Nclex file 1

Nclex file 1 1. The nurse is caring for a 17 month-old with acetaminophen poisoning. Which of the following lab reports should the nurse review first? D) Liver enzymes (AST and ALT) 2. The nurse is teaching parents about diet for a 4 month-old infant with gastroenteritis and mild dehydration. In addition to oral rehydration fluids, the diet should include A) Formula or breast milk 3. The nurse instructs the client taking dexamethasone (Decadron) to take it with food or milk. What is the physiological basis for this instruction? B) Stimulates hydrochloric acid production 4. The nurse is planning care for a 3 month-old infant immediately postoperative following placement of a ventriculoperitoneal shunt for hydrocephalus. The nurse needs to A) Assess for abdominal distention 5. The mother of a 2 year-old hospitalized child asks the nurse's advice about the child's screaming every time the mother gets ready to leave the hospital room. What is the best response by the nurse? C) "Keep in mind that for the age this is a normal response to being in the hospital." 6. When caring for a client receiving warfarin sodium (Coumadin), which lab test would the nurse monitor to determine therapeutic reponse to the drug? C) Prothrombin time 7. The nurse is caring for a 4 year-old 2 hours after tonsillectomy and adenoidectomy. Which of the following assessments must be reported immediately? D) Increased restlessness 8. The nurse admits a 7 year-old to the emergency room after a leg injury. The x-rays show a femur fracture near the epiphysis. The parents ask what will be the outcome of injury. The appropriate response by the nurse should be which of these statements? B) "In some instances the result is a retarded bone growth." 9. A client receiving chlorpromazine HCL (Thorazine) is in psychiatric home care. During a home visit the nurse observes the client smacking her lips alternately with grinding her teeth. The nurse recognizes this assessment finding as what? D) Tardive dyskinesia10. During the check up of a 2 month-old infant at a well baby clinic, the mother expresses concern to the nurse because a flat pink birthmark on the baby's forehead and eyelid has not gone away. What is an appropriate response by the nurse? C) "Telangiectatic nevi are normal and will disappear as the baby grows." 11. A client has returned to the unit following a renal biopsy. Which of the following nursing interventions is appropriate? C) Monitor vital signs 12. A client has been admitted with a fractured femur and has been placed in skeletal traction. Which of the following nursing interventions should receive priority? B) Frequent neurovascular assessments of the affected leg 13. The nurse is teaching a client newly diagnosed with asthma how to use the metereddose inhaler (MDI). The client asks when they will know the canister is empty. The best response is A) Drop the canister in water to observe floating 14. While teaching the family of a child who will take phenytoin (Dilantin) regularly for seizure control, it is most important for the nurse to teach them about which of the following actions? A) Maintain good oral hygiene and dental care 15. A 7 month pregnant woman is admitted with complaints of painless vaginal bleedingover several hours. The nurse should prepare the client for an immediate B) Abdominal ultrasound 16. The nurse is assessing a 17 year-old female client with bulimia. Which of the following laboratory reports would the nurse anticipate? C) Decreased potassium 17. An 80 year-old client on digitalis (Lanoxin) reports nausea, vomiting, abdominal cramps and halo vision. Which of the following laboratory results should the nurse analyze first? A) Potassium levels 18. The nurse caring for a 9 year-old child with a fractured femur is told that a medication error occurred. The child received twice the ordered dose of morphine an hour ago. Which nursing diagnosis is a priority at this time? C) Ineffective breathing patterns related to central nervous system depression 19. The nurse notes that a 2 year-old child recovering from a tonsillectomy has a temperature of 98.2 degrees Fahrenheit at 8:00 AM. At 10:00 AM the child's mother reports that the child "feels very warm" to touch. The first action by the nurse should be to C) Reassess the child's temperature 20. The nurse is teaching a newly diagnosed asthma client on how to use a peak flow meter. The nurse explains that this should be used toB) Measure forced expiratory volume 21. The nurse is performing a pre-kindergarten physical on a 5 year old. The last series of vaccines will be administered. What is the preferred site for injection by the nurse? C) Vastus lateralis 22. A newly admitted elderly client is severely dehydrated. When planning care for this client, which task is appropriate to assign to an unlicensed assistive personnel (UAP)? B) Report hourly outputs of less than 30 ml/hr 23. The nurse has admitted a 4 year-old with the diagnosis of possible rheumatic fever. Which statement by the parent would cause the nurse to suspect an association with this disease? B) Strep throat went through all the children at the day care last month. 