NCLEX Review Study Guide Comprehensive
Study online at https://quizlet.com/_464h9g
1. A client with diabetes mellitus calls the clinic nurse and reports that she has
been vomiting during the night and now has diarrhea. Which question does
the nurse make a priority of asking the client?: "Have you tested your blood glucose?"
2. A client's oral intake of liquids includes 120 mL on the night shift, 800 mL
on the day shift, and 650 mL on the evening shift. The client is receiving an
intravenous (IV) antibiotic every 12 hours, diluted in 50 mL of normal saline
solution. The nurse empties 700 mL of urine from the client's Foley catheter
at the end of the day shift. Thereafter, 500 mL of urine is emptied at the end
of the evening shift and 325 mL at the end of the night shift. Nasogastric tube
drainage totals 155 mL for the 24-hour period, and the total drainage from
the Jackson-Pratt device is 175 mL. What is the client's total intake during the
24-hour period?: 1670mL
3. A client with heart failure suddenly experiences profound dyspnea, pallor,
audible wheezing, and cyanosis, and the nurse suspects pulmonary edema.
The nurse would first:: Raise the head of the client's bed
4. A client with cervical cancer who is undergoing chemotherapy with cisplatin
(Platinol). For which adverse effect of cisplatin will the nurse assess the client?-
: Hearing loss
5. Alendronate (Fosamax) is prescribed for a client with postmenopausal osteo-
porosis. The nurse provides information on the medication to the client. When
does the nurse tell the client to take the alendronate?: Every morning before breakfast, with
a full glass of water
6. A client with emphysema is receiving theophylline (Theo-24). While providing
dietary instructions, the nurse tells the client that it is acceptable to consume:-
: Apple juice
7. A nurse is reviewing the record of a client scheduled for electroconvulsive
therapy (ECT). Which of the following diagnoses, if noted on the client's record,
would indicate a need to contact the physician who is scheduled to perform
the ECT?: Recent stroke
8. An emergency department nurse is assessing a client with acute closed-angle
glaucoma. Which of the following characteristics of the disorder does the nurse
expect the client to exhibit? Select all that apply.: Nausea
, NCLEX Review Study Guide Comprehensive
Study online at https://quizlet.com/_464h9g
Eye pain
Vomiting
Headache
9. The nurse administers intravenous morphine sulfate to a client in pulmonary
edema. For which intended effect of the medication does the nurse monitor
the client?: Relief of anxiety
10. An emergency department nurse is told that a client with carbon monoxide
poisoning resulting from a suicide attempt is being brought to the hospital by
emergency medical services. Which intervention will the nurse carry out as a
priority upon arrival of the client?: Administering 100% oxygen
11. A client with agoraphobia will undergo systematic desensitization through
graduated exposure. In explaining the treatment to the client, the nurse tells
the client that this technique involves:: Gradually introducing the client to a phobic object or
situation in a predetermined sequence of least to most frightening
12. A client with a medical history of diabetes mellitus is found to have sarcoido-
sis, and oral prednisone is prescribed. The nurse provides instructions to the
client about the medication and tells the client to:: Closely monitor the blood glucose level
13. Enalapril maleate (Vasotec) is prescribed for a hospitalized client. Which
assessment does the nurse perform as a priority before administering the
medication?: Checking the client's blood pressure
14. A client who has undergone abdominal hysterectomy asks the nurse when
she will be able to resume sexual intercourse. The nurse tells the client that
sexual intercourse may be resumed:: In about 6 weeks, when the vaginal vault is satisfactorily healed
15. A nurse on the evening shift checks a physician's prescriptions and notes that
the dose of a prescribed medication is higher than the normal dose. The nurse
calls the physician's answering service and is told that the physician is off for
the night and will be available in the morning. The nurse should:: Ask the answering
service to contact the on-call physician
16. A hospitalized female client with mania enters the unit community room and
says to a client who is wearing a blue shirt, "Boys in blue are fun to do! Boys in
blue are fun to do!" What is the appropriate response by the nurse?: "Don't say that.
