• NEW NCLEX PN

• NEW NCLEX PN • SEPTEMBER FILE QUESTIONS AND ANSWERS 1. While assessing a one-month-old infant, which of the findings warrants further investigation by the nurse? Select all that apply. A. Abdominal respirations B.Irregular breathing rate C.Inspiratory grunt D.Increased heart rate with crying E.Nasal flaring F. Cyanosis G.Asymmetric chest movement 2. A triage nurse has these four (4) clients arrive in the emergency department within 15 minutes. Which client should the triage nurse send back to be seen first? B.A teenager who got a singed beard while camping 3. While planning care for a toddler, the nurse teaches the parents about the expected developmental changes for this age. Which statement by the mother shows that she understands the child’s developmental needs? C.“I understand the need to use those new skills.” 4. The nurse is preparing to administer an enteral feeding to a client via a nasogastric feeding tube. The most important action of the nurse is: A. Verify correct placement of the tube 5. The nurse is caring for a client with a serum potassium level of 3.5 mEq/L. The client is placed on a cardiac monitor and receives 40 mEq potassium chloride in 1000 ml of 5% dextrose in water IV. Which of the following EKG patterns indicates to the nurse that the infusions should be discontinued? C.Tall peaked “T” waves 6.A nurse prepares to care for a 4-year-old newly admitted for rhabdomyosarcoma. The nurse should alert the staff to pay more attention to the function of which area of the body? A. All striated muscles 7. The nurse anticipates that for a family who practices Chinese medicine the priority goal would be to: A. Achieve harmony D.Restore yin and yang 8. During an assessment of a client with cardiomyopathy, the nurse finds that the systolic blood pressure has decreased from 145 to 110 mm Hg and the heart rate has risen from 72 to 96 beats per minute and the client complains of periodic dizzy spells. The nurse instructs the client to: C.Force fluids and reassess blood pressure 9. The nurse prepares the client for insertion of a pulmonary artery catheter (Swan-Ganz catheter). The nurse teaches the client that the catheter will be inserted to provide information about: D.Left ventricular functioning 10.A nurse enters a client’s room to discover that the client has no pulse or respirations. After calling for help, the first action the nurse should take is: B.Initiate high-quality chest compressions 11.A client is receiving digoxin (Lanoxin) 0.25 mg daily. The health care provider has written a new order to give metoprolol (Lopressor) 25 mg B.I.D. In assessing the client prior to administering the medications, which of the following should the nurse report immediately to the health care provider? A. Blood pressure 94/60 mm Hg 12. A nurse is reviewing a patient’s chart and notices that the patient suffers from Lyme disease. Which of the following microorganisms is related to this condition? A.Borrelia burgdorferi 13. A fragile 87-year-old female has recently been admitted to the hospital with increased confusion and falls over the last two (2) weeks. She is also noted to have a mild left hemiparesis. Which of the following tests is most likely to be performed? D. CT scan 14. An 85-year-old male has been losing mobility and gaining weight over the last two (2) months. The patient also has the heater running in his house 24 hours a day, even on warm days. Which of the following tests is most likely to be performed? C.Thyroid function tests 15. A 20-year-old female attending college is found unconscious in her dorm room. She has a fever and a noticeable rash. She has just been admitted to the hospital. Which of the following tests is most likely to be performed first? C.Blood cultures 16. 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 17. 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 18. 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 (7) years and admitted with bacterial pneumonia five days ago. 19. 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 20. 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 21. 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 22. 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 23. A registered nurse who usually works in a spinal rehabilitation unit is floated to the emergency department. Which of these clients should the charge nurse assign to this RN? C.An adolescent who has been on pain medications terminal cancer with an initial assessment finding pupils and a relaxed respiratory rate of 11, 24. When teaching a client with coronary artery disease about nutrition, the nurse should emphasize: C.Avoiding very heavy meals 25. To assist an adult client to sleep better the nurse recommends which of the following? (Select all that apply.) 