24. A nurse assigned to a manipulative client for 5 days becomes aware of feelings for a reluctance to interact with the client. The next action by the nurse should be to A) Discuss the feeling of reluctance with an objective peer or supervisor 25. A client is being treated for paranoid schizophrenia. When the client became loud and boisterous, the nurse immediately placed him in seclusion as a precautionary measure. The client willingly complied. The nurse’s action A) May result in charges of unlawful seclusion and restraint 26. A client has been admitted to the Coronary Care Unit with a myocardial infarction. Which nursing diagnosis should have priority? A) Pain related to ischemia 27. The provisions of the law for the Americans with Disabilities Act require nurse managers to B) Provide reasonable accommodations for disabled individuals 28. A 42 year-old male client refuses to take propranolol hydrochloride (Inderal) as prescribed. Which client statement s from the assessment data is likely to explain his noncompliance? C) "I have diminished sexual function." 29. A school-aged child has had a long leg (hip to ankle) synthetic cast applied 4 hours ago. Which statement from the mother indicates that teaching has been inadequate? D) ”I think I remember that standing cannot be done until after 72 hours." 30. Which statement best describes time management strategies applied to the role of a nurse manager? C) Set daily goals with a prioritization of the work31. The pediatric clinic nurse examines a toddler with a tentative diagnosis of neuroblastoma. Findings observed by the nurse that is associated with this problem include which of these? D) Abdominal mass and weakness 32. A 15 year-old client has been placed in a Milwaukee Brace. Which statement from the adolescent indicates the need for additional teaching? A) "I will only have to wear this for 6 months." 33. The nurse manager has been using a decentralized block scheduling plan to staff the nursing unit. However, staff have asked for many changes and exceptions to the schedule over the past few months. The manager considers self scheduling knowing that this method will D) Improve team morale 34. A client is admitted to the emergency room following an acute asthma attack. Which of the following assessments would be expected by the nurse? A) Diffuse expiratory wheezing 35. The nurse manager hears a health care provider loudly criticize one of the staff nurses within the hearing of others. The employee does not respond to the health care provider's complaints. The nurse manager's next action should be to D) Request an immediate private meeting with the health care provider and staff nurse 36. A client is admitted to a voluntary hospital mental health unit due to suicidal ideation. The client has been on the unit for 2 days and now states “I demand to be released now!” The appropriate action is for the nurse to C) Let’s discuss your decision to leave and then we can prepare you for discharge. 37. A client is admitted with infective endocarditis (IE). Which symptom would alert the nurse to a complication of this condition? B) Heart murmur 38. A nurse admits a premature infant who has respiratory distress syndrome. In planning care, nursing actions are based on the fact that the most likely cause of this problem stems from the infant's inability to B) Maintain alveolar surface tension 39. An 18 year-old client is admitted to intensive care from the emergency room following a diving accident. The injury is suspected to be at the level of the 2nd cervical vertebrae. The nurse's priority assessment should be C) Respiratory function 40. The nurse is caring for a client who was successfully resuscitated from a pulseless dysrhythmia. Which of the following assessments is CRITICAL for the nurse to include in the plan of care?A) Hourly urine output 41. The charge nurse on the night shift at an urgent care center has to deal with admitting clients of a higher acuity than usual because of a large fire in the area. Which style of leadership and decision-making would be best in this circumstance? A) Assume a decision-making role 42. A nurse is caring for four newborns. Which of the following findings should the nurse report to the provider? a. A newborn who has a high-pitched cry with exaggerated Moro reflex 43. A nurse in a provider’s office is caring for a 20-year-old client who is at 12 weeks of gestation and requests an amniocentesis to determine the gender of the fetus. Which of the following responses should the nurse make? b. This procedure determines if your baby has genetic or congenital disorders 44. A nurse is caring for a client who is postpartum. The client reports no relief in perineal pain following the administration of oxycodone/acetaminophen. Which of the following actions should the nurse take first? a. Reposition the client 45. A nurse is caring for a client who is in active labor and has gonorrhea. For which of the following potential complications of gonorrhea should the nurse monitor? d. Chorioamnionitis 46. A nurse is caring for a client who is in labor. The nurse observes late decelerations of the fetal heart rate on the external fetal monitor. After placing the client in a side-lying position, which of the following actions should the nurse take? a. Administer oxygen via a face mask 47. A nurse is caring for a newborn who has exstrophy of the bladder. Which of the following actions should the nurse take prior to the beginning of surgical correction? c. Cover the newborn’s bladder with a sterile, non-adherent dressing 48. A nurse is reviewing the laboratory report of a client who is 24 hrs postpartum vaginal delivery. The client has a hemoglobin level of 9.0 g/dL and hematocrit of 25%. Which of the following actions should the nurse take? c. Initiate IV access for isotonic solution with an 18-gauge catheter 49. A nurse is caring for a client who is receiving magnesium sulfate by continuous IV infusion for sever preeclampsia. Which of the following findings should the nurse report to the provider? d. Urine output 20 mL/hr50. A nurse is performing a heel stick on a newborn. Which of the following actions should the nurse take? d. Use an automatic puncture device on the heel 51. A