CDM FINAL EXAM NCLEX Questions Answered_Summer 2023.

CDM FINAL EXAM NCLEX Q’S And A’s Self Care Deficit: Dressing 1. The nurse is planning care for a client who has severe arthritis and has very limited fine motor hand dexterity. Which of the following would the nurse identify as the most relevant defining characteristic for this client for the nursing diagnosis of Self-Care Deficit: Dressing? a. Inability to choose clothing b. Inability to maintain appearance c. Inability to use zippers d. Impaired ability to obtain clothing 2. The nurse is developing a plan of care for a client who has advanced dementia. The nurse recognizes that there is a Self-Care Deficit: Dressing related to which of the following? a. Anxiety b. Cognitive impairment c. Environmental barriers d. Weakness 3. The nurse is planning care during rehabilitation for a client who experienced left sided weakness following a stroke. Which of the following outcomes would be the most desirable for this client’s nursing diagnosis of Self-Care Deficit: Dressing? a. Client will dress and groom self to optimal potential. b. Client will identify types of assistive technology. c. Client will be dressed by a caregiver. d. Client will explore potential barriers to dressing. 4. A client had a recent fall and has residual dizziness. What action by the nurse best promotes safety for the client during dressing? a. Have the client sit for as much dressing as possible. b. Perform the majority of dressing for the client. c. Teach the client to hold the bed with one hand. d. Use a gait belt in case the patient falls during dressing. 5. The nurse is teaching a client who has right sided weakness due to a stroke methods for easier dressing. Which of the following interventions should the nurse include in this teaching session? a. Stand while dressing. b. Use clothing that fastens in the back. c. Use smart machine-based prompting. d. Dress the affected side first. Self Care Deficit: Feeding 6. The nurse is planning care for a client who has Parkinson’s disease with severe hand tremors. Which of the following would the nurse identify as the most relevant defining characteristic for this client for the nursing diagnosis of Self-Care Deficit: Feeding? a. Inability to cook food b. Inability to chew food c. Inability to bring food to mouth d. Impaired ability to manipulate food in mouth 7. The nurse is developing a plan of care for a right hand dominant client who had a right rotator cuff repair. The nurse recognizes that there is a Self-Care Deficit: Feeding related to which of the following? a. Environmental barriers b. Musculoskeletal impairment c. Neuromuscular impairment d. Perceptual impairment8. The nurse is planning care for a client who is left hand dominant and is experiencing right sided weakness and a frequent cough following a stroke. Which of the following outcomes would be the most desirable for this client’s nursing diagnosis of Self-Care Deficit: Feeding? a. Client will feed self safely. b. Client will identify assistive technology for feeding. c. Client will use adaptive utensils for feeding. d. Client will explore potential barriers to feeding. 9. The nurse is providing a training session for the staff who participates in assisting clients with eating. Which of the following timeframes should the nurse convey is needed per client meal to promote weight gain in at risk clients? a. 10 minutes b. 13 minutes c. 20 minutes d. 42 minutes 10. The nurse is planning care for a client receiving a tube feeding. Which one of the following interventions for the client should the nurse include for safety to help prevent aspiration pneumonia? a. Swab mouth once each shift with foam toothettes. b. Provide regular oral care using toothbrush. c. Avoid oral care to reduce oral secretions d. Apply moisturizer to lips every 4 hours. Self Care Deficit: Toileting 11. During assessment the nurse identifies that a client needs assistance with ambulation. Which of the following would the nurse identify as the most relevant defining characteristic for this client’s nursing diagnosis Self-Care Deficit: Toileting? a. Inability to manipulate clothing for toileting b. Inability to get to toilet or commode c. Inability to wash hands after toileting d. Inability to carry out proper toilet hygiene 12. The nurse is developing a plan of care for a client who uses a wheelchair and requires toileting assistance. The nurse recognizes that there is a Self-Care Deficit: Toileting related to which of the following? a. Impaired transfer ability b. Environmental factors c. Fatigue d. Decreased motivation 13. The nurse is planning care for a client who experienced a traumatic amputation of the right arm. Which of the following outcomes would be most applicable for this client’s nursing diagnosis of Self-Care Deficit: Toileting? a. Client will toilet safely. b. Client will state satisfaction with ability to use adaptive devices for toileting. c. Client will toilet with assistance of caregiver. d. Client will wear adult incontinence briefs for safety 14. The nurse is planning to place a client with a fractured hip on a bed pan. Which one of the following interventions has research shown would be most effective in reducing