NCLEX DEC FILE 2 2023 question & answer latest update

NCLEX DEC FILE 2 1. Potential Which individual is at greatest risk for developing hypertension? A. 45-year-old African-American attorney 2. 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 3. Which complication of cardiac catheterization should the nurse monitor for in the initial 24 hours after the procedure? B. Thrombus formation 4. 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 5. 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 6. 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 7. 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. 8. 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 9. 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 10. 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 11. 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 12. 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, 13. When teaching a client with coronary artery disease about nutrition, the nurse should emphasize: C.Avoiding very heavy meals 14. 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 15. 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 16. 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 17. 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 18. 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 19. 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 20. 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.” 21. 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 22. 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.” 23. A client decided early in her pregnancy to breast-feed her first baby. She gave birth to a normal, full- term girl and is now progressing toward the establishment of successful lactation. To remove the babyfrom her breast, she should be instructed to: A. Insert a clean finger into the baby’s mouth beside the nipple 24. A gravida 2 para 1 client delivered a full-term newborn 12 hours ago. The nurse finds her uterus to beboggy, high, and deviated to the right. The most appropriate nursing action is to: A. Have the client void and then re-evaluate the fundus 25. 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: C. 3-1-1-0-2 26. 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 gravida and para system to record the client’s obstetrical history, the nurse should record: A. Gravida 3 para 2 27. client is hospitalized with severe preeclampsia. While she receives magnesium sulfate(MgSO4) therapy, the nurse knows it is safe to repeat the dosage if: A. Respirations are>16 breaths/min 28. Prenatal clients are routinely monitored for early signs of pregnancy-induced hypertension (PIH). For theprenatal client, which of the following blood pressure changes from baseline would be most significant for the nurse to report as indicative of PIH? C. 114/70 to 140/88 29. . Which nursing implication is appropriate for a client undergoing a paracentesis? A. Have the client void before the procedure. 30. The nurse would assess the client’s correct understanding of the fertility awareness methods that enhance conception, if the client stated that: A. "At ovulation, my basal body temperature should rise about 0.5F." 31. A couple is planning the conception of their first child. The wife, whose normal menstrual cycle is 34 days in length, correctly identifies the time that she is most likely to ovulate if she states that ovulationshould occur on day: A. 20+2 days 32. A client is pregnant with her second child. Her last menstrual period began on January 15. Her expecteddate of delivery would be: A. October 22 33. The nurse instructs a pregnant client (G2P1) to rest in a side-lying position and avoid lying flat on herback. The nurse explains that this is to avoid "vena caval syndrome," a condition which: A. Occurs when blood pressure increases sharply with changes in position 34. Other drugs may be ordered to manage a client’s ulcerative colitis. Which of the following medications,if ordered, would the nurse question? A. 6-Mercaptopurine 34. A male client is scheduled for a liver biopsy. In preparing him for this test, the nurse should: A. Explain that his vital signs will be checked frequently after the test 35. After a liver biopsy, the best position for the client is: A. Right lateral 36. A complication for which the nurse should be alert following a liver biopsy is: A. Shock 37. 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: A. Metabolic alkalosis 38. A client is experiencing muscle weakness and lethargy. His serum K+is 3.2. What other symptoms mighthe exhibit? A. Dysrhythmias 39. Following a gastric resection, which of the following actions would the nurse reinforce with the client inorder to alleviate the distress from dumping syndrome? A. Eating a low-carbohydrate diet 40. Azulfidine (Sulfasalazine) may be ordered for a client who has ulcerative colitis. Which of the following isa nursing implication for this drug? A. Observe for skin rash and diarrhea. 