If you can't control yourself, we'll help you."
, NCLEX Review Study Guide Comprehensive
Study online at https://quizlet.com/_464h9g
17. A client with HIV infection who has been found to have histoplasmosis is
being treated with intravenous amphotericin B (Fungizone). Which parameter
does the nurse check to detect the most common adverse effect of this med-
ication?: Intake and output
18. A nurse is gathering subjective and objective data from a client with suspect-
ed rheumatoid arthritis (RA). Which early manifestations of RA would the nurse
expect to note? Select all that apply.: Fatigue
Low-grade fever
19. Phenelzine sulfate (Nardil) is prescribed for a client with depression. The
nurse provides information to the client about the adverse effects of the
medication and tells the client to contact the physician immediately if she
experiences:: Neck stiffness or soreness
20. A client is receiving an intravenous infusion of oxytocin (Pitocin) to stimulate
labor. The nurse monitoring the client notes uterine hypertonicity and imme-
diately:: Stops the oxytocin infusion
21. A nurse is assessing a pregnant woman for the presence of edema. The
nurse places a thumb on the top of the client's foot, then exerts pressure and
releases it and notes that the thumb has left a persistent depression. On the
basis of this finding, the nurse concludes that:: Pitting edema is present
22. A nurse is caring for a client with community-acquired pneumonia who is
being treated with levofloxacin (Levaquin). For which of the following findings,
indicating an adverse reaction to the medication, does the nurse monitor the
client?: Fever
23. A client receiving parenteral nutrition (PN) suddenly experiences chest pain
and dyspnea, and the nurse suspects an air embolism. The nurse immediately
places the client in a lateral Trendelenburg position, on the left side. What
action does the nurse take next?: Clamping the intravenous catheter
24. A nurse is preparing a poster for a health fair booth promoting primary
prevention of skin cancer. Which of the following recommendations does the
nurse include on the poster? Select all that apply.: Seek medical advice if you find a skin lesion.
, NCLEX Review Study Guide Comprehensive
Study online at https://quizlet.com/_464h9g
25. A nurse is providing instructions to a client with glaucoma who will be
using acetazolamide (Diamox) daily. Which of the following findings, an adverse
effect, does the nurse instruct the client to report to the physician?: Dark urine
26. A nurse is providing morning care to a client who has undergone surgery to
repair a fractured left hip. Which item is most important for the nurse to use in
turning the client from side to side to change the bed linens?: Abduction device
27. A nurse is performing an assessment of a client being admitted to the
hospital with a diagnosis of multiple sclerosis. The client tells the nurse that
she took baclofen (Lioresal) for the past 9 months but completely stopped the
medication 2 days ago because it was making her feel weak. On the basis of
this information, the nurse notes in the plan of care that the client should be
monitored most closely for:: Seizure activity
28. A nurse administers nitroglycerin sublingually to a client with angina pec-
toris who complains of chest pain. The medication is ineffective, so the nurse
prepares to administer a second dose. Before administering the nitroglycerin,
which action does the nurse make a priority?: Checking the client's blood pressure
29. A nurse provides information to a client with coronary artery disease (CAD)
about smoking-cessation measures. Which statement by the client indicates a
need for further information?: "I should drink a cup of coffee if I feel the urge to smoke."
30. A client with myasthenia gravis who has been taking pyridostigmine bro-
mide (Mestinon) for the treatment of the disorder comes to the emergency
department complaining of severe muscle weakness, and cholinergic crisis is
diagnosed. Which medication does the nurse prepare for immediate use in
treating the crisis?: Atropine sulfate
31. A rape victim being treated in the emergency department says to the nurse,
"I'm really worried that I've got HIV now." What is the appropriate response by
the nurse?: "Let's talk about the information that you need to determine your risk of contracting HIV."
