to prevent autonomic dysreflexia (hyperreflexia). Which
intervention
nurse does the
incorporate into the plan to prevent this
complication?
a. Keeping the fan running in the client's
room
b. Keeping the linens wrinkle free under
theLimiting
c. client bladder catheterization to once every
12Avoiding
d. hours the administration of enemas and rectal suppositories Correct
answers
The mostBfrequent cause of autonomic dysreflexias are a distended
bladder and
impacted feces. Other causes include stimulation of the skin by tactile,
thermal,stimuli.
painful or The nurse renders care in such a way as to minimize
these risks.
,A nurse provides home care instructions to a client who has been fitted
with a halo
device to treat a cervical fracture. Which statement by the client indicates
the need for
further
teaching?
a. I need to get more fluids and fiber into
myI should
b. diet cut my food into small pieces
before
c. I needI eat
to put powder under the vest twice a day to prevent
sweating
d. I have to check the pin sites everyday and watch for signs of
infection Correct
answers
Cleanse the skin under the wool liner each day to prevent rashes
and soars.
A nurse is caring for a client with increased intracranial pressure. In
which position
should the nurse maintain the
client?
a. Supine with the head
extended
b. Side lying with the neck
flexed
c. Supine with the head turned to
the side midline and elevated 30-45 degrees Correct
d. Head
answers
Proper D
positioning promotes venous drainage from the cranium to
minimize ICP.
A client with a basilar skull fracture has clear fluid leaking from the ears.
The nurse
should take which action
first?
a. Asses the clear fluid for
protein
b. Check the clear fluid for
glucose
c. Place cotton calls or dry gauze loosely in
theUse
d. earsan otoscope to assess the tympanic membrane for rupture Correct
answers
CSF B
contains glucose not
protein.
A nurse is caring for a client who has just undergone cardioversion. Which
intervention
is the nurse's priority after this
procedure.
a. Administer
b. Monitoring the
oxygen
BP
c. Administering antidysrhythmic
medications
d. Monitoring the client's LOC Correct
answers
ABC's A
of nursing. All other choices are correct, but not
priority.
A client with diabetes mellitus who is scheduled to have blood drawn for
of the glycosylated hemoglobin (HbA1c) level asks the nurse why the test is
determination
necessary
if he is performing blood glucose monitoring at home. Which is the best
response
nurse to for the
provide?
a. Detect diabetic
complications
b. Assess long-term glycemic
control
c. Determine whether the client is at risk for
hypoglycemia
d Determine whether the prescribed insulin dosage is correct Correct
answers B
, A nurse caring for a client with acquired immunodeficiency syndrome is
monitoring
client the of complications. Which of the following would cause
for signs
the nurse
suspect to
infection with Pneumocystis jirovec?
SATA
a.
Diarrhea
b.
Tachypnea
c. Pedal
edema
d. Intermittent
fever
e. Dyspnea with
ambulating
f. Expectoration of frothy mucus Correct answers
B,opportunistic
A D, E respiratory infection associated with AIDs that causes,
dyspnea
nonproductive cough, intermittent fever, fatigue, anorexia,
tachypnea, wt. loss.
Zidovudine is prescribed for a client with AIDS. The nurse tells the
client that to
important it is
report back to the clinic as scheduled for which follow-up
diagnostic?
a. Blood glucose
checks
b. Blood pressure
checks
c. Complete blood counts
(CBC)
d. Electrocradiographic studies Correct
answers C is an antiviral medication that cause cause agranulocytosis
Zidovudine
and anemia.
After a non-immunocompromised client undergoes a Mantoux test for TB
infection,
area an
of induration 6 mm wide developed. The client asks the nurse what
this result
means. Which is the best
response?
a. We'll have to repeat the test because the result was
inconclusive
b. The swollen area is small, so that means your test result is
negative
c. You've been exposed to TB so you will need to have a
chest
d. Youx-ray
need to get started on medication right away because you have
TB Correct
answers
B
Indurations less than 10 mm (non-immunocompromised)
and 5 mm
(immunocompromised) is considered a negative result after 48-72 hrs.
Results greater
indicate exposure and possible TB infection. Morse testing (x-ray) will
be needed.
A clients arterial blood gases are analyzed; pH 1.49, paO2 97 mmHg, HCO3-
22 mEq/L.
Which acid base balance disturbance does the nurse identify from
these
a. results?
Metabolic
acidosis
b. Metabolic
c. Respiratory
alkalosis
acidosis
d. Respiratory alkalosis Correct
answers D paCo2 >45 mmHg and RAlkalosis is paCo2 <35 mmHg. MAcidosis
RAcidosis:
HCO3-
is less than 22 mEq/L and MAlkalosis is HCO3- greater than 26
mEq/L.
A client has recently been diagnosed with deep vein thrombosis of the right
leg.
of Which
the following interventions of the nurse immediately
implement?
a. Elevating the foot of the bed 6
inches
b. Placing ice packs on and under the
right
c. leg
Documenting the need for hourly calf
measurements
