NCLEX PN EXAM 155 Questions & Answers Latest Update Graded A 2023

1. A 30-year-old male client is admitted to the psychiatric unit with a diagnosis of bipolar disorder. For the last 2 months, his family describes him as being “on the move,” sleeping 3–4 hours nightly, spending lots of money, and losing approximately 10 lb. During the initial assessment with the client, the nurse would expect him to exhibit which of the following? C. Exaggerated self-importance 2. Diabetes during pregnancy requires tight metabolic control of glucose levels to prevent perinatal mortality. When evaluating the pregnant client, the nurse knows the recommended serum glucose range during pregnancy is: A. 70 mg/dL and 120 mg/dL 3. When evaluating a client with symptoms of shock, it is important for the nurse to differentiate between neurogenic and hypovolemic shock. The symptoms of neurogenic shock differ from hypovolemic shock in that: A. In neurogenic shock, the skin is warm and dry 4. A 55-year-old man is admitted to the hospital with complaints of fatigue, jaundice, anorexia, and claycolored 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 exposure to hepatitis. Which of the following represents a high-risk group for contracting this disease? B. Oncology nurses 5. A schizophrenic client has made sexual overtures toward her physician on numerous occasions. During lunch, the client tells the nurse, “My doctor is in love with me and wants to marry me.” This client is using which of the following defense mechanisms? B. Projection 6. When teaching a sex education class, the nurse identifies the most common STDs in the United States as: A. Chlamydia 7. 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: C. Encourage pursed-lip breathing 8. In a client with chest trauma, the nurse needs to evaluate mediastinal position. This can best be done by: C. Palpating for trachial deviation 9 Clinical manifestations seen in left-sided rather than in right-sided heart failure are: D. Decreased peripheral perfusion and rales 10. In assessing cardiovascular clients with progression of aortic stenosis, the nurse should be aware that there is typically: D. Increased left ventricular systolic pressures and hypertrophy 11. 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 would be important to include in the initial history? D. Headaches, malaise, or sore throat 12. When administering phenytoin (Dilantin) to a child, the nurse should be aware that a toxic effect of phenytoin therapy is: A. Stephens-Johnson syndrome 13. The nurse should know that according to current thinking, the most important prognostic factor for a client with breast cancer is: B. Axillary node status 14. Three weeks following discharge, a male client is readmitted to the psychiatric unit for depression. His wife stated that he had threatened to kill himself with a handgun. As the nurse admits him to the unit, he says, “I wish I were dead because I am worthless to everyone; I guess I am just no good.” Which response by the nurse is most appropriate at this time? D. “You’ve been feeling sad and alone for some time now?” 15. Which of the following should be included in discharge teaching for a client with hepatitis C? C. He should avoid alcoholic beverages during his recovery period. 16. The initial treatment for a client with a liquid chemical burn injury is to: B. Flush the exposed area with large amounts of water 17. 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? D. 60% complex carbohydrate, 12%–15% protein, 20%–25% fat 18. The primary reason for sending a burn client home with a pressure garment, such as a Jobst garment, is that the garment: A. Decreases hypertrophic scar formation 19. The nurse would expect to include which of the following when planning the management of the client with Lyme disease? B. Tetracycline treatment 20. A 6-year-old child is attending a pediatric clinic for a routine examination. What should the nurse assess for while conducting a vision screening? C. Strabismus 21. A 52-year-old client’s abdominal aortic aneurysm ruptured. She received rapid massive blood transfusions for bleeding. One potential complication of blood administration for which she is especially at risk is: C. Hypocalcemia 22. A young boy tells the nurse, “I don’t like my Dad to kiss or hug my Mom. I love my Mom and want to marry her.” The nurse recognizes this stage of growth and development as: B. Oedipus complex 23. A 19-year-old client fell off a ladder approximately 3 ft to the ground. He did not lose consciousness but was taken to the emergency department by a friend to have a scalp laceration sutured. The nurse instructs the client to: C. Return to the hospital immediately if he develops confusion, nausea, or vomiting 24. At 32 weeks’ gestation, a client is scheduled for a fetal activity test (nonstress test). She calls the clinic and asks the RN, “How do I prepare for the test I am scheduled for?” The RN will most likely inform her of the following instructions to help prepare her for the test: D. “You will have to remain as still as you possibly can.” 25. The nurse instructs a client on the difference between true labor and false labor. The nurse explains, “In true labor: B. Uterine contractions will strengthen with walking.” 