2024 (January) Nclex Practice
A nurse is caring for a client who has a depressed skull fracture of the bone that makes up the larger
part of the upper and side wall of the cranium. This fracture is located on which of the following bones?
a. sphenoid
b. occipital
c. parietal
d. frontal ANS: Parietal
-sphenoid forms part of face
-occipital is the back of the skull
-frontal is the front of the skull
What is the primary dietary alteration for a client who has heart failure? ANS: Sodium Restriction
ex: turkey sandwich with whole-wheat bread
A nurse is caring for a clinet who has multiple sclerosis and is receiving interferon beta-1a. The nurse
should identify that which of the following client statements indicates a potential adverse effect of the
medication?
a. my body aches all over
b. i have abdominal cramping
c. my hair seems to be thinning
d. it hurts when i urinate ANS: My body aches all over
-adverse effects of interferon beta-1a include flu-like symptoms
,A nurse is teaching a client with cystic fibrosis about daily chest physiotherapy. Which of the following is
the purpose of these treatments?
a. to encourage deep breaths
b. to mobilize secretions in the airways
c. to dilate the bronchioles
d. to stimulate the cough reflex ANS: To mobilize secretions in the airways
- the purpose is to loosen and promote the drainage of secretions from the lungs
A nurse is performing a nonstress test (NST) on a client who is at 41 weeks of gestation. The client asks
what the purpse of the test is/ Which of the following responses should the nurse provide?
a. this test will determine if you are likely to deliver within the next week
b. this test will help determine if your baby is healthy
c. this test can see how you baby responds when you have contractions
d. this test will determine if you're baby's lungs are mature ANS: This test will help determine if your
baby is healthy
- This NST is used as a prenatal fetal assessment, it tracks fetal heart rate patterns expected with fetal
movement and can help identify fetal distress
A nurse cares for a client receiving chemotherapy. The latest blood work shows:
platelet count 18,000/mm3
WBC count of 5,000/mm3
Which intervention does the nurse implement?
,a. respiratory transmission precautions
b. contact transmission precautions
c. bleeding precautions
d. neutropenic precautions ANS: Bleeding precautions
-normal platelet count is 150,000-400,000/mm3
bleeding precautions should be implemented with a platelet count less than
A nurse is teaching a female client who has pyelonephritis about the disorder. Which of the following
pieces of information should the nurse include to help the client prevent a recurrence?
a. douche after vaginal intercourse
b. wipe from front to back after defecation
c. avoid foods that are high in phosphate
d. add yogurt to your diet regularly ANS: Wipe from front to back after defecation
-pyelonephritis (renal infection)
-phosphate can help kidney stones
-yogurt helps with genital tract infections
A nurse is accepting a transfer from the postanesthesia care unit (PACU) of a client who has had a
subtotal thyroidectomy. Which of the following pieces of equipment should the nurse have available at
the bedside for this client?
a. cardiac monitor
b. defibrillator
, c. thoracotomy tray
d. tracheostomy tray ANS: Tracheostomy tray
-laryngeal edema is common after thyroidectomy, which can result in airway obstruction and emergency
intubation can be difficult due to the swelling so a nurse should have this tray
-thoracotomy = for chest tube insertion
A nurse is planning dietary teaching for a client who has diabetes mellitus. Which of the following
actions should the nurse plan to take first?
a. obtain sample menus from the dietitian to give to the client
b. ask the client to identify the types of food she prefers
c. identify the recommended range of the client's blood glucose level
d. discuss long-term complications that can result from non-adherence to the dietary plan ANS: Ask the
client to identify the types of food she prefers
-Nursing process: assess, diagnosis, planning, implementation and evaluation
A nurse is providing dietary teaching to a client who has late-stage chronic kidney disease (CKD). Which
of the following nutrients should the nurse instruct the client to increase her diet?
