NCLEX Hurst Readiness Exam 1

The nurse is teaching a group of pregnant women about hormonal changes during pregnancy. The nurse recognizes that teaching was successful when the women identify which hormone as causing amenorrhea? Progesterone The client is admitted to the hospital following a motor vehicle accident and has sustained a closed chest wound. The nurse notes paradoxical chest wall movement. Which problem does the nurse suspect? Flail chest Which client can a nurse manager safely transfer from the telemetry unit to the obstetrical unit in order to receive a new admit? Client diagnosed with seizure disorder. The nurse is teaching a group of clients who have reduced peripheral circulation how to care for their feet. What points should the nurse include? gradually. Check shoes for rough spots in the lining. File toenails straight across. Break in new shoes When caring for young adult clients, which developmental tasks would the nurse expect to see? Developing meaningful and intimate relationships. Giving and sharing with an individual without asking what will be given or shared in return. What symptoms does the nurse expect to see in a client with bulimia nervosa? Feelings of self-worth unduly influenced by weight. Recurrent episodes of binge eating. Recurrent inappropriate compensatory behavior to prevent weight gain. A client who has had a laparoscopic cholecystectomy develops pain in the left shoulder. Vital signs, laboratory studies, and an electrocardiogram are within normal limits. What does the nurse recognize as a contributing cause of the pain? Carbon dioxide used intraperitoneally is irritating the phrenic nerve. A client is admitted to the medical unit with an acute onset of fever, chills and RUQ pain. Vital signs are: T 99.8°F (37.7°C), P 132, RR 34, B/P 142/82. ABG results are: pH-7.53, PaCO2 30, HCO3 22. The nurse determines that this client is in what acid/base imbalance? Respiratory alkalosis An unlicensed assistive personnel (UAP) has explained how to prevent the spread of infection to the charge nurse. Which statement by the UAP indicates that further teaching is needed? "When caring for a client who has a suppressed immune response, a N95 mask should be worn." The nurse is preparing to discharge a client who has been placed on tranylcypromine. The nurse teaches the client about food to avoid while taking this medication. What food choice by the client confirms appropriate understanding of the teaching? Salami Which nurse is providing cost effective care to a client? Providing palliative care to a terminally ill client. Beginning discharge planning on admit. Counseling clients on cigarette smoking cessation. Educating a group of parents on the importance of childhood immunizations. A client is admitted for observation following an unrestrained motor vehicle accident. A bystander stated that the client lost consciousness for 1-2 minutes. On admission, the client reports a headache and had a Glasgow coma scale (GCS) of 14. The GCS is now 12. What is the priority nursing intervention for this client? Notify the primary healthcare provider. The nurse is assessing a client who is being treated with a non-steroidal antiinflammatory medication (NSAID) for an acute flare-up of gout. Which finding is expected in the assessment? Dramatic decrease in pain after beginning medications. A home care nurse is preparing to perform venipuncture on a client to draw blood. As the nurse gathers supplies, the client begins to experience palpitations, trembling, nausea, shortness of breath and a feeling of losing control. How should the nurse communicate with this client? Use simple words. The nurse is preparing a client for surgery. Which methods are appropriate for the nurse to use in removing excessive body hair? Removing the hair with clippers. Using a depilatory cream. A new mother calls the clinic and tells the nurse, "I don't have any help taking care of my 3 week old baby. I don't know what to do. I just feel like I can't take care of him anymore. I wish I never had him sometimes. Maybe then my husband would spend more time at home." What would be the nurse's best response? "Come to the clinic now so that we can help you." The primary healthcare provider instructs the nurse to place body tissue obtained from a biopsy into a container with formalin prior to sending it to pathology. The nurse has not handled formalin before. What would be the nurse's best action? Read about formalin on the Material Safety Data Sheet (MSDS). The nurse is administering medication to an elderly client who has no visitors. The client takes the pills, and, as the client hands the medication cup back to the nurse, grabs onto the nurse's hand tightly. What is the most logical rationale for the client's action? Scared