NCLEX EXAM (Latest ) Nursing and
Healthcare I | Questions & Answers | 100 %
Correct | highly Grade A - Galen
A 24-year-old client presents to the emergency department protesting "I am God. The
nurse identifies this as a
Haloperidol (Haldol) - CORRECT ANSWERS—
Acute episodes of mania, lithium is effective in 1-2 weeks, but it may take up to 4
weeks, or even a few months treat symptoms fully. Sometimes an antipsychotic agent is
prescribed the first few days or weeks of an acute episode to manage severe behavioral
excitement and acute psychotic symptoms. In addition to the lithium, which one of the
following medications might the physician prescribe?
Release restraints every 2 hours for client to exercise. - CORRECT ANSWERS-
A violent client remains in restraints for several hours. Which of the following
interventions is most appropriate while he is in restraints?
Observe for headaches, dizziness, and anorexia - CORRECT ANSWERS-
The pediatrician has diagnosed tinea capitis in an 8-year-old girl and has placed her on
oral griseofulvin. The nurse should emphasize which of these instructions to the mother
and/or child?
Decrease ammonia formation - CORRECT ANSWERS—
A client with cirrhosis of the liver becomes comatose and is started on neomycin 300
mg q6h nasogastric tube. The rationale for this therapy is to:
Observe for evidence of bleeding. - CORRECT ANSWERS—
A 5-year-old has just had a tonsillectomy and adenoidectomy. Which of these nursing
measures should be included in the postoperative care?
Decreased absent pedal pulse in the left leg - CORRECT ANSWERS-
An 80-year-old male client with a history of arteriosclerosis is experiencing severe pain
in his left leg that started approximately 20 minutes ago. When performing the
admission assessment, the nurse would expect to observe which of the following:
Hematocrit 60% - CORRECT ANSWERS—
, A 16-month-old infant is being prepared for tetralogy of Fallot repair. In the nursing
assessment, which lab value should elicit further assessment and requires notification
of physician? 7.39
Walk him as he paces. - CORRECT ANSWERS—
A male client is experiencing extreme distress. He begins to pace up and down the
corridor. What nursing intervention is appropriate when communicating with the pacing
client?
Walk with him as he paces. - CORRECT ANSWERS—
A male client is experiencing extreme distress. He begins to pace up and down the
corridor. What nursing intervention is appropriate when communicating with the pacing
client?
Locate the position of the placenta and fetus - CORRECT ANSWERS—
Prior to an amniocentesis, a fetal ultrasound is done in order to
February 27 - CORRECT ANSWERS—
A 25-year-old client believes she may be pregnant with her first child. She schedules
an obstetric examination with the nurse practitioner to determine the status of her
possible pregnancy. Her last menstrual period began May 20, and her estimated date of
confinement using Nagele's rule is:
Gestational diabetes mellitus - CORRECT ANSWERS—
A client is now pregnant for the second time. Her first child weighed 4536 g at delivery.
The client's glucose tolerance test shows elevated blood sugar levels. Because she only
shows signs of diabetes when she is pregnant, she is classified as having:
Vitamin C - CORRECT ANSWERS—
The nurse is assisting a 4th-day postoperative cholecystectomy client in planning her
meals for tomorrow's menu. Which vitamin is the most essential in promoting tissue
healing?
Allowing him to do as much for himself as he is able, including learning to do pin-site
care under supervision - CORRECT ANSWERS—
A 10-year-old client with a pin in the right femur is immobilized in traction. He is
exhibiting behavioral changes including restlessness, difficulty with problem solving,
inability to concentrate on activities, and monotony. Which of the following nursing
implementations would be most effective in helping him cope with immobility?
First trimester - CORRECT ANSWERS—
In client teaching, the nurse should emphasize that fetal damage occurs more
frequently with ingestion of drugs during:
High Fowler - CORRECT ANSWERS—
, On admission, the client has signs and symptoms of pulmonary edema. The nurse
places the client in the most appropriate position for a client in pulmonary edema, which
is:
Respiratory obstruction - CORRECT ANSWERS—
A client has returned to the unit from the recovery room after having a thyroidectomy.