1. Drinking a glass of wine just before retiring to bed 2. Eating a large meal 1 hour before bedtime 3. Consuming a small glass of warm milk at bedtime 26. The nurse recognizes that a client is experiencing insomnia when the client reports (select all that apply): 1. Extended time to fall asleep 3. Difficulty staying asleep 4. Feeling tired after a night’s sleep . 27. The nurse teaches the mother of a newborn that in order to prevent sudden infant death syndrome (SIDS) the best position to place the baby after nursing is (select all that apply): 2. Side-lying 3. Supine 28. A client has a diagnosis of primary insomnia. Before assessing this client, the nurse recalls the numerous causes of this disorder. Select all that apply: 1. Chronic stress 4. Excessive caffeine 6. Environmental noise 29. Select all that apply to the use of barbiturates in treating insomnia: 2. Barbiturates deprive people of REM sleep 4. When the barbiturates are discontinued, the REM sleep increases. 5. Nightmares are often an adverse effect when discontinuing barbiturates. 30. Select all that apply that is appropriate when there is a benzodiazepine overdose: 2. Gastric lavage 3. Activated charcoal and a saline cathartic 5. Administration of Flumazenil 31. A 6-year-old child with leukemia is hospitalized and is receiving combination chemotherapy. Laboratory results indicate that the child is neutropenic, and the nurse prepares to implement protective isolation procedures. Which interventions would the nurse initiate? Select all that apply. 2. Place the child on a low-bacteria diet. 3. Change dressings using sterile technique. 5. Perform meticulous hand washing before caring for the child. 32. A 16-year-old child is brought to the emergency department by his mother with a complaint that the child just experienced a tonic-clonic seizure. On arrival in the emergency department no apparent seizures were occurring. The mother states that her son is taking medication for the seizure disorder. The nurse plans care, knowing that which of the following medications are used for long-term control of tonic-clonic seizures? Select all that apply. 3. Gabapentin (Neurontin) 4. Ethosuximide (Zarontin) 5. Carbamazepine (Tegretol) 33. A child has been diagnosed with meningococcal meningitis. Which of the following isolation techniques is appropriate? 4. Isolation precautions for at least 24 hours after the initiation of antibiotics 34. A client enters the emergency department confused, twitching, and having seizures. His family states he recently was placed on corticosteroids for arthritis and was feeling better and exercising daily. On data collection, he has flushed skin, dry mucous membranes, an elevated temperature, and poor skin turgor. His serum sodium level is 172 mEq/L. Choose the interventions that the health care provider would likely prescribe. Select all that apply. 1. Monitor intake and output. 2. Monitor vital signs. 3. Maintain sodium-reduced diet. 4. Monitor electrolyte levels. 5. Increase water intake orally. 35. A client has died, and a nurse asks a family member about the funeral arrangements. The family member refuses to discuss the issue. The nurse’s appropriate action is to: 4. Remain with the family member without discussing funeral arrangements. 36. A client is scheduled for a myelogram, and the nurse provides a list of instructions to the client regarding preparation for the procedure. Which instructions should the nurse place on the list? Select all that apply. 1. Jewelry will need to be removed. 2. An informed consent will need to be signed. 4. The procedure will take approximately 45 minutes. 37. A client with a closed head injury is receiving phenytoin (Dilantin), an anticonvulsant medication. Which of the following would indicate that the client is experiencing side effects related to this medication? Select all that apply. 3. Constipation 4. Bleeding gums 5. Hyperglycemia 38. A client with carcinoma of the lung develops the syndrome of inappropriate antidiuretic hormone (SIADH) as a complication of the cancer. The nurse anticipates that which of the following may be prescribed? Select all that apply. 1. Radiation 2. Chemotherapy 3. Increased fluid intake 4. Serum sodium blood levels 6. Medication that is antagonistic to antidiuretic hormone (ADH) 39. A client with carcinoma of the lung develops the syndrome of inappropriate antidiuretic hormone (SIADH) as a complication of the cancer. The nurse anticipates that which of the following may be prescribed? Select all that apply. 1. Radiation 2. Chemotherapy 4. Serum sodium blood levels 6. Medication that is antagonistic to antidiuretic hormone (ADH) 40. The clinic nurse is assisting to perform a focused data collection process on a client who is complaining of symptoms of a cold, a cough, and lung congestion. Which of the following would the nurse include for this type of data collection? Select all that apply. 