and lonely and grabs the nurse's hand for comfort. A nurse is caring for a 65 year-old client diagnosed with dehydration. The client has been receiving intravenous normal saline at 150 mL/hour for the past 4 hours. Which finding would the nurse need to notify the primary healthcare provider? Anxiety The nurse reassesses the client's pain level after administering an oral analgesic. The client states that the pain is better but continues to report a backache. Which non-pharmacologic interventions may help the client's backache? Assisting the client into a side lying position. Providing a back massage. Providing heat therapy. Using distraction techniques. The nurse is caring for a client on the pediatric unit. The primary healthcare provider prescribes phenytoin 30 mg by mouth every 8 hours for a client weighting 18 kg. The recommended dosage is 5 mg/kg/day. What does the nurse determine is the safe dosage for the child in mg/day? Round your answer to the nearest whole number. 5mg x 18 kg = 90 mg/day Which client diagnosis would require the nurse to initiate droplet precaution? Whooping cough Which finding would indicate to the nurse that a client is at nutritional risk and should receive a dietary consult? Six year old who had surgery 5 days ago, receiving clear liquid diet since surgery. A nurse observes a fire has started in the trash can of a client's room. What steps should the nurse take? Place steps in priority from first to last. First, remove the client from the room. Second, activate the fire alarm. Third, close the door to the client's room. Fourth, obtain the fire extinguisher. Fifth, extinguish the fire. What laboratory results would the nurse anticipate finding in a client receiving chemotherapy who is experiencing pancytopenia? White blood cell count of 3,800 (3.8 x 109/L) Platelet count of 90,000/μL (90 x 109/L) Red blood cell count of 3.0 million/mcL (3.0 x 1012/L) A client is taking a nonsteroidal anti-inflammatory drug (NSAID) for the relief of joint pain. A gastrointestinal bleed is suspected. Which laboratory value alerts the nurse to the possibility that the client is chronically losing small amounts of blood? Elevated reticulocyte count Which client should the nurse, working the Emergency Department (ED), see first? Client with adrenal insufficiency who feels weak. A newly admitted client with schizophrenia tells the nurse, "The doctor is trying to steal my organs for science." Which response by the nurse would be most therapeutic? Are you feeling afraid now? What discharge instruction should a nurse provide to a client diagnosed with Hepatitis B to provide adequate nutrition? Suggest client eat several small meals a day, with the largest at breakfast. The nurse is teaching the client with asthma on proper use of an inhaler. Which statements by the client indicates that teaching has been successful? select all that apply "Exhale completely before using my inhaler. "Inhale slowly and push down firmly on the inhaler." "Rinse my mouth with water after using my inhaler." The unlicensed assistive personnel (UAP) reports to the nurse that a client with Alzheimer's has been walking into rooms on the unit and stating, "This is my room, so get out!" What is the best instruction the nurse can give to the UAP? Hang a familiar object on the door to enhance room recognition. A client arrives at the emergency department with a pneumothorax. A chest tube is inserted and placed to 20 cm of suction. Two hours later, the nurse notes tidaling in the water-seal chamber. Based on this data, what intervention should the nurse initiate? Document the finding. Which task would be appropriate for the charge nurse to assign to a LPN/VN? Collect data on a new client admit. Bolus feeding a client who has a gastrostomy tube. Reinserting a nasogastric tube (NG) that a client accidentally pulled out. Monitor patient control analgesic (PCA) pump pain medication being delivered to a client. A nurse is teaching a renal transplant client about self care after discharge. As part of the information about transplant rejection, the nurse cautions the client to notify the primary healthcare provider of which occurrence? Tenderness over the kidney An elderly client receives instructions regarding the use of warfarin sodium. Which statement indicates to the nurse that the client understands the possible food interactions which may occur with this medication? "I will have to watch my intake of salads, something that I really love." The nurse sees that the new medication noted in a recent prescription is on the client's list of allergies. In the role of client advocate, what actions should the nurse take to ensure client safety? Notify the primary healthcare provider immediately that the medication prescribed is on