a. calcium
b. phosphorus
c. potassium
d. sodium ANS: Calcium
-CKD can cause hypocalcemia due to reduced production of vitamin D which is needed for calcium
absorption
A nurse is caring for a client who has a depressed skull fracture of the bone that makes up the larger
part of the upper and side wall of the cranium. This fracture is located on which of the following bones?
a. sphenoid
b. occipital
c. parietal
d. frontal ANS: Parietal
-sphenoid forms part of face
-occipital is the back of the skull
-frontal is the front of the skull
What is the primary dietary alteration for a client who has heart failure? ANS: Sodium Restriction
ex: turkey sandwich with whole-wheat bread
A nurse is caring for a clinet who has multiple sclerosis and is receiving interferon beta-1a. The nurse
should identify that which of the following client statements indicates a potential adverse effect of the
medication?
a. my body aches all over
b. i have abdominal cramping
c. my hair seems to be thinning
d. it hurts when i urinate ANS: My body aches all over
-adverse effects of interferon beta-1a include flu-like symptoms
,A nurse is teaching a client with cystic fibrosis about daily chest physiotherapy. Which of the following is
the purpose of these treatments?
a. to encourage deep breaths
b. to mobilize secretions in the airways
c. to dilate the bronchioles
d. to stimulate the cough reflex ANS: To mobilize secretions in the airways
- the purpose is to loosen and promote the drainage of secretions from the lungs
A nurse is performing a nonstress test (NST) on a client who is at 41 weeks of gestation. The client asks
what the purpse of the test is/ Which of the following responses should the nurse provide?
a. this test will determine if you are likely to deliver within the next week
b. this test will help determine if your baby is healthy
c. this test can see how you baby responds when you have contractions
d. this test will determine if you're baby's lungs are mature ANS: This test will help determine if your
baby is healthy
- This NST is used as a prenatal fetal assessment, it tracks fetal heart rate patterns expected with fetal
movement and can help identify fetal distress
A nurse cares for a client receiving chemotherapy. The latest blood work shows:
platelet count 18,000/mm3
WBC count of 5,000/mm3
Which intervention does the nurse implement?
,a. respiratory transmission precautions
b. contact transmission precautions
c. bleeding precautions
d. neutropenic precautions ANS: Bleeding precautions
-normal platelet count is 150,000-400,000/mm3
bleeding precautions should be implemented with a platelet count less than
A nurse is teaching a female client who has pyelonephritis about the disorder. Which of the following
pieces of information should the nurse include to help the client prevent a recurrence?
a. douche after vaginal intercourse
b. wipe from front to back after defecation
c. avoid foods that are high in phosphate
d. add yogurt to your diet regularly ANS: Wipe from front to back after defecation
-pyelonephritis (renal infection)
-phosphate can help kidney stones
-yogurt helps with genital tract infections
A nurse is accepting a transfer from the postanesthesia care unit (PACU) of a client who has had a
subtotal thyroidectomy. Which of the following pieces of equipment should the nurse have available at
the bedside for this client?
a. cardiac monitor
b. defibrillator
, c. thoracotomy tray
d. tracheostomy tray ANS: Tracheostomy tray
-laryngeal edema is common after thyroidectomy, which can result in airway obstruction and emergency
intubation can be difficult due to the swelling so a nurse should have this tray
-thoracotomy = for chest tube insertion
A nurse is planning dietary teaching for a client who has diabetes mellitus. Which of the following
actions should the nurse plan to take first?
a. obtain sample menus from the dietitian to give to the client
b. ask the client to identify the types of food she prefers
c. identify the recommended range of the client's blood glucose level
d. discuss long-term complications that can result from non-adherence to the dietary plan ANS: Ask the
client to identify the types of food she prefers
-Nursing process: assess, diagnosis, planning, implementation and evaluation
A nurse is providing dietary teaching to a client who has late-stage chronic kidney disease (CKD). Which
of the following nutrients should the nurse instruct the client to increase her diet?
a. calcium
b. phosphorus
c. potassium
d. sodium ANS: Calcium
-CKD can cause hypocalcemia due to reduced production of vitamin D which is needed for calcium
absorption