the client’s anxiety about its use? a. Placing waterproof pads on bed. b. Provide analgesics 30 minutes after bed pan use. c. Warm bedpan with hot water. d. Discuss use of bed pan with client prior to its use.15. A nurse is caring for a hospitalized client with urinary frequency. What action by the nurse best promotes patient safety? a. Assess the client’s fall risk with a standardized tool. b. Obtain a prescription for an indwelling catheter. c. Provide a bedside commode for the client to use. d. Remind the client to get assistance with toileting. Readiness for enhanced comfort; comfort, impaired 1. A nurse is caring for a client with the diagnosis of Readiness for Enhanced Comfort. Which of the following Nursing Outcomes Classification (NOC) outcomes would be inconsistent with the nurse’s knowledge of this diagnosis? a. Symptom control b. Comfort status c. Spiritual health d. Secondary health promotion 2. The mother of an infant is distressed because the baby needs to have blood drawn. What instruction by the nurse would decrease both the mother’s and the baby’s discomfort? a. Encourage the mother to hold the baby in a skin-to-skin embrace. b. Assure the mother that the baby cannot feel any real pain. c. Take the baby from the mother during the blood draw procedure. d. Swaddle the baby snugly except for the area of the venipuncture. 3. The nurse is caring for a client with dementia who appears to be in discomfort. Which intervention should the nurse attempt with this client? a. Guided imagery b. Healing touch c. Simple massage d. Distraction techniques 4. The nurse is caring for a post-operative client from an unfamiliar culture. The nurse is frustrated because the client will not take pain medication, but refuses to get out of bed. What action by the nurse is best? a. Teach the client how pain control helps with increasing activity. b. Give the client pain medications without explaining what they are. c. Ask the client what pain and illness represent in his/her culture. d. Have the provider discuss pain medication with the client. 5. A client is admitted with end-stage cancer and has several medications ordered for pain control, including long-acting narcotics, non-narcotic pain medications, and medications for breakthrough pain. The client complains loudly of pain of 2 on a 1-10 scale and is angry that the pain cannot be controlled. Which intervention by the nurse is best? a. Administer the medication for breakthrough pain. b. Ask the client to explain more about the pain. c. Inform the provider that the client needs more medication. d. Teach the client how different pain medications work. Activity intolerance 6. A post-operative client will be getting out of bed and walking to the chair for the first time since surgery. Which intervention by the nurse is best? a. Pre-medicate the client for pain prior to the activity. b. Take the client’s vital signs prior to beginning the activity. c. Call the provider and request a physical therapy consultation. d. Encourage the client to do as much as possible him- or herself.7. A nurse is ambulating a client in the hallway. The client begins to act confused and seems weaker than earlier. Which action by the nurse takes priority? a. Stop ambulating the client and have someone bring a wheelchair. b. Return the client to bed immediately, ambulating slowly. c. Have the client rest, then resume ambulating at a slower pace. d. Encourage the client to take slow deep breaths while returning to bed. 8. A client has been on bed rest for several weeks and now has orders to begin increasing activity as tolerated. The client is concerned about tolerating more activity. Which action by the nurse is best? a. Teach the client about the benefits of increased activity. b. Assist the client in setting realistic short term activity goals c. Discuss all the potential complications of remaining bedfast d. Call the provider and request a physical therapy consultation. 9. A client with Chronic Obstructive Pulmonary Disease (COPD) wants increased activity but complains of extreme weakness with each attempt at ambulating. Which action by the nurse is best? a. Arrange a dietary consult. b. Place oxygen on the client c. Limit the client’s activity. d. Encourage walking shorter distances. 10. A hospitalized older client needs to increase activity, but is unsteady and complains of dizziness with activity. Which action by the nurse is most important? a. Evaluate the client’s medications. b. Ask the client if he/she is just afraid of falling. c. Perform lower extremity strength testing. d. Reassure the client that someone will help with ambulation. Anxiety 11. A client presents to the medical clinic complaining of a feeling of unease and anxiety without a known cause. While conducting the assessment, what other finding should the nurse be most alert for? a. Diarrhea b. Heart failure c. Diabetes d. Excessive salivation 12. A nurse has performed discharge teaching on a client with moderate anxiety. Which statement by the client indicates the teaching has been effective? a. “If I practice my breathing exercises, I will never be anxious again.” b. “I will keep the phone number for the anxiety hotline with me.” c. “I can double my medications if I feel really anxious sometimes.” d. “It’s OK to have 1-2 drinks a day to help relieve my anxiety.” 