41. In evaluating the laboratory results of a client with severe pressure ulcers, the nurse finds that her albumin level is low. A decrease in serum albumin would contribute to the formation of pressure ulcers because: A. The proteins needed for tissue repair are diminished. 41. Which of the following menu choices would indicate that a client with pressure ulcers understands therole diet plays in restoring her albumin levels? A. Broiled fish with rice 42. The nurse observes that a client has difficulty chewing and swallowing her food. A nursing responsedesigned to reduce this problem would include: A. Ordering a mechanical soft diet for her 43. When a client with pancreatitis is discharged, the nurse needs to teach him how to prevent anotheroccurrence of acute pancreatitis. Which of the following statements would indicate he has an understanding of his disease? A. "I will look into attending Alcoholics Anonymous meetings." 44. A 54-year-old client is admitted to the hospital with a possible gastric ulcer. He is a heavy smoker. Whendiscussing his smoking habits with him, the nurse should advise him to: A. Smoke only right after meals 45. Iron dextran (Imferon) is a parenteral iron preparation. The nurse should know that it: A. Requires use of the Z-track method 46. The nurse teaches a male client ways to reduce the risks associated with furosemide therapy. Which ofthe following indicates that he understands this teaching? A. "I’ll be sure to rise slowly and sit for a few minutes after lying down." 47. A client is taught to eat foods high in potassium. Which food choices would indicate that this teachinghas been successful? A. Pork chop, baked acorn squash, brussel sprouts 48. The nurse would be sure to instruct a client on the signs and symptoms of an eye infection andhemorrhage. These signs and symptoms would include: A. Eye pain and itching 49. The nurse would teach a male client ways to minimize the risk of infection after eye surgery. Which ofthe following indicates the client needs further teaching? A. "I will wear an eye patch for the first 3 postoperative days." 50. With a geriatric client, the nurse should also assess whether he has been obtaining a yearly vaccinationagainst influenza. Why is this assessment important? A. Older clients have less effective immune systems. 51. The nurse provides a male client with diet teaching so that he can help prevent constipation in thefuture. Which food choices indicate that this teaching has been understood? A. Cooked oatmeal and grapefruit half 52. One of the medications that is prescribed for a male client is furosemide (Lasix) 80 mg bid. To reduce hisrisk of falls, the nurse would teach him to take this medication: A. On arising and no later than 6 PM 53. In cleansing the perineal area around the site of catheter insertion, the nurse would: A. Wipe the catheter away from the urinary meatus 54. Nursing interventions designed to decrease the risk of infection in a client with an indwelling catheterinclude: A. Cleanse area around the meatus twice a day 55. A client tells the nurse that she has had a history of urinary tract infections. The nurse would do furtherhealth teaching if she verbalizes she will: A. Limit her fluid intake after 6 PM so that there is not a great deal of urine in her bladder while she sleeps 56. An 83-year-old client has been hospitalized following a fall in his home. He has developed a possiblefecal impaction. Which of the following assessment findings would be most indicative of a fecal impaction? A. Abdominal pain 57. A 74-year-old female client is 3 days postoperative. She has an indwelling catheter and has been progressing well. While the nurse is in the room, the client states, "Oh dear, I feel like I have to urinate again!" Which of the following is the most appropriate initial nursing response? A. Check the collection bag and tubing to verify that the catheter is draining properly. 58. Dietary planning is an essential part of the diabetic client’s regimen. The American Diabetes Association recommends which of the following caloric guidelines for daily meal planning? A. 60% complex carbohydrate, 12%15% protein, 20%25% fat 59. A type I diabetic client is diagnosed with cellulitis in his right lower extremity. The nurse would expectwhich of the following to be present in relation to his blood sugar level? A. An increased blood sugar level 60. The physician has ordered that a daily exercise program be instituted by a client with type I diabetes following his discharge from the hospital. Discharge instructions about exercise should include which ofthe following? A. A snack may be needed before and/or during exercise. 