1. Auscultating lung sounds 2. Obtaining the client’s temperature 4. Obtaining information about the client’s respirations 41. A community health nurse is conducting a teaching session about terrorism with members of the community and discussing information regarding anthrax. The nurse tells those attending that anthrax can be transmitted via which route(s)? Select all that apply. 1. Skin 3. Inhalation 4. Gastrointestinal 42. The emergency room nurse is providing discharge teaching to the parents of a 2-year-old child who sustained burns from a hot cup of coffee that had been left on the kitchen counter. The nurse evaluates that the parents have correctly understood the teaching when they state which of the following? 1. “We will be sure to not leave hot liquids unattended.” 43. 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? 3. Nursing staff are led by a nurse when providing care to a group of clients. 44. A licensed practical nurse is planning the client assignments for the day. Which of the following is the most appropriate assignment for the nursing assistant? 2. A client who requires frequent ambulation 45. A male client who has heart failure receives an additional dose of bumetanide as prescribed 4 hours after the daily dose. The nurse assesses him 15 minutes after administering the medication and reminds him to save all urine in the bathroom. Thirty minutes later the nurse finds the client on the floor, unresponsive, and bleeding from a laceration. Determine the issues that support the client’s malpractice claim. Select all that apply. 2. Increased risk of hypotension 3. Failure to teach the client adequately 4. Increased need to protect the client 46. A nurse develops a plan of care for a client following a lumbar puncture. Which interventions should be included in the plan? Select all that apply. 1. Monitor the client’s ability to void. 2. Maintain the client in a flat position. 3. Restrict fluid intake for a period of 2 hours. 4. Monitor the client’s ability to move the extremities. 5. Inspect the puncture site for swelling, redness, and drainage. 47. A nurse employed in an emergency department is assigned to assist with the triage of clients arriving to the emergency department for treatment on the evening shift. The nurse would assign the highest priority to which of the following clients? 4. A client with chest pain who states that he just ate pizza that was made with a very spicy sauce 48. A nurse enters a client’s room and notes that the client’s lawyer is present and that the client is preparing a living will. The living will requires that the client’s signature be witnessed, and the client asks the nurse to witness the signature. Which of the following is the appropriate nursing action? 1. Decline to sign the will. 49. A nurse has reinforced instructions to the client with hyperparathyroidism regarding home care measures related to exercise. Which statement by the client indicates a need for further instruction? Select all that apply. 3. “I need to limit playing football to only the weekends.” 5. “I should exercise in the evening to encourage a good sleep pattern.” 50. A nurse in a medical unit is caring for a client with heart failure. The client suddenly develops extreme dyspnea, tachycardia, and lung crackles, and the nurse suspects pulmonary edema. The nurse immediately notifies the registered nurse and expects which interventions to be prescribed? Select all that apply. 1. Administering oxygen 2. Inserting a Foley catheter 3. Administering furosemide (Lasix) 4. Administering morphine sulfate intravenously 51. A nurse is admitting a client with a possible diagnosis of chronic bronchitis. The nurse collects data from the client and notes that which of the following signs supports this diagnosis? Select all that apply. 2. Early onset cough 4. Purulent mucus production 5. Mild episodes of dyspnea 52. A nurse is assigned to care for a client admitted to the hospital after sustaining an injury from a house fire. The client attempted to save a neighbor involved in the fire but, in spite of the client’s efforts, the neighbor died. Which action would the nurse take to enable the client to work through the meaning of the crisis? 3. Inquiring about the client’s feelings that may affect coping 53. A nurse is assigned to care for a client with a peripheral IV infusion. The nurse is providing hygiene care to the client and would avoid which of the following while changing the client’s hospital gown? 2. Disconnecting the IV tubing from the catheter in the vein 54. A nurse is assigned to care for four clients. When planning client rounds, which client would the nurse check first? 1. A client on a ventilator 55. A nurse is assisting with collecting data from an African-American client admitted to the ambulatory care unit who is scheduled for a hernia repair. Which of the following information about the client is of least priority during the data collection? 2. Psychosocial 56. A nurse is assisting with planning care for a client with an internal radiation implant. Which of the following should be included in the plan of care? Select all that apply. 