26. After the fetal activity test (nonstress test) is completed, the RN is looking at the test results on the monitor strip. The RN observes that the fetal heart accelerated 5 beats/min with each fetal movement. The accelerations lasted 15 seconds and occurred 3 times during the 20- minute test. The RN knows that these test results will be interpreted as: A. A reactive test 27. A 70-year-old client has pneumonia and has just had a respiratory arrest. He has just been intubated with an 8- mm endotracheal tube. During auscultation of his chest, breath sounds were found to be absent on the left side. The nurse identifies the most likely cause of this as: C. Right mainstem bronchus intubation 28. After performing a sterile vaginal exam on a client who has just been admitted to the unit in active labor and placed on an electronic fetal monitor, the RN assesses that the fetal head is at 21 station. She documents this on the monitor strip. Fetal head at 21 station means that the fetal head is located where in the pelvis? B. One centimeter above the ischial spines 29. Cheyne-Stokes respiratory pattern can be associated with which of the following conditions? C. Increased intracranial pressure 30. A 47-year-old client has been admitted to the general surgery unit for bowel obstruction. The doctor has ordered that an NG tube be inserted to aid in bowel de-compression. When preparing to insert a NG tube, the nurse measures from the: D. Tip of the nose to the ear lobe to the xiphoid process or midepigastric area 31. Because a client is taking an MAO inhibitor, it is necessary to discuss the need for adherence to a lowtyramine diet. Which of the following are foods that she should avoid? A. Pickled, aged, smoked, and fermented foods 32. The nurse documents a client’s surgical incision as having red granulated tissue. This indicates that the wound is: D. Healing 33. A 16-year-old client with a diagnosis of oppositional defiant disorder is threatening violence toward another child. In managing a potentially violent client, the nurse: A. Must use the least restrictive measure possible to control the behavior 34. A client returns to the cardiovascular intensive care unit following his coronary artery bypass graft. In planning his care, the most important electrolyte the nurse needs to monitor will be: C. Potassium 35. A client is admitted to the hospital with diabetic ketoacidosis. The emergency room nurse should anticipate the administration of: B. Humulin R 36. A client has received digoxin 0.25 mg po daily for 2 weeks. Which of the following digoxin levels indicates toxicity? D. 3.0 ng/mL 37. A male client received a heart-lung transplant 1 month ago at a local transplant center. While visiting the nursing center to have his blood pressure taken, he complains of recent weakness and fatigue. He also tells the nurse that he is considering stopping his cyclosporine because it is expensive and is causing his face to become round. He fears he will catch viruses and be more susceptible to infections. The nurse responds to this last statement by explaining that cyclosporine: A. Is given to prevent rejection and makes him less susceptible to infection than other oral corticosteroids 38. Decreased pulmonary blood flow, right-to-left shunting, and deoxygenated blood reaching the systemic circulation are characteristic of: A. Tetralogy of Fallot 39. As a postoperative cholecystectomy client completes tomorrow’s dinner menu, the nurse knows that one of the following meal choices will best provide the essential vitamin(s) necessary for proper tissue healing? D. Chicken breast fillet in tomato sauce, potatoes, mustard greens, orange and strawberry slices 40. While changing the dressing on a client’s central line, the nurse notices redness and warmth at the needle insertion site. Which of the following actions would be appropriate to implement based on this finding? C. Document in the nurse’s notes and notify the physician after redressing the site. 41. The nurse has been assigned a client who delivered a 6- lb, 12-oz baby boy vaginally 40 minutes ago. The initial assessment of greatest importance for this client would be: D. Character of the fundus 42. When assessing residual volume in tube feeding, the feeding should be delayed if the amount of gastric contents (residual) exceeds: D. 50 mL 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. A Charge nurse is teaching a group of newly licensed nurses about the correct use of restraints. Which of the following examples should the charge nurse include in the teaching? Keeping the side rails of a toddlers crib elevated 72. A charge nurse is teaching a newly licensed nurse about the facilities computerized documentation system. Which of the following information should the nurse include? Information technology will install a firewall to secure client information 73. A nurse overhears two assisteve personals discussing care for a client while in the elevator.. which of the following actions should the nurse take? Report the incident to the ap’s charge nuse 74. A nurse is assessing a client who is 1 day postoperative following the placement of an ileostomy. Which of the following findings should the nurse report to the provider? The stoma has a purplish hue 75. A nurse is providing teaching to a client who has heart failure and a new prescription for furosemide. Which of the following statements should the nurse make? Rise slowly when getting out of bed 76. A home health nurse is performing a home safety evaluation for an older adult client who uses a walker. The nurse should identify that which of the following findings indicates proper home safety? 