nurse is caring for a client who has bladder distention following a vaginal birth. Which of the following actions should the nurse take first? d. Assist the client to the bathroom 52. A nurse is providing teaching about increasing dietary fiber to an antepartum client who reports constipation. Which of the following food selections has the highest fiber content per cup? b. Lentils 53. A nurse is caring for a client following an amniocentesis. The nurse should observe the client for which of the following complications? a. Hemorrhage 54. A nurse in a clinic is caring for a client who is in her second trimester of pregnancy. The client expresses concern about preparing her 2-year-old child for a new sibling. Which of the following is an appropriate response by the nurse? b. Require scheduled interactions between the toddler and the baby 55. A nurse is assessing current medication use with a client who is at 6 weeks of gestation. The nurse should recognize that pregnancy is a contraindication to the administration of which of the following +medications? d. Isotretinoin 56. A nurse is reviewing the immunization status of a client who is pregnant. The nurse should inform the client that it is safe for her to receive which of the following immunizations during pregnancy? a. Tetanus 57. A nurse is reviewing laboratory findings for a client who is at 20 weeks of gestation. Which of the following findings should the nurse report to the provider? c. Fasting blood glucose 180 mg/dL 58. A nurse is caring for a client who is at 35 weeks of gestation and on bed rest due to severe preeclampsia. Which of the following is an appropriate action for the nurse to take? d. Keep the lights dimmed in the room 60. A nurse is caring for a client who is 2 days postpartum and states, “I want to continue breastfeeding, but my nipples are so sore.” Which of the following responses should the nurse make? b. Allow expressed milk to air dry on the nipples after feeding your infant 61. A nurse is caring for a newborn immediately following birth and notes a large amount of mucus in the newborn’s mouth and nose. Identify the sequence the nurse should follow when performing suctionwith a bulb syringe. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.) Compress the bulb syringe Place the bulb syringe in newborn’s mouth Use bulb syringe to suction newborn’s nose Assess the newborn for reflex bradycardia 62. A nurse is receiving report on four postpartum clients. Which of the following clients should the nurse plan to attend to first? a. A client who has hyporeflexia while receiving IV magnesium sulfate – hyporeflexia = absent??? c. A client who reports changing her perineal pad every 2 hours – heavy not extreme 63. A nurse is teaching a client about using a diaphragm. Which of the following instructions should the nurse include in the teaching? b. Replace the diaphragm every 2 years 64. A nurse is admitting a client to the birthing unit who reports her contractions started 1 hour ago. The nurse determines the client is 80% effaced and 8 cm dilated. The nurse realizes that the client is at risk for which of the following conditions? d. Postpartum hemorrhage 65. A nurse is providing vehicle safety education to the parents of a premature newborn. Which of the following statements should the nurse include in the teaching? a. Your newborn will need to have a car seat test prior to discharge 66. A nurse is providing discharge instructions to a client who is breastfeeding her newborn. Which of the following instructions should the nurse include? c. Allow the baby to feed at least every 3 hours 67. A nurse is assessing a client who is 2 days postpartum. Which of the following findings indicates a complication? c. Hypotonic uterus 68. A nurse is reviewing the medical record of a client who had a vaginal delivery 3 hours ago. Which of the following findings place the client at risk for postpartum hemorrhage? (Select all that apply.) c. Labor induction with oxytocin d. History of uterine atony 69. The nurse is performing a physical assessment on a toddler. Which of the following should be the first action? B) Use minimal physical contact 70. A client has been tentatively diagnosed with Graves' disease (hyperthyroidism).Which of these findings noted on the initial nursing assessment requires quick intervention by the nurse? C) The appearance of eyeballs that appear to "pop" out of the client's eye sockets 71. Which serum blood findings with diabetic ketoacidosis alerts the nurse that immediate action is required? C) HCT of 60 72. The nurse is preparing the teaching plan for a group of parents about risks to toddlers. The nurse plans to explain proper communication in the event of accidental poisoning. The nurse should plan to tell the parents to first state what substance was ingested and then what information should be the priority for the parents to communicate? D) The affected child's age and weight 73. A 2 year-old child is brought to the health care provider's office with a chief complaint of mild diarrhea for 2 days. Nutritional counseling by the nurse should include which statement? B) Continue with the regular diet and include oral rehydration fluids 74. The nurse is teaching an elderly client how to use MDI's (multi-dose inhalers). The nurse is concerned that the client is unable to coordinate the release of the medication with the inhalation phase. What is the nurse's best recommendation to improve delivery of the medication? B) Adding a spacer device to the MDI canister 75. Which of the following manifestations observed by the school nurse confirms the presence of pediculosis capitis in students? D) Whitish oval specks sticking to the hair