1. Wearing gloves when emptying the client’s bedpan 2. Keeping all linens in the room until the implant is removed 3. Wearing a film (dosimeter) badge when in the client’s room 4. Wearing a lead apron when providing direct care to the client 57. The nurse is caring for a client after a supratentorial craniotomy in which a large tumor was removed from the left side. Choose the positions in which the nurse can safely place the client. Select all that 5. In a semi-Fowler’s position 6. With the head in a midline position 58. A nurse is caring for a client after thyroidectomy and notes that calcium gluconate is prescribed for the client. The nurse determines that this medication has been prescribed to: 3. Treat hypocalcemic tetany. 59. A nurse is caring for a client with a healthcare-associated infection caused by methicillin-resistant Staphylococcus aureus who is on contact precautions. The nurse prepares to provide colostomy care to the client. Which of the following protective items will be required to perform this procedure? 3. Gloves, a gown, and goggles 60. A nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client closely for which acid-base disorder that is most likely to occur in this situation? 2. Metabolic alkalosis 61. A nurse is caring for a client with diabetic ketoacidosis and documents that the client is experiencing Kussmaul’s respirations. Based on this documentation, which of the following did the nurse most likely 4. Respirations that are abnormally deep, regular, and increased in rate 62. Which nursing interventions are appropriate for a client recovering from surgery for retinal detachment? Select all that apply. 1. Monitor for hemorrhage. 2. Administer eye medications. 3. Maintain the eye patch or shield. 4. Assist with activities of daily living. 6. Educate regarding symptoms of retinal detachment. 63. A nurse is caring for a client with leukemia and notes that the client has poor skin turgor and flat neck and hand veins. The nurse suspects hyponatremia. What additional signs would the nurse expect to note in this client if hyponatremia is present? 4. Postural blood pressure changes 64. A nurse is caring for a group of clients who are taking herbal medications at home. Which of the following clients should be instructed not to take herbal medications? 3. A 10-year-old female client with a urinary tract infection 65. A nurse is caring for an infant with a diagnosis of tetralogy of Fallot. The infant suddenly becomes cyanotic and the oxygen saturation reading drops to 60%. Choose the interventions that the nurse should perform. Select all that apply. 2. Notify the registered nurse. 4. Prepare to administer morphine sulfate. 5. Prepare to administer intravenous fluids. 6. Prepare to administer 100% oxygen by face mask. 66. A nurse is collecting data on a client with severe preeclampsia. Choose the findings that would be noted in severe preeclampsia. Select all that apply. 1. Oliguria 4. Proteinuria 3+ 6. Blood pressure 168/116 mm Hg 67. A patient is admitted to the same day surgery unit for liver biopsy. Which of the following laboratory tests assesses coagulation? Select all that apply. 1. Partial thromboplastin time. 2. Prothrombin time. 3. Platelet count. 68. A patient is admitted to the hospital with suspected polycythemia vera. Which of the following symptoms is consistent with the diagnosis? Select all that apply. 2. Increased clotting time. 3. Hypertension. 4. Headaches. 69. The nurse is teaching the client how to use a metered dose inhaler (MDI) to administer a Corticosteroid drug. Which of the following client actions indicates that he is using the MDI correctly? Select all that apply. 1. The inhaler is held upright. 4. Mouth is rinsed with water following administration 70. The nurse is teaching a client with polycythemia vera about potential complications from this disease. Which manifestations would the nurse include in the client’s teaching plan? Select all that apply. 2. Visual disturbance 3. Headache 4. Orthopnea 5. Gout 71. Which of the following would be priority assessment data to gather from a client who has been diagnosed with pneumonia? Select all that apply. 1. Auscultation of breath sounds 3. Presence of chest pain. 5. Color of nail beds 72. The nurse is teaching a client who has been diagnosed with TB how to avoid spreading the disease to family members. Which statement(s) by the client indicate(s) that he has understood the nurses instructions? Select all that apply. 2. “I should always cover my mouth and nose when sneezing.” 4. “I should use paper tissues to cough in and dispose of them properly.” 5. “I can use regular plate and utensils whenever I eat.” 73. The nurse is admitting a client with hypoglycemia. Identify the signs and symptoms the nurse should expect. Select all that apply. 