32. A nurse is providing instruction to a client with osteoporosis regarding
appropriate foods to include in the diet. The nurse tells the client that one food
item high in calcium is:: Sardines
Study online at https://quizlet.com/_464h9g
1. A client with diabetes mellitus calls the clinic nurse and reports that she has
been vomiting during the night and now has diarrhea. Which question does
the nurse make a priority of asking the client?: "Have you tested your blood glucose?"
2. A client's oral intake of liquids includes 120 mL on the night shift, 800 mL
on the day shift, and 650 mL on the evening shift. The client is receiving an
intravenous (IV) antibiotic every 12 hours, diluted in 50 mL of normal saline
solution. The nurse empties 700 mL of urine from the client's Foley catheter
at the end of the day shift. Thereafter, 500 mL of urine is emptied at the end
of the evening shift and 325 mL at the end of the night shift. Nasogastric tube
drainage totals 155 mL for the 24-hour period, and the total drainage from
the Jackson-Pratt device is 175 mL. What is the client's total intake during the
24-hour period?: 1670mL
3. A client with heart failure suddenly experiences profound dyspnea, pallor,
audible wheezing, and cyanosis, and the nurse suspects pulmonary edema.
The nurse would first:: Raise the head of the client's bed
4. A client with cervical cancer who is undergoing chemotherapy with cisplatin
(Platinol). For which adverse effect of cisplatin will the nurse assess the client?-
: Hearing loss
5. Alendronate (Fosamax) is prescribed for a client with postmenopausal osteo-
porosis. The nurse provides information on the medication to the client. When
does the nurse tell the client to take the alendronate?: Every morning before breakfast, with
a full glass of water
6. A client with emphysema is receiving theophylline (Theo-24). While providing
dietary instructions, the nurse tells the client that it is acceptable to consume:-
: Apple juice
7. A nurse is reviewing the record of a client scheduled for electroconvulsive
therapy (ECT). Which of the following diagnoses, if noted on the client's record,
would indicate a need to contact the physician who is scheduled to perform
the ECT?: Recent stroke
8. An emergency department nurse is assessing a client with acute closed-angle
glaucoma. Which of the following characteristics of the disorder does the nurse
expect the client to exhibit? Select all that apply.: Nausea
, NCLEX Review Study Guide Comprehensive
Study online at https://quizlet.com/_464h9g
Eye pain
Vomiting
Headache
9. The nurse administers intravenous morphine sulfate to a client in pulmonary
edema. For which intended effect of the medication does the nurse monitor
the client?: Relief of anxiety
10. An emergency department nurse is told that a client with carbon monoxide
poisoning resulting from a suicide attempt is being brought to the hospital by
emergency medical services. Which intervention will the nurse carry out as a
priority upon arrival of the client?: Administering 100% oxygen
11. A client with agoraphobia will undergo systematic desensitization through
graduated exposure. In explaining the treatment to the client, the nurse tells
the client that this technique involves:: Gradually introducing the client to a phobic object or
situation in a predetermined sequence of least to most frightening
12. A client with a medical history of diabetes mellitus is found to have sarcoido-
sis, and oral prednisone is prescribed. The nurse provides instructions to the
client about the medication and tells the client to:: Closely monitor the blood glucose level
13. Enalapril maleate (Vasotec) is prescribed for a hospitalized client. Which
assessment does the nurse perform as a priority before administering the
medication?: Checking the client's blood pressure
14. A client who has undergone abdominal hysterectomy asks the nurse when
she will be able to resume sexual intercourse. The nurse tells the client that
sexual intercourse may be resumed:: In about 6 weeks, when the vaginal vault is satisfactorily healed
15. A nurse on the evening shift checks a physician's prescriptions and notes that
the dose of a prescribed medication is higher than the normal dose. The nurse
calls the physician's answering service and is told that the physician is off for
the night and will be available in the morning. The nurse should:: Ask the answering
service to contact the on-call physician
16. A hospitalized female client with mania enters the unit community room and
says to a client who is wearing a blue shirt, "Boys in blue are fun to do! Boys in
blue are fun to do!" What is the appropriate response by the nurse?: "Don't say that.