61. A 27-year-old man was diagnosed with type I diabetes 3 months ago. Two weeks ago he complained of pain, redness, and tenderness in his right lower leg. He is admitted to the hospital with a slight elevation of temperature and vague complaints of "not feeling well." At 4:30 PM on the day of his admission, hisblood glucose level is 50 mg; dinner will be served at 5:00 PM. The best nursing action would be to: A. Have him drink 4 oz of orange juice 62. A male client receives 10 U of regular human insulin SC at 9:00 AM. The nurse would expect peak actionfrom this injection to occur at: C. 12 noon 63. Which of the following nursing orders should be included in the plan of care for a client with hepatitis C? A. The nurse should use universal precautions when obtaining blood samples. 64. Which of the following should be included in discharge teaching for a client with hepatitis C? A. He should avoid alcoholic beverages during his recovery period. 65. A 55-year-old man is admitted to the hospital with complaints of fatigue, jaundice, anorexia, and clay- colored stools. His admitting diagnosis is "rule out hepatitis." Laboratory studies reveal elevated liver enzymes and bilirubin. In obtaining his health history, the nurse should assess his potential for exposureto hepatitis. Which of the following represents a high-risk group for contracting this disease? A. Oncology nurses 66. A diagnosis of hepatitis C is confirmed by a male client’s physician. The nurse should be knowledgeable of the differences between hepatitis A, B, and C. Which of the following are characteristics of hepatitis C? A. The incubation period is 226 weeks. 67. The nurse is aware that nutrition is an important aspect of care for a client with hepatitis. Which of thefollowing diets would be most therapeutic? A. High carbohydrate and high calorie 68. The primary reason for sending a burn client home with a pressure garment, such as a Jobst garment, isthat the garment: A. Decreases hypertrophic scar formation 69. A client with emphysema is placed on diuretics. In order to avoid potassium depletion as a side effect ofthe drug therapy, which of the following foods should be included in his diet? A. Potatoes 70. Which of the following would the nurse expect to find following respiratory assessment of a client withadvanced emphysema? A. Distant breath sounds 71. The nurse assists a client with advanced emphysema to the bathroom. The client becomes extremely short of breath while returning to bed. The nurse should: A. Encourage pursed-lip breathing 72. Signs and symptoms of an allergy attack include which of the following? A. Prolonged expiration 73. During burn therapy, morphine is primarily administered IV for pain management because this route: A. Facilitates absorption because absorption from muscles is not dependable 74. The medication that best penetrates eschar is: A. Mafenide acetate (Sulfamylon) 75. When the nurse is evaluating lab data for a client 1824 hours after a major thermal burn, the expectedphysiological changes would include which of the following? A. Elevated hematocrit 76. The nurse notes hyperventilation in a client with a thermal injury. She recognizes that this may be areaction to which of the following medications if applied in large amounts? A. Mafenide acetate 77. 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 nursingintervention would be to: A. Perform a halo test and glucose level on the drainage 78. A client with a diagnosis of C-4 injury has been stabilized and is ready for discharge. Because this client isat risk for autonomic dysreflexia, he and his family should be instructed to assess for and report: Answer: B A. Headache and facial flushing 79. The initial treatment for a client with a liquid chemical burn injury is to: A. Flush the exposed area with large amounts of water 80.The most important reason to closely assess circumferential burns at least every hour is that they mayresult in: A. Loss of peripheral pulses 81.When evaluating a client with symptoms of shock, it is important for the nurse to differentiate betweenneurogenic and hypovolemic shock. The symptoms of neurogenic shock differ from hypovolemic shock in that: A. In neurogenic shock, the skin is warm and dry 82. Which of the following would have the physiological effect of decreasing intracranial pressure (ICP)? A. Decreased PaCO2 83. A client with a C-34 fracture has just arrived in the emergency room. The primary nursing intervention is: A. Airway assessment and stabilization 84. In a client with chest trauma, the nurse needs to evaluate mediastinal position. This can best be