77. The client utilizes a night light in the hallway and bathroom A nurse is assessing a school age child who has a urinary tract infection. Which of the following should the nurse expect? Enuresis 78. A nurse is teaching a newly licensed nurse about incident reports. Which of the following statements by the newly licensed nurse indicates an understandings of the teaching? They assist with unit quality impovements 79. A nurse is caring for a client who has preeclampsia and is receiving magnesium sulfate. The nurse should identify that which of the following findings is a manifestation of magnesium toxicity? Hyperreflexia 80. A nurse is preparing to teach the parents of a child who ahs cystic fibrosis. Which of the following instructions should the nurse plan to include? Provide a diet high in protein and calories 81. A nurse is admitting a client who has a blood culture positive for MRSA. There are no private rooms available. The nurse should place the client in a room with which of the following clients? A client who has CDIFF 82. A nurse is caring for a client who is at 11 weeks of gestation. Which of the following immunixation should the nurse recommend? Influenza 83. A nurse is reviewing home recommendations with a client sho is postoperative following knee surgery. Which of the following recommendations should the nurse make? Place handrall in the enteryway of the house 84. A nurse is caring for a client who has gestational hypertension and is experiencing toxic effects due to magnesium sulfate therapy. The nurse shoud anticipate administering which of the following medications? Calcium gluconate 85. A nurse is providing teaching about crutch safety to a client. Which of the following client actions indicates an understanding of the teaching? The client keeps her axillae free of pressure 86. A nurse is caring for a client who is 12 hr postoperative following a TURP. Which of the following findings should the nruse report to the provideR? Burgundy colored urine 87. A nurse on a mental health unit is caring for a client who is being admitted immediately following a sexual assult. Which of the following interventions should the nruse include in the plan of care? Limit the number of staff members providing care to the patient 88. A nurse is assessing an older adult client for social isolation. The nurse should identify that which of the following statements by the client indicates a risk for social isolation? My son moved across the country for a new job 89. A nurse is caring for a group of clients. Which of the following actions by the nurse demonstrates client advocacy? Assisting a client to obtain a second opinion for a diagnosis 90. A nurse in an ER is caring for a client who has a closed head injury. Which of the following actions should the nurse take first? Determine the clients Glasgow coma scale score 91. A nruse is preparing to assist with the lumbar puncture of an infant. The nurse should plan to place the infant in which of the following positions? Flexed side lying 92. A nurse is caring for a schoolage child who has sickle cell anemia and is in vaso occlusive crisis. Which of the following actions should the nurse take? Increase oral fluid intake 93. A nurse is caring for a client who ahs chronic kidney failure and a serum potassium level of 6.8. which of the following actions should the nurse take? Initiate continuous cardiac monitoring for the client 94. A nurse is caring for a client who is wearing antiembolic stockings. Which of the following interventions should the nurse include in the plan of care? Determine if the stockings are binding 95. A nurse in a family practice clinic for idiopathic scoliosis. Which of the following assesments should the nurse perform as part of this screening ? Observe for sacral dimpling 96. A nurse is educating the guardian of a toddler about the behaviors to expect immediately following discharge. Which of the following statements should the nurse include in the teaching? Your child will demand your attention after a period of acting indifferent 97. A nurse realizes that the wrong medication has been administered to a client. Which of the following actions should the nurse take first? Measure the client’s vital signs 98. A nurse is preparing to assist the provider with a paracentesis for a client who has ascites. Which of the following actions should the burse plan to take? Have the client void prior to the procedure 99. A nurse is caring for a client who is in the advanced stage of ALS. Which of the following referral is the nurses priority? Speech therapy 100. A nurse is working in a health department is conducting a health screening for a group of farmworkers. Which of the following client statement indicates a possible health