If you can't control yourself, we'll help you."
, NCLEX Review Study Guide Comprehensive
Study online at https://quizlet.com/_464h9g
17. A client with HIV infection who has been found to have histoplasmosis is
being treated with intravenous amphotericin B (Fungizone). Which parameter
does the nurse check to detect the most common adverse effect of this med-
ication?: Intake and output
18. A nurse is gathering subjective and objective data from a client with suspect-
ed rheumatoid arthritis (RA). Which early manifestations of RA would the nurse
expect to note? Select all that apply.: Fatigue
Low-grade fever
19. Phenelzine sulfate (Nardil) is prescribed for a client with depression. The
nurse provides information to the client about the adverse effects of the
medication and tells the client to contact the physician immediately if she
experiences:: Neck stiffness or soreness
20. A client is receiving an intravenous infusion of oxytocin (Pitocin) to stimulate
labor. The nurse monitoring the client notes uterine hypertonicity and imme-
diately:: Stops the oxytocin infusion
21. A nurse is assessing a pregnant woman for the presence of edema. The
nurse places a thumb on the top of the client's foot, then exerts pressure and
releases it and notes that the thumb has left a persistent depression. On the
basis of this finding, the nurse concludes that:: Pitting edema is present
22. A nurse is caring for a client with community-acquired pneumonia who is
being treated with levofloxacin (Levaquin). For which of the following findings,
indicating an adverse reaction to the medication, does the nurse monitor the
client?: Fever
23. A client receiving parenteral nutrition (PN) suddenly experiences chest pain
and dyspnea, and the nurse suspects an air embolism. The nurse immediately
places the client in a lateral Trendelenburg position, on the left side. What
action does the nurse take next?: Clamping the intravenous catheter
24. A nurse is preparing a poster for a health fair booth promoting primary
prevention of skin cancer. Which of the following recommendations does the
nurse include on the poster? Select all that apply.: Seek medical advice if you find a skin lesion.
, NCLEX Review Study Guide Comprehensive
Study online at https://quizlet.com/_464h9g
25. A nurse is providing instructions to a client with glaucoma who will be
using acetazolamide (Diamox) daily. Which of the following findings, an adverse
effect, does the nurse instruct the client to report to the physician?: Dark urine
26. A nurse is providing morning care to a client who has undergone surgery to
repair a fractured left hip. Which item is most important for the nurse to use in
turning the client from side to side to change the bed linens?: Abduction device
27. A nurse is performing an assessment of a client being admitted to the
hospital with a diagnosis of multiple sclerosis. The client tells the nurse that
she took baclofen (Lioresal) for the past 9 months but completely stopped the
medication 2 days ago because it was making her feel weak. On the basis of
this information, the nurse notes in the plan of care that the client should be
monitored most closely for:: Seizure activity
28. A nurse administers nitroglycerin sublingually to a client with angina pec-
toris who complains of chest pain. The medication is ineffective, so the nurse
prepares to administer a second dose. Before administering the nitroglycerin,
which action does the nurse make a priority?: Checking the client's blood pressure
29. A nurse provides information to a client with coronary artery disease (CAD)
about smoking-cessation measures. Which statement by the client indicates a
need for further information?: "I should drink a cup of coffee if I feel the urge to smoke."
30. A client with myasthenia gravis who has been taking pyridostigmine bro-
mide (Mestinon) for the treatment of the disorder comes to the emergency
department complaining of severe muscle weakness, and cholinergic crisis is
diagnosed. Which medication does the nurse prepare for immediate use in
treating the crisis?: Atropine sulfate
31. A rape victim being treated in the emergency department says to the nurse,
"I'm really worried that I've got HIV now." What is the appropriate response by
the nurse?: "Let's talk about the information that you need to determine your risk of contracting HIV."
32. A nurse is providing instruction to a client with osteoporosis regarding
appropriate foods to include in the diet. The nurse tells the client that one food
item high in calcium is:: Sardines