13. The nurse’s aide is taking vital signs on a client admitted with severe anxiety. The aide reports a blood pressure of 90/58 mmHg, a pulse of 56 beats/minute, and respirations of 10 breaths/minute. Which statement by the nurse is most accurate? a. “The client must be less anxious than previously.” b. “Vital signs do not give accurate information about anxiety.” c. “If he were anxious, his blood pressure would be sky-high.” d. “Lowered blood pressure and pulse can be a sign of anxiety.” 14. Which of the following does the nurse understand about anxiety? a. The patient never knows the source of the anxiety. b. The patient always knows the source of the anxiety. c. Often the source of the anxiety is not known to the patient.d. There are no physical manifestations of anxiety. 15. A client presents to the Emergency Department with symptoms of severe anxiety. Which question or statement by the nurse would be most important? a. “Does anyone else in your family have anxiety?” b. “Have you been using alcohol or other drugs recently?” c. “You look fine to me. Why are you so anxious?” d. “What problems are you having in your life right now?” Risk for aspiration 16. A nurses’ aid has finished feeding a frail, older client and has lowered the head of the bed at the client’s request for a nap. Which action by the nurse is most appropriate? a. Document how the client tolerated the feeding and amount of intake. b. Listen to the client’s lungs and have the aid get a set of vital signs. c. Raise the head of the client’s bed to at least 30 degrees for the next hour. d. Ask the client if he/she would like to have the ordered sleeping medication. 17. A nurse in a rehabilitation facility is preparing to admit a new patient from an inpatient hospital who had a stroke. Which action by the nurse is most appropriate? a. Ensure there is a suction machine and tubing in the room. b. Request a dietary consult for an appropriate diet. c. Request blue dye from the pharmacy to add to the client’s food. d. Consult with the provider and request a swallowing study. 18. A nurse is preparing to administer a tube feeding through a small bore feeding tube that has been in place for several days. Which action by the nurse is most appropriate? a. Instill air through the tube and ausculate for air sounds in the client’s stomach. b. Measure the distance of the tube outside the body, comparing it to the chart. c. Check the pH of the gastric residual using nitrazine paper. d. Call radiology and request a chest x-ray to confirm placement of the tube. 19. A nurses’ aid is working with an unresponsive client receiving a tube feeding. Which action by the nurse requires immediate intervention? a. Recording the client’s daily weight in the chart b. Reconnecting the enteral tube feeding line when it comes apart c. Maintaining the head of the client’s bed at 30-45 degrees d. Turning the tube feeding off to reposition the client. 20. An older client has had a stroke and needs some assistance with feeding. Which instruction by the nurse to the nurses’ aid is most important? a. “Be sure to brush the client’s teeth after meals.” b. “Please document what the client eats in the chart.” c. “Weigh the client daily at the same time on the same scale.” d. “Help the client choose foods he/she prefers for meals.” Chronic Pain 21. A nurse is interviewing a client with chronic pain who does not take any analgesics but rather “pushes through it”. What question or statement by the nurse would be most helpful? a. “Tell me about any concerns you have regarding treatment for pain.” b. “Why won’t you take anything for your pain? Are you afraid of addiction?” c. “Pushing through the pain will eventually just make the pain worse.” d. “Aren’t you afraid you are damaging something by not treating your pain?” 22. A client is given a new prescription for opioid pain medication to treat chronic pain and is also given prescriptions for a stool softener and stimulant laxative. The client only wants to fill the pain medication prescription. What response by the nurse is best? a. “Well wait and see if you have constipation, then fill them if you do.”b. “People on opioid medications have to take medications for their bowels.” c. “You don’t have to fill any of these prescriptions if you don’t want to.” d. “Constipation is a side effect of opioids that does not seem to improve over time.” 23. A patient with a chronic pain exacerbation is admitted for surgery. The patient needs pre-operative teaching. What action should the nurse take first? a. Treat the client’s pain. b. Plan the teaching session. c. Assess the client’s learning style. d. Ask about pain management strategies. 