2. Palpitations 3. Diaphoresis 4. Slurred speech 74. Which adaptations should the nurse caring for a client with diabetic ketoacidosis expect the client to exhibit? Select all that apply: 2. Low PCO2 4. Acetone breath 75. When planning care for a client with ulcerative colitis who is experiencing symptoms, which client care activities can the nurse appropriately delegate to a unlicensed assistant? Select all that apply. 2. Providing skin care following bowel movements 4. Maintaining intake and output records 5. Obtaining the client’s weight. 76. Which of the following nursing diagnoses would be appropriate for a client with heart failure? Select all that apply. 1. Ineffective tissue perfusion related to decreased peripheral blood flow secondary to decreased cardiac output. 3. Decreased cardiac output related to structural and functional changes. 77. A nurse is monitoring a client with Graves’ disease for signs of thyrotoxicosis (thyroid storm). Which of the following signs and symptoms, if noted in the client, will alert the nurse to the presence of this crisis? Select all that apply. 2. Fever 3. Sweating 4. Agitation 78. A nurse is monitoring a group of clients for acid-base imbalances. Which clients are at highest risk for metabolic acidosis? Select all that apply. 3. Diabetic mellitus client 4. Malnourished client 6. Renal failure client 79. The nurse is preparing a teaching plan for a client who is undergoing cataract extraction with intraocular implant. Which home care measures will the nurse include in the plan? Select all that apply. 1. To avoid activities that require bending over 3. To place an eye shield on the surgical eye at bedtime 5. To contact the surgeon if a decrease in visual acuity occurs 6. To take acetaminophen (Tylenol) for minor eye discomfort 80. The nurse is preparing a teaching plan for a client who is undergoing cataract extraction with intraocular implant. Which home care measures will the nurse include in the plan? Select all that apply. 1. To avoid activities that require bending over 3. To place an eye shield on the surgical eye at bedtime 5. To contact the surgeon if a decrease in visual acuity occurs 81. A nurse is providing a list of instructions to a client who is scheduled to have an electroencephalogram (EEG). Choose the instructions that the nurse places on the list. Select all that apply. 2. Tea and coffee are restricted on the day of the test. 3. The test will take between 45 minutes and 2 hours. 4. The hair should be washed the evening before the test. 82. The nurse is providing discharge teaching to the client who was given a prescription for nifedipine (Adalat) for blood pressure management. Which instructions should the nurse include? Select all that apply. 3. “Take pulse rate each day.” 4. “Weigh at the same time each day.” 5. “Palpitations may occur early in therapy.” 6. “Be careful when rising from sitting to standing.” 83. A nurse is providing teaching regarding the prevention of Lyme disease to a group of teenagers going on a hike in a wooded area. Which of the following points should the nurse include in the session? Select all that apply. 1. Tuck pant legs into socks. 2. Wear closed shoes when hiking. 3. Apply insect repellent containing DEET. 4. Cover the ground with a blanket when sitting. 84. A nurse is reinforcing instructions to a client following a total laryngectomy about caring for the stoma. Choose the instructions that the nurse provides to the client. Select all that apply. 1. Protect the stoma from water. 2. Soaps should be avoided near the stoma. 3. Wash the stoma daily using a washcloth. 5. Apply a thin layer of petroleum jelly to the skin surrounding the stoma. 85. A nurse is reviewing the health records of assigned clients. The nurse plans care knowing that which client is at risk for fluid volume deficit? 2. The client with a colostomy 86. A nurse is told in report that a client has a positive Chvostek’s sign. What other data would the nurse expect to find on data collection? Select all that apply. 2. Tetany 3. Diarrhea 4. Possible seizure activity 5. Hypoactive bowel sounds 6. Positive Trousseau’s sign 87. A nurse lawyer provides an education session to the nursing staff regarding client rights. A nurse asks the lawyer to describe an example that may relate to invasion of client privacy. A nursing action that indicates a violation of this right is: 3. Taking photographs of the client without consent 88. A nurse notes in the medical record that a client with Cushing’s syndrome is experiencing fluid overload. Which interventions should be included in the plan of care? Select all that apply. 1. Monitoring daily weight 2. Monitoring intake and output 3. Maintaining a low-potassium diet 5. Maintaining a low-sodium diet 89. A nurse notes in the medical record that a client with Cushing’s syndrome is experiencing fluid overload. Which interventions should be included in the plan of care? Select all that apply. 