risk? I eat veggies directly from the field where I work 101. A nurse is caring for a client who received a transfusion of 250 mo of packed RBCs. The nurse should identify that which of the following findings indicates the client is responding positively to the transfusion? The client’s hgm level increases following the transfusion 102. A nurse is caring for a group of client who have chronic pain. Which of the following clients should the nurse identify as a candidate for OT? A client who had painful hands due to degenerative joint disease 103. A nurse is planning care for a client who has unilateral paralysis and dysphagia following a right hemisphere stroke. Which of the following interventions should the nurse include in the plan? Place the clients left arm on a pillow while he is sitting 104. A nurse is assessing a client who is postoperative and has a history of pulmonary embolism. Which of the following findings is the priority for th nurse to report to the provider? Dyspnea 105. A nurse is providing dietary teaching to a client who had CKD. Which of the following instructions should the nurse include? Restrict foods containing phosphorus 106. A nurse is preparing to obtain a health history from a client who is on bedrest. Which of the following positions should the nurse take to place the client at ease? Sit in a chair next to the bed 107. Nurse is performing dressing change for client was a sacral wound using negative pressure wound therapy. Which The following actions should the nurse take first? d) Determine pain level 108. A nurses caring for client recovery from the bowel surgery who has nasogastric tube connected to low intermittent suction. Which the following assessment findings should indicate to the nurse that the NG tube may not be functioning properly? c) Abdominal rigidity 109. A nurse is preparing to administer TPN with added fat supplements to a client who has malnutrition. Which of the following action should the nurse take? b) Check for an allergy to eggs 110. A charge nurse is discussing the use of applying ice to a client’s injured knee with a newly licensed nurse. Which of the following should the nurse identify as a benefit? (A/C?) c) Decreased capillary permeability 111 Nurse is developing discharge care plans for client has osteoporosis. To prevent injury the nurse should instruct the client to a) Perform weight bearing exercises 112 A nurse on acute med-surgical unit is performing assessments on a group of clients. Which is highest priority? a) The client has surgical hypoparathyroidism and positive Trousseau’s sign 113 Nurses caring for a client was congestive heart failure. Which of the following prescriptions for the provider should the nurse anticipate? c) Give the client enalapril 2.5 mg PO twice daily 114 A nurse is caring for a client who has a prescription for sertraline to treat depression. Which of the following statements by the client indicates an understanding of the medication treatment plan? c) I understand I may experience difficulty sleeping on this medication 115. A nurse has been caring for a female client who has bruises on her arms that she explains are a result of physical abuse by her husband. The client states, “I don’t know how much longer I can take this, but I’m afraid he’ll really hurt me if I leave. “Which of the following is an appropriate nursing intervention?” b) Help the client to recognize the signs of escalation of abuse behavior 116. A client was having suicidal thoughts tells the nurse “It just does not seem worth it anymore. Why not end my misery?” Which of the following responses for the nurses appropriate? b) Do you have a plan to end your life? 117. Nurse providing discharge teaching to the client who has schizophrenia and is starting therapy with Clozapine. Which of the following is the highest priority for the client to report to the provider? c) Fever 118. A nurse is preparing a client for surgery. The client states, "I'm sure this surgery will not help me get better" Which of the following responses should the nurse make "You're saying that you are doubtful that this procedure will benefit you. " 119. A nurse at a long term care facility is transcribing new prescriptions for 4 client s. Which of the following prescriptions is accurately transcribed by the nurse? ANS: Potassium chloride 20 mEq PO every morning 120. A charge nurse in a long term care facility notices an assistants repeated failure to provide oral care for clients. Which of the following actions should the nurse take? Discuss the unacceptable behavior with the AP while reinforcing expectations. 