24. An older client is complaining of severe pain after a fall that caused a femur fracture. What medication would the nurse choose for this client? a. Meperidine b. Acetaminophen c. Lorazepam d. Morphine 25. A nurse is caring for a client who has a new prescription for an opioid analgesic for cancer pain. The nurse has taught the mechanism of action, side effects and how to manage them, what to report to the provider, and how to take the medication. What other teaching topic does the nurse include as the priority? a. Other medications that might be prescribed b. Fears related to addiction to the medication c. Contact information for the prescribing provider d. How to titrate the medication based on pain Constipation 26. The nurse assessing clients for constipation would be least concerned with the client having which assessment finding? a. Hypoactive bowel sounds b. Borborygmi c. Anorexia d. Percussed abdominal tympany 27. A nurse is conducting an educational session on healthy bowel habits to community members attending a workshop. How much fiber does the nurse encourage participants to eat daily? a. 10-12 grams b. 15-23 grams c. 18-25 grams d. 20-22 grams 28. A nurse is caring for a client who recently added increased fiber to the diet, and now avoids fiber because it led to abdominal distention, flatus, and abdominal pain. What response by the nurse is best? a. “How much fiber did you add to your daily diet?” b. “You realize high fiber foods are best to prevent constipation.” c. “Tell me what foods you added and how you added them.” d. “Did your health care provider instruct you on a high fiber diet?” 29. The nurse has instructed a client on high fiber foods and the recommended daily fiber intake. What else should the nurse include in the teaching plan as a priority? a. Drink 6-8 glasses of water daily. b. Only eat whole wheat pasta and rice. c. Be sure to increase your fluid intake. d. Get most of your fiber at night. 30. The nurse is caring for a busy executive complaining of chronic constipation who states the dailydiet contains sufficient fiber and water intake is adequate. What other assessment question would provide the nurse the most useful information? a. “Do you eat out for a lot of your meals during the day?” b. “Are you able to go to the bathroom when you first notice the urge?” c. “Define ‘adequate fiber and water intake’ for your daily diet.” d. “Have you tried any over the counter laxative or stool softeners?” Fluid Volume Deficit 31. The nurse is assessing four hospitalized clients for fluid volume deficit. Which client should the nurse assess further as the priority? a. 102 kg client; urine output 73 ml in 1 hour b. 98 kg client; urine specific gravity 1.042 c. 106 kg client; pulse 108 beats/minute d. 79 kg client; cannot obtain fluids 32. A client has fluid volume deficit and the provider has prescribed isotonic IV solution at a rate of 100 ml/hour. Which solution does the nurse choose? a. 0.9% sodium chloride (NS) b. 0.45% sodium chloride (1/2 NS) c. 5% dextrose in water (D5W) d. 10% dextrose in water (D10W) 33. The nurse has delegated taking orthostatic vital signs to the unlicensed assistive personnel (UAP). The UAP reports the following vital signs. Which client should the nurse assess as the priority? a. Lying BP: 122/86 mmHg; standing BP 116/78 mmHg b. Lying BP: 144/94 mm Hg; standing BP 136/88 mmHg c. Lying BP: 118/76 mmHg; standing BP 128/88 mmHg d. Lying BP: 136/96 mmHg; standing BP 134/76 mmHg 34. A student nurse is giving hand-off report to the registered nurse on four clients who have fluid volume deficit. Which client should the registered nurse assess first? a. 86-year-old client, IV fluids infusing at 100 ml/hour, rales bilaterally b. 66 kg client, urine output averages 36ml/hour for the last 4 hours c. 100 kg client, lying BP 128/72 mmHg, standing BP 118/68 mmHg d. 76-year-old client, urine specific gravity 1.028 35. The charge nurse in a long term care facility wants to decrease the incidence of fluid volume deficit in the facility’s residents. What action by the nurse is best? a. Create a policy mandating monthly urine specific gravity tests. b. Perform comprehensive assessments for fluid volume deficit. c. Weigh the residents weekly on the same scale each morning. d. Institute “fluid rounds” offering beverages every 2 hours. Impaired Gas Exchange 36. A nurse is caring for a hospitalized client. The family reports the client is “not acting right”. What action by the nurse takes priority? a. Assess the client’s oxygenation status. b. Perform a mental status evaluation. c. Review today’s white blood cell count d. Take the client’s blood pressure and pulse. 37. A client’s oxygen saturation is 99% while in bed; when ambulating the client’s oxygen saturation is 92%. What intervention by the nurse is most appropriate? a. Keep the client on strict bedrest. b. Allow the client chair activity only. c. Administer oxygen when the client ambulates.d. Refer the client to pulmonary rehabilitation. 38. The student nurse is giving hand off report to the registered nurse on four clients who have impaired gas exchange. Which client should the nurse assess first? a. Oxygen saturation 93% b. Respiratory rate 20 breaths/minute c. Cyanotic nail beds d. Partial pressure of oxygen 42 mmHg 39. The nurse in a long term care facility notices that one resident who walks with a walker leans forward on the walker near the end of the activity. What action by the nurse is most important? a. Assess the resident’s lower limb strength. b. Assess the resident’s oxygenation status. c. Refer the resident to physical therapy. d. Instruct the resident not to walk alone. 