1. Monitoring daily weight 2. Monitoring intake and output 4. Monitoring extremities for edema 5. Maintaining a low-sodium diet 90. Which instruction should the nurse provide to the client with diabetes mellitus receiving acarbose (Precose)? Select all that apply. 2. “Take the medication with each meal.” 4. “Side effects include abdominal bloating and flatus.” 5. “Take some form of glucose if hypoglycemia occurs.” 6. “Report symptoms such as shortness of breath or tiredness.” 91. A nurse prepares a list of home care instructions for the parents of a child who has a plaster cast applied to the left forearm. Choose the instructions that would be included on the list. Select all that apply. 2. Keep small toys and sharp objects away from the cast. 5. Contact the health care provider if the child complains of numbness or tingling in the extremity. 6. Elevate the extremity on pillows for the first 24 to 48 hours after casting to prevent swelling. 92. A nurse reinforces instructions to the mother of a child who has been hospitalized with croup. Which of the following statements, if made by the mother, would indicate the need for further instruction? 1. “I will give my child cough syrup if a cough develops.” 93. The nurse would anticipate the use of which medications in the treatment of the client with heart failure? Select all that apply. 1. Diuretics 4. Cardiac glycosides 5. Phosphodiesterase (PDE) inhibitors 6. Angiotensin-converting enzyme (ACE) inhibitors 94. The parent of a toddler asks a nurse when it is safe to place the car safety seat in a face-forward position. Which of the following is the best nursing response? 1. When the toddler weighs 20 lb and is 1 year old 95. A pregnant woman has a positive history of genital herpes, but she has not had lesions during her pregnancy. The nurse plans to provide which of the following information to the client? 4. “You will be evaluated at the time of delivery for herpetic genital tract lesions. If they are present, a cesarean delivery will be needed.” 96. Which of these clients are most likely to develop fluid (circulatory) overload? Select all that apply. 1. A premature infant 2. A 101-year-old man 3. A client on renal dialysis 6. A client with congestive heart failure 97. An unconscious client who is bleeding profusely is brought to the emergency department after a serious accident. Surgery is required immediately to save the client’s life. With regard to informed consent for the surgical procedure, which of the following is the best action? 4. Transport the client to the operating department immediately, as required by the health care provider without obtaining an informed consent. 98. When caring for a 3-year-old child, the nurse should provide which toy for this child? 2. A wagon 99. When the nurse is collecting data from the older adult, which of the following findings would be considered normal physiological changes? Select all that apply. 2. Decline in visual acuity 5. Increased susceptibility to urinary tract infections 6. Increased incidence of awakening after sleep onset 100. Which data indicates to the nurse that a client may be experiencing ineffective coping? 1. Constantly neglects personal grooming 101. The nurse notes that a client is quite suspicious during an assessment interview and believes that her family is under investigation by the CIA. What would the appropriate nursing interventions be with this client? Select all that apply: 1. Use active listening skills to seek information from the client. 2. Encourage the client to describe the problem as she sees it. 3. Ask the client to tell you exactly what she thinks is happening. 102. Which nursing interventions will assist in reducing pressure points that may lead to pressure ulcers? Check all that apply: 2. Avoid use of donut type devices. 4. Elevate the HOB no more than 30 degrees when possible. 5. When the client is side lying, use the 30 degree lateral inclined position. 6. Avoid uninterrupted sitting in a chair or wheelchair. 103. The nurse is evaluating a client recently diagnosed with primary open angle glaucoma (POAG). What will an important nursing action be? Select all that apply: 1. Review meds the client is currently on to determine whether any of them cause an increased intraocular pressure as a side effect. 5. Have the client demonstrate the use of eye drops. 6. Assess the client for chronic diseases such as diabetes. 104. A nurse understands that a patient may experience pain during peritoneal dialysis because of which of the following? Select all that apply: 2. Too rapid installation 4. Accumulation of dialysate solution under the diaphragm 105. The nurse is evaluating a client’s response to hemodialysis. Which lab results will indicate the dialysis was effective? Select all that apply: 1. Serum potassium level decreases from 5.4 to 4.6 mEq/L 2. Cr decreases from 1.6 to 0.8 mg/dL 5. BUN decreases from 110 to 90 mg/dL 106. The nurse understands that the following clinical findings are indications for dialysis. Select all that apply: 1. Volume overload 3. K 5.2 mEq/L 5. Metabolic acidosis 6. Cr 5.0 mg/dL 107. The nurse is assessing a client who had a fractured femur repaired with an external fixator device. Which assessment finding would cause the nurse concern regarding the development of compartment syndrome? Select all that apply: 2. Paresthesia distal to area of injury. 