121. A Nurse is reinforcing teaching with a male client who is uncircumcised about obtaining a cleancatch midstream urine specimen. Identify the sequence of actions the client should take after washing his hands. Retract the foreskin to expose the glans cleanse the penis using an antiseptic swab Begin to urinate pass the urine container into the stream collect the specimen move the container out of the stream Replace the foreskin 122. A nurse is reinforcing teaching with a client who has a new diagnosis of type 2 diabetes mellitus and inquires about information concerning oral anti diabetic agents. In addition to the provider, where should the nurse refer the client for information? A pharmacist Package inserts American Diabetes Association 123. A nurse is caring for four clients who are all scheduled for surgery on the same day. Which of the following nursing actions demonstrates that the nurse possesses effective time management skills? Gathers all needed supplies and equipment before entering client rooms Completes one task before beginning a new task Documents the clients' preoperative vital signs when they are taken Delegates tasks to an assistive personnel (AP) that are within his range of function 124. A nurse in a long term care facility is serving on the ethics committee, which is addressing a client care dilemma. Which of the following strategies will facilitate resolving the dilemma? Determine the facts related to the dilemma. Identify possible solutions. Consider the client's wishes. 125. A clients daughters phones the charge nurse to report that the night nurse did not provide good care of her mother. Which response should the practical nurse make? c. Tell the daughter to talk with the units nurse manager. 126. A nurse is caring for a client who speaks a language different from the nurse. Which of the following actions should the nurse take? use a facility based interpreter of the same sex as the client 127. A nurse is caring for a 1 day old newborn who has jaundice and is receiving phototherapy. Which of the following actions should the nurse take? Ensure that the newborn wears a diaper 128. The client is admitted to the unit after a motor vehicle accident with a temperature of 102°F rectally. The nurse is aware that the most likely explanation for the elevated temperature is: A. There was damage to the hypothalamus. 129. The nurse is caring for the client following a cerebral vascular accident. Which portion of the brain is responsible for taste, smell, and hearing? C. Temporal 130. A 20-year-old is admitted to the rehabilitation unit following a motorcycle accident. Which would be the appropriate method for measuring the client for crutches? B. Measuring 3 inches under the axilla 131. The nurse is doing bowel and bladder retraining for the client with paraplegia. Which of the following is not a factor for the nurse to consider? D. Sexual function 132. The client returns to the recovery room following repair of an intrathoracic aneurysm. Which finding would require further investigation? B. Urinary output 20mL in the past hour 133. The nurse is teaching the client regarding use of sodium warfarin. Which statement made by the client would require further teaching? C. “I take aspirin for a headache.” 134. A client with a femoral popliteal bypass graft is assigned to a semiprivate room. The most suitable roommate for this client is the client with: A. Hypothyroidism 135. The nurse has just received shift report and is preparing to make rounds. Which client should be seen first? C. The client who was admitted 1 hour ago with shortness of breath 136. The doctor has ordered antithrombolic stockings to be applied to the legs of the client with peripheral vascular disease. The nurse knows that the proper method of applying the stockings is: A. Before rising in the morning 137. The nurse is preparing a client with an axillo-popliteal bypass graft for discharge. The client should be taught to avoid: C. Sitting in a straight chair 138. While caring for a client with hypertension, the nurse notes the following vital signs: BP of 140/20, pulse 120, respirations 36, temperature 100.8°F. The nurse’s initial action should be to: A. Call the doctor 139. The nurse is caring for a client with peripheral vascular disease. To correctly assess the oxygen saturation level, the monitor may be placed on the: C. Earlobe 140. Dalteparin (Fragmin) has been ordered for a client with pulmonary embolis. Which statement made by the graduate nurse indicates inadequate understanding of the medication? C. “I will check the PTT before administering the medication.” 141. The client has a prescription for a calcium carbonate compound to neutralize stomach acid. The nurse should assess the client for: A. Constipation 142. A client who has been receiving urokinase has a large bloody bowel movement. What nursing action would be best for the nurse to take immediately? D. Stop the urokinase, notify the physician, and prepare to administer amicar 143. Which of the following best describes the language of a 24-month-old? C. Able to verbalize needs 144. In terms of cognitive development, a 2-year-old would be expected to: B. Use magical thinking 145. 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 146.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.” 147.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 148. 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 149.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 150.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 151.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 152.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 153.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 154.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 155. 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