40. The nurse is caring for a client who returned to the nursing unit following a hip replacement. The client complains of severe pain and the nurse administers IV morphine. What action by the nurse is the priority? a. Assess the client’s pain in 45 minutes. b. Take the client’s vital signs in 30 minutes. c. Assess the client’s respiratory status in 15 minutes. d. Help the client assume a position of comfort. Sedentary Lifestyle 41. A nurse works with a client in the family medicine clinic who is very overweight and sedentary. The client understands the benefits of daily activity but says there is no desire to begin exercising or increase activity. What action by the nurse is best? a. Remind the client of the health hazards of a sedentary lifestyle. b. Ask the client what motivates him/her in daily life. c. Refer the client to a community based fitness center. d. Explore if the client’s work benefits cover gym memberships. 42. The nurse is helping a client establish goals for steps each day. After wearing a pedometer for 2 weeks, the client knows the average number of daily steps is 2800. What goal does the nurse encourage the client to achieve in 4 weeks? a. 3800 b. 4800 c. 5800 d. 6800 43. The pediatric nurse works with a group of children who are sedentary. What advice by the nurse would most likely be successful? a. Get up and walk around during ads on television b. Only play video games 1 day a week c. Find a time to exercise with your parents d. Join a community sports team 44. An older client asks the nurse about the benefits of Tai Chi. What response by the nurse is best? a. Improved balance b. Increased leg strength c. Improved cognitive function d. Increased aerobic capacity 45. The client asks the nurse how often weight training should be done each week. What response by the nurse is best? a. 1-2 times per week b. 2-3 times per weekc. 3-4 times per week d. At least 4 times per week Hypothermia 46. A client’s temperature is 33° C (91.4° F). What action by the nurse is best? a. Prepare to perform continuous internal temperature monitoring. b. Check tympanic temperature every 30 minutes to 1 hour. c. Teach the client about temporal artery temperature measurements d. Delegate taking vital signs, including temperature to unlicensed personnel. 47. A nurse has come upon the scene of a bus accident in frigid weather. The bus has gone off a cliff and there are several people sitting or lying on the roadside. Which person should the nurse attend to first? a. Shivering b. Weak, slow pulse c. Red skin d. Headache 48. A client has a core temperature of 32.2° C (90° F). Which action by the nursing student requires the registered nurse to intervene? a. Removes wet, cold clothing b. Places blankets on client’s head c. Obtains a forced-air warming blanket d. Gives the client warm beverages 49. The nurse is caring for a client who is being actively rewarmed for moderate hypothermia. The client’s suddenly develops pulseless ventricular tachycardia. Which action by the nurse takes priority? a. Determine the rate of rewarming. b. Begin immediate high-quality CPR. c. Check the client’s vital signs. d. Increase the infusion of warmed IV solutions. 50. A client has suffered an out-of-hospital cardiac arrest. The nurse prepares to institute therapeutic hypothermia. What action by the nurse is inconsistent with this treatment modality? a. Using two methods of temperature monitoring b. Providing care with a ventilator bundle c. Allowing shivering only during rewarming d. Implementing pressure sore prevention methods 51. The faculty member explains to students that which alteration is a normal age-related change that predisposes the older client to hypothermia? a. Decreased sense of thirst b. Diminished balance c. Decreased temperature sensitivity d. Reduced metabolic rate Obesity 52. The nurse working with obese clients informs them that which meal is the most important for controlling weight? a. Breakfast b. Brunch c. Lunch d. Dinner 53. An obese client asks the nurse how much physical activity is recommended for weight loss. How many minutes per week does the nurse recommend to this client?a. 70 minutes/week b. 100 minutes/week c. 150 minutes/week d. 200 minutes/week 54. A nurse is working with a weight loss group. Which client statement by a client indicates better weight management? a. “I ate too much over the weekend, but it’s time to get back on track.” b. “I don’t want to be part of a weight loss group; I’d rather do it on my own.” c. “I simply cannot ever be around ice cream or I will eat all of it.” d. “I know I will never be able to have fast food again.” 55. Which client has the most realistic and helpful goal for managing obesity? a. “I want to lose 10 pounds in 1 month.” b. “I will keep a food journal 5 days a week.” c. “I plan to lose 20 pounds by summer.” d. “I want to drop 2 dress sizes.” 56. The nurse is teaching a client stimulus-control techniques to manage obesity. What statement by the client indicates good understanding of this method? a. “I will have to eat alone from now on.” b. “I have to stop buying junk food.” c. “I need to cook different meals for my family.” d. “I should listen to soft music while eating.”