Comprehensive Nursing Concepts, Clinical Judgment,
NCLEX Readiness, and Patient Care Management
The nurse is feeding an older adult who was admitted with aspiration pneumonia.
The client is weak and begins coughing while attempting to drink through a straw.
Which intervention should the nurse implement?
A. Teach coughing and deep breathing exercises
B. Assess the client's oral cavity for ulcerations
C. Request thick nectar liquids for the client
D. Monitor the client when using a straw for liquids ---------CORRECT ANSWER------
-----------A. Teach coughing and deep breathing exercises
A client diagnosed with calcium kidney stones has a history of gout. A new
prescription for aluminum hydroxide is scheduled to begin at 0730. Which client
medication should the nurse bring to the healthcare provider's attention?
A. Esinapril
B. Allopurinol
C. Furosemide
D. Aspirin, low dose ---------CORRECT ANSWER-----------------B. Allopurinol
A client with urge incontinence was treated with onabotuilinumtoxinA injections
and is now experiencing urinary retention. Which action should the nurse include
in the client's plan of care?
,A. Provide a bedside commode for immediate use in the client's room
B. Teach the client techniques for performing intermittent catheterization
C. Explain the need to limit intake of oral fluids to reduce client discomfort
D. Remind the client to practice pelvic floor (Kegel) exercises regularly ---------
CORRECT ANSWER-----------------D. Remind the client to practice pelvic floor
(Kegel) exercises regularly
After a spider bite on the lower extremity, a client is admitted for treatment of an
infection that is spreading up the leg. Which admission assessment findings
should the nurse report to the healthcare provider? (Select all that apply)
A. Location of the initial IV site
B. Red blood cell count (RBC)
C. Swollen lymph nodes in the groin
D. White blood cell count (WBC)
E. Core body temperature ---------CORRECT ANSWER-----------------C. Swollen lymph
nodes in the groin
D. White blood cell count (WBC)
E. Core body temperature
The home care nurse visits a client who has cancer. The client reports having a
good appetite but experiencing nausea when smelling food cooking. Which action
should the nurse implement?
A. Encourage family members to cook meals outdoors and bring the cooked food
inside
,B. Assess the client's mucous membranes and report the findings to the
healthcare provider
C. Advise the client to replace cooked foods with a variety of different nutritional
supplements
D. Instruct the client to take an antiemetic before every meal to prevent excessive
vomiting ---------CORRECT ANSWER-----------------A. Encourage family members to
cook meals outdoors and bring the cooked food inside
An adult client is admitted to the emergency department after falling from the
ladder. While waiting to have a computed tomography (CT) scan, the client
requests something for a severe headache. When the nurse offers a prescribed
dose of acetaminophen, the client asks for something stronger. Which
intervention should the nurse implement?
A. Review client's history for use of illicit drugs
B. Explain the reason for using only non-narcotics
C. Assess client's pupils for their reaction to light
D. Request that the CT scan be done immediately ---------CORRECT ANSWER---------
--------B. Explain the reason for using only non-narcotics
The nurse is caring for a client who has chronic obstructive pulmonary disease
(COPD) and chest pain related to a recent fall. What nursing intervention requires
the greatest caution when caring for a client with COPD?
A. Monitoring telemetry and cardiac rhythm
B. Assisting client to cough and deep breath
C. Administering narcotics for pain relief
, D. Increasing the client's fluid intake ---------CORRECT ANSWER-----------------C.
Administering narcotics for pain relief
The nurse is providing care for a client with schizophrenia who receives
haloperidol decanoate 75mg IM every 4 weeks. The client begins developing a
puckering and smacking of the lips and facial grimacing. Which intervention
should the nurse implement?
A. Monitor lying, sitting, and standing blood pressures
B. Provide coaching in relaxation techniques
C. Complete abnormal involuntary movement scale (AIMS)
D. Discontinue all medications immediately ---------CORRECT ANSWER-----------------
C. Complete abnormal involuntary movement scale (AIMS)
Prolonged exposure to high concentrations of supplemental oxygen over several
days can cause which pathophysiological effect?
A. Disrupted surfactant production
B. Metabolic acidosis
C. Aphasia and memory loss
D. Deep sleep or coma ---------CORRECT ANSWER-----------------A. Disrupted
surfactant production
A client who recently received a prescription for ramelteon to treat sleep
deprivation reports experiencing several side effects since taking the drug. Which
side effect should the nurse report to the healthcare provider?