doneby: A. Palpating for trachial deviation 85. Priapism may be a sign of: A. Altered neurological function 86. Which classification of drugs is contraindicated for the client with hypertrophic cardiomyopathy? A. Positive inotropes 87. To ensure proper client education, the nurse should teach the client taking SL nitroglycerin to expectwhich of the following responses with administration? A. Stinging, burning when placed under the tongue 88. When a client is receiving vasoactive therapy IV, such as dopamine (Intropin), and extravasation occurs,the nurse should be prepared to administer which of the following medications directly into the site? A. Phentolamine (Regitine) 89. Which of the following would differentiate acute from chronic respiratory acidosis in the Answer: B assessment ofthe trauma client? A. Increased HCO3 90.Which of the following signs and symptoms indicates a tension pneumothorax as compared to an openpneumothorax? A. Mediastinal tissue and organ shifting 91. Hematotympanum and otorrhea are associated with which of the following head injuries? A. Basilar skull fracture 92. Assessment of the client with pericarditis may reveal which of the following? A. Pericardial friction rub and pain on deep inspiration 93. Clinical manifestations seen in left-sided rather than in right-sided heart failure are: 94. In the client with a diagnosis of coronary artery disease, the nurse would anticipate the complication ofbradycardia with occlusion of which coronary artery? A. Right coronary artery 95. When inspecting a cardiovascular client, the nurse notes that he needs to sit upright to breathe. Thisbehavior is most indicative of: A. Congestive heart failure 96. When a client questions the nurse as to the purpose of exercise electrocardiography (ECG) in the diagnosis of cardiovascular disorders, the nurse’s response should be based on the fact that: A. Ischemia can be diagnosed because exercise increasesO2 consumption and demand 97. In assessing cardiovascular clients with progression of aortic stenosis, the nurse should be aware thatthere is typically: A. Increased left ventricular systolic pressures and hypertrophy 98. The cardiac client who exhibits the symptoms of disorientation, lethargy, and seizures may be exhibitinga toxic reaction to: A. Lidocaine (Xylocaine) 99. Which of the following ECG changes would be seen as a positive myocardial stress test response? A. ST-segment depression 100. The nurse would need to monitor the serum glucose levels of a client receiving which of the followingmedications, owing to its effects on glycogenolysis and insulin release? Answer: B A. Epinephrine (Adrenalin) 101. Which of the following medications requires close observation for bronchospasm in the client withchronic obstructive pulmonary disease or asthma? A. Propranolol (Inderal) 102. The following medications were noted on review of the client’s home medication profile. Which of the medications would most likely potentiate or elevate serum digoxin levels? A. Quinidine 103. The priority nursing goal when working with an autistic child is: A. To establish trust with the child 104. The child with iron poisoning is given IV deforoxamine mesylate (Desferal). Following administration, thechild suffers hypotension, facial flushing, and urticaria. The initial nursing intervention would be to: A. Stop the medication, and begin a normal saline infusion 105. As the nurse assesses a male adolescent with chlamydia, the nurse determines that a sign of chlamydiais: A. Epididymitis 106. When teaching a mother of a 4-month-old with diarrhea about the importance of preventingdehydration, the nurse would inform the mother about the importance of feeding her child: A. Soy-based, lactose-free formula 107. The primary reason that an increase in heart rate (100 bpm) detrimental to the client with a myocardialinfarction (MI) is that: A. Decreased coronary artery perfusion due to decreased diastolic filling time will occur, which willincrease ischemic damage to the myocardium 108. To appropriately monitor therapy and client progress, the nurse should be aware that increasedmyocardial work and O2 demand will occur with which of the following? A. Positive inotropic therapy 109. When administering phenytoin (Dilantin) to a child, the nurse should be aware that a toxic effect ofphenytoin therapy is: A. Stephens-Johnson syndrome 110. When assessing a child with diabetes insipidus, the nurse should be aware of the cardinal signs of: Answer: B A. Anemia and vomiting 111. A child is admitted to the emergency room with her mother. Her mother states that she has beenexposed to chickenpox. During the assessment, the nurse would note a characteristic rash: A. That appears profusely on the trunk and sparsely on