the client's list of medication allergies. Stop the medication on the client's medication administration record. Check the client's allergy band against the list of client allergies documented in the medical record. ... A nurse manager notices that unit nurses consistently forget to ask clients to rate their pain level on a scale of 0-10. What strategies could the nurse manager initiate to improve performance? Provides "just in time" posters outlining the importance of pain assessment. Conducts brief in-services for each shift. Counsels nurses when pain level scale is not utilized. Ensures that a complete and clear performance standard exists. Assesses nurses' reasons for not using pain level scale. Which statement by a client scheduled to be discharged home following treatment for alcoholism would indicate to the nurse that further instruction is necessary? "I should go to an Alcoholics Anonymous meeting when I feel the need to drink alcohol." A confused elderly client is brought to the emergency department by a family member who states the client fell down a flight of stairs. In addition to multiple facial contusions, x-rays reveal a spiral fracture of the left forearm. After assisting the primary healthcare provider in applying a short arm cast, the nurse identifies which action as a priority in discharge planning? Notify social services to arrange a home visit. The nurse is teaching a group of clients about selective serotonin reuptake inhibitors (SSRI). Which comment by a client in the group indicates adequate understanding of the effects/side effects of the medications? I may expect increased sweating while taking this drug. Which assessment findings does the nurse expect to find when assessing a client admitted to the emergency department with left sided congestive heart failure? Bibasilar crackles Orthopnea A nurse is teaching a client about post-procedure thoracentesis nursing care. Which statements should the nurse include? Checking your vital signs frequently. Examining the dressing for bleeding. Listening to and percussing your lungs. Palpating around the incision site for air under the skin. A new nurse is documenting in a client's electronic record. Which documentation would the charge nurse evaluate as appropriate documentation by the new nurse? Forty year old admitted with diagnosis of cholecystitis to room 410 for surgical services. Permit signed for laparoscopic cholecystectomy after discussing procedure with surgeon. Transferred to surgical suite per stretcher with side rails up, in stable condition. The nurse has been educating a client on a new prescription for amitriptyline 25 mg PO twice a day. The nurse recognizes that teaching has been successful when the client makes which statement? I will wear long sleeves and a hat when I go for my afternoon walks. A primary healthcare provider has prescribed sterile saline 1.5 mL IM every 4 hours as needed for pain for a client who reports frequent "severe" headaches. What action should the nurse take? Discuss client rights with the primary healthcare provider A client is being treated in the emergency department for dehydration. Which central venous pressure (CVP) reading would the nurse identify as the desired response to treatment? 4 mm Hg The nurse is admitting a client with a fifteen year history of poorly controlled diabetes mellitus. During the initial assessment the client reports experiencing "numb feet." What nursing action takes priority? Examine the client's feet for signs of injury. A client is admitted to the intensive care unit after overdosing on meperidine. What is the nurse's first priority? Administer naloxone hydrochloride 0.4 mg IV every 2-3 minutes prn. When performing an admission assessment, what should the nurse recognize as signs/symptoms of hyperthyroidism? Nervousness Exophthalmos Hot and sweating A newly admitted client tells the nurse, "I am hearing voices." Which response by the nurse is most appropriate? Tell me what the voices are saying to you. The nurse in the clinic would recognize which client statement as most indicative of gallbladder disease? "Yesterday, when I ate a hamburger and french fries, my belly really hurt." Which client assignments are most appropriate for the charge nurse to delegate to an LPN/VN who works on the pediatric unit? 10 year old paraplegic in for bowel training. 7 year old in Buck's traction for a femur fracture. The nurse is teaching the family of a newly diagnosed diabetic client about treatment of hypoglycemia at home. Which guidelines should be given to the family of the client? Treat a mild episode with 10-15 grams of carbohydrate. What activities should a nurse recommend to a group of adolescents who have been diagnosed with rheumatoid arthritis? Bicycle riding Swimming