3. Toes on affected leg cool to touch and edematous. 5. Complaints of leg pain unrelieved by analgesics or repositioning. 108. The nurse is preparing discharge for a patient with GERD. What would be important for the nurse to include in this teaching plan? Select all that apply: 1. Elevate the HOB. 2. Decrease intake of caffeine. 3. Discuss strategies for weight loss if overweight. 5. Take ranitidine (Zantac) at hs. 109. The nurse is preparing a client for cardiac catheterization. Which nursing interventions are necessary in preparing the client for this procedure. Select all that apply: 1. Verify consent has been signed. 2. Explain procedure to client. 5. Obtain a 12 lead ECG 6. Obtain history of shellfish allergy. 110. The nurse has been assigned a group of cardiac clients. What would be the most important information for the nurse to check on the initial evaluation of each client? Select all that apply: 1. Presence of cardiac pain. 3. Presence of jugular vein distention. 4. Heart sounds and apical rate. 5. Presence of diaphoresis. 111. The nurse is teaching a client about home care and treatment of venous stasis ulcers in his leg. What should be included in the nurse’s instructions? Select all that apply: 2. Healing will be facilitated by wearing leg compression devices. 3. When the client is in sitting position, he should keep his legs elevated. 4. 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: 1. Nausea 4. Hyperpigmentation 5. 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? 3. Nursing staff are led by a nurse when providing care to a group of clients. 114. A licensed practical nurse is planning the client assignments for the day. Which of the following is the most appropriate assignment for the nursing assistant? 2. A client who requires frequent ambulation 115. A male client who has heart failure receives an additional dose of bumetanide as prescribed 4 hours after the daily dose. The nurse assesses him 15 minutes after administering the medication and reminds him to save all urine in the bathroom. Thirty minutes later the nurse finds the client on the floor, unresponsive, and bleeding from a laceration. Determine the issues that support the client’s malpractice claim. Select all that apply. 2. Increased risk of hypotension 3. Failure to teach the client adequately 4. Increased need to protect the client 6. Lack of follow-up nursing actions 116. A client’s record from the ED indicates that she overdosed on phenelzine sulfate (Nardil), a monoamine oxidase (MAO) inhibitor. Which diet would be the most appropriate at this time? Tyramine-free 117. Which of the following symptoms might the nurse observe in a client with a lithium blood level over 2.0? Vomiting, impaired consciousness, decreased blood pressure 118. A client with IDDM is given IV insulin for a blood glucose level of 520 mg/dL. Life-threatening complications may occur initially, so the nurse will monitor him closely for serum: Potassium level of 6.3 mEq/L 119. The nurse and prenatal client discuss the effects of cigarette smoking on pregnancy. It would be correct for the nurse to explain that with cigarette smoking there is increased risk that the baby will have: A low birth weight 120. A 26-year-old male client is brought by his wife to the emergency department (ED) unconscious. Blood is drawn for a stat blood count (CBC), fasting blood sugar level, and electrolytes. An indwelling urinary catheter is inserted. He has a history of type 1 diabetes (insulindependent diabetes mellitus [IDDM]). A diagnosis of ketoacidosis is made. Stat lab values reveal a blood sugar level of 520 mg/dL. Which of the following should the nurse expect to administer in the ER? Regular insulin by IV infusion 121. In teaching the client about proper umbilical cord care, the nurse recommends that: The area be cleansed at diaper changes with alcohol and inspected for redness or drainage 122. A 24-hours’ postpartum client complains of discomfort at the episiotomy site. On assessment, the nurse notes the episiotomy is without signs of infection. To relieve the discomfort, the nurse should first: Assist her with a sitz bath 123. Due to his prolonged history of alcohol abuse, an alcoholic client will most likely have deficiencies of which of the following nutrients? Thiamine and pyroxidine 124. A female client has been treated since childhood for mitral valve prolapse. The antibiotic of choice for her during pregnancy would be: Erythromycin 125. A client is being admitted to the labor and delivery unit. She has had previous admissions for “false labor.” Which clinical manifestation would be most indicative of true labor? Progressive dilatation and effacement of the cervix 126. A 2-year-old boy fell out of bed and has a subdural hematom A. When his mother leaves him for the first time, you will expect the child to: Cry 127. A client undergoes a transurethral resection, prostate (TURP). He returns from surgery with a three-way continuous Foley irrigation of normal saline in progress. The purpose of this bladder irrigation is to prevent: Clot formation 128. A 25-year-old client believes she may be pregnant with her first child. She schedules an obstetric examination with the nurse practitioner to determine the status of her possible pregnancy. Her last menstrual period began May 20, and her estimated date of confinement using Nägele’s rule is: February 27 129. The therapeutic blood-level range for lithium is: 0.5–1.5 mEq/L 130. Which of the following ECG changes would be seen as a positive myocardial stress test response? ST-segment depression 131. A psychotic client who believes that he is God and rules all the universe is experiencing which type of delusion? Grandiose 132. During burn therapy, morphine is primarily administered IV for pain management because this route: Facilitates absorption because absorption from muscles is not dependable 133. Assessment of the client with pericarditis may reveal which of the following? Pericardial friction rub and pain on deep inspiration 134. A client who has sustained a basilar skull fracture exhibits blood-tinged drainage from his nose. After establishing a clear airway, administering supplemental O2, and establishing IV access, the next nursing intervention would be to: Perform a halo test and glucose level on the drainage 135. To appropriately monitor therapy and client progress, the nurse should be aware that increased myocardial work and O2 demand will occur with which of the following? A. Positive inotropic therapy 96. The most important reason to closely assess circumferential burns at least every hour is that they may result in: Loss of peripheral pulses 137. A pregnant client comes to the office for her first prenatal examination at 10 weeks. She has been pregnant twice before; the first delivery produced a viable baby girl at 39 weeks 3 years ago; the second pregnancy produced a viable baby boy at 36 weeks 2 years ago. Both children are living and well. Using the GTPAL system to record her obstetrical history, the nurse should record: 3-1-1-0-2 138. A 68-year-old woman is admitted to the hospital with chronic obstructive pulmonary disease (COPD). She is started on an aminophylline infusion. Three days later she is breathing easier. A serum theophylline level is drawn. Which of the following values represents a therapeutic level? 14 µ g/mL 139. A nasogastric (NG) tube inserted preoperatively is attached to low, intermittent suctions. A client with an NG tube exhibits these symptoms: He is restless; serum electrolytes are Na 138, K 4.0, blood pH 7.53. This client is most likely experiencing: Metabolic alkalosis 140. A 16-year-old student has a long history of bronchial asthma and has experienced several severe asthmatic attacks during the school year. The school nurse is required to administer 0.2 mL of 1/1000 solution of epinephrine SC during an asthma attack. How does the school nurse evaluate the effectiveness of this intervention? Decreased inspiratory difficulty 141. Nursing interventions designed to decrease the risk of infection in a client with an indwelling catheter include: Cleanse area around the meatus twice a day 142. A 23-year-old borderline client is admitted to an inpatient psychiatric unit following an impulsive act of self- mutilation. A few hours after admission, she requests special privileges, and when these are not granted, she stands up and angrily shouts that the people on the unit do not care, and she storms across the room. The nurse should respond to this behavior by: Communicating a desire to assist the client to regain control, offering a one-to-one session in a quiet area 143. A client is being discharged with albuterol (Proventil) and beclomethasone dipropionate (Vanceril) to be administered via inhalation three times a day and at bedtime. Client teaching regarding the sequential order in which the drugs should be administered includes: Bronchodilator followed by the glucocorticoid 144. A gravida 2 para 1 client delivered a full-term newborn 12 hours ago. The nurse finds her uterus to be boggy, high, and deviated to the right. The most appropriate nursing action is to: Have the client void and then re-evaluate the fundus 145. During a client’s first postpartum day, the nurse assessed that the fundus was located laterally to the umbilicus. This may be due to: Urine retention or a distended bladder