the extremities 112. Discharge teaching was effective if the parents of a child with atopic dermatitis could state theimportance of: A. Furry, soft stuffed animals for play 113. An 8-year-old child comes to the physician’s office complaining of swelling and pain in the knees. His mother says, "The swelling occurred for no reason, and it keeps getting worse." The initial diagnosis is Lyme disease. When talking to the mother and child, questions related to which of the following wouldbe important to include in the initial history? A. Headaches, malaise, or sore throat 114. Whats priority for a patient who is allergic to bananas? Replace latex 115. How to prevent a renal calculi? limit tea and chocolate 116. If a patient is in F-vib what medication to give? Adenosine 117.A nurse is caring for a patient and is unable to palpate a pedal pulse. What should the nurse do next? Obtain a doppler 118. A client with a history of COPD has established a walking program. How do we know that walking is effective? Cardiovascular improvement 119.Post -op A client informs the nurse that he know all about how to breath. How should the nurse respond? Order 100 units in 250ml to infuse at 12units/hr 12/100 *250= 30 120. A client complains of pain in the right calf. What is the nurse's priority? Remain in bed 121. A client just returned after having a TURP and has clot. What should the nurse do? slowly irrigate Answer: B 122. What's Priority for a client with Multiple Scerolosis and has urinary rention? Self cathetherization 123. The nurse is monitoring drainainge of an abscess. What lab should the nurse monitor? WBCs 124. What intervetion the nurse shoudl implement for a patient with Congestive Heart Failure? Use bedside commode when needing to void 125. What intervention should be done for post op cataract extraction? implement deep breathing 126. A client is discharged on Prednisolone. What should the patient report? Wt gain 127A client is diagnosed with Pyelinephritis. What is priority? IV antibiotics 128. What is a diet for Osteomalacia? Milk and cereal 129.What should the nurse instruct a client who has Raynuads Syndrome to do at work? Use space heater 130. What to teach a client with GERD? Wear loose clothing 131. How should a client with COPD breath? Pursed lips 132. A client presents with the s/s of Diabetes type 2 and feeling shaky. What is the nurse priority? Obtain glucose level 133. What should the HCP order for a client with Hypothyroidism who has depression and can not sleep? Request PRN... 134. What should a client with Ulcerative Colitis report? Stool with fatty streaks MRSA intervetions? contact precaution, culture & sensitivity, monitor WBCs CKD lab to report? K 6.5 135. A client has a positive guaic stool. What lab to review? Platelets Phenochrocytoma with HA Assess the blood pressure Suprapubic prostateomy concern? Urine leakacge Abdominal cramping after surgery .... Answer: B 136. A client tells the nurse that her biopsy results indicate that the cancer cells are well differentiated How should the nurse respond? Ask HCP 137. A client that has Asthma has bronchocontriction with increase mucus Ulcer that is venous Irregular What lab indicate a Diabetic is adhering to regiment? A1c 138. A client has 40% of burns. Which fluid is needed during the acute phase? Latated Ringers 139. A client has a pain of 8 out of 10 on the pain scale ? Administer opioids and non pharmacological interventions 140. What should be included in the teaching for a client with Diabetes Mellitus with an ulcer? Check shoes before putting them on 141. The HCP orders 8200 units and available is 2ml each 1ml. How much to give 0.8 142.A client with Gullian Barre is not blinking. What intervention to implement? Administer lubericant 143. What is a concern for a client with Diabetes Insipidous? Sodium level 185 144. What would indicate a sign of dementia in a client with AIDS? A change in writing 145. What should the nurse evaluate with a client that has ORIFSA? Select All Verify Monitor for manifestations of compartment syndrome 146. What intervention will the nurse implement when caring for a client with a pulmonary infection? Select All Assess breathing, change in level of consciousness, monitor skin color 147. What is needed for a client that has traction applied and need repositioning? A trapeze bar 148. A client is being seen at the clinic for Tinea Pedia. What question to ask Are you taking the prescription Tolfnate 149. What should the nurse do after reading the results of a TB test that read 5mm? Document the findings 150. A client that had a CVA has visual impairment and has not be able to eat all of his food. What should the nurse instruct the family to do? Visual Meloma observe for what Appearance