The nurse knows that a major complication after a thyroidectomy is:
Mother calls infant by name. - CORRECT ANSWERS—
The nurse should facilitate bonding during the postpartum period. What should the
nurse expect to observe in the taking-hold phase?
Respect the client's family's wishes. - CORRECT ANSWERS--A female client has just
died. Her family is requesting that all nursing staff leave the room. The family's religious
leader has arrived and is ready to conduct a ceremony for the deceased in the room,
requesting that only family members be present. The nurse assigned to the client
should perform the appropriate nursing action, which might include:
Wear a patch over one eye - CORRECT ANSWERS—
A woman diagnosed with multiple sclerosis is disturbed with diplopia. The nurse will
teach her to
Level of consciousness - CORRECT ANSWERS—
One of the most reliable assessment tools for adequacy of fluid resuscitation in burned
children is:
Urine output - CORRECT ANSWERS—
Which one of the following is considered a reliable indicator for assessing the adequacy
of fluid resuscitation in a 3-year-old child who suffered partial- and fullthickness burns to
25% of her body?
Headache and facial flushing - CORRECT ANSWERS—
A client with a diagnosis of C-4 injury has been stabilized and is ready for discharge.
Because this client is at risk for autonomic dysreflexia, he and his family should be
instructed to assess for and report:
Phenytoin (Dilantin) - CORRECT ANSWERS-
A client states to his nurse that I was told by the doctor not to take one of my drugs
because it seems to have caused decreasing blood cells. Based on this information,
which drug might the nurse expect to be discontinued?
Administer the morning lithium dose as scheduled - CORRECT ANSWERS—
A client has been taking lithium 300 mg po bid for the past two weeks. This morning her
lithium level was 1 mEq/L. The nurse should:
Maintaining an adequate level of hydration - CORRECT ANSWERS—
Healthcare I | Questions & Answers | 100 %
Correct | highly Grade A - Galen
A 24-year-old client presents to the emergency department protesting "I am God. The
nurse identifies this as a
Haloperidol (Haldol) - CORRECT ANSWERS—
Acute episodes of mania, lithium is effective in 1-2 weeks, but it may take up to 4
weeks, or even a few months treat symptoms fully. Sometimes an antipsychotic agent is
prescribed the first few days or weeks of an acute episode to manage severe behavioral
excitement and acute psychotic symptoms. In addition to the lithium, which one of the
following medications might the physician prescribe?
Release restraints every 2 hours for client to exercise. - CORRECT ANSWERS-
A violent client remains in restraints for several hours. Which of the following
interventions is most appropriate while he is in restraints?
Observe for headaches, dizziness, and anorexia - CORRECT ANSWERS-
The pediatrician has diagnosed tinea capitis in an 8-year-old girl and has placed her on
oral griseofulvin. The nurse should emphasize which of these instructions to the mother
and/or child?
Decrease ammonia formation - CORRECT ANSWERS—
A client with cirrhosis of the liver becomes comatose and is started on neomycin 300
mg q6h nasogastric tube. The rationale for this therapy is to:
Observe for evidence of bleeding. - CORRECT ANSWERS—
A 5-year-old has just had a tonsillectomy and adenoidectomy. Which of these nursing
measures should be included in the postoperative care?
Decreased absent pedal pulse in the left leg - CORRECT ANSWERS-
An 80-year-old male client with a history of arteriosclerosis is experiencing severe pain
in his left leg that started approximately 20 minutes ago. When performing the
admission assessment, the nurse would expect to observe which of the following:
Hematocrit 60% - CORRECT ANSWERS—
, A 16-month-old infant is being prepared for tetralogy of Fallot repair. In the nursing
assessment, which lab value should elicit further assessment and requires notification
of physician? 7.39
Walk him as he paces. - CORRECT ANSWERS—
A male client is experiencing extreme distress. He begins to pace up and down the
corridor. What nursing intervention is appropriate when communicating with the pacing
client?
Walk with him as he paces. - CORRECT ANSWERS—
A male client is experiencing extreme distress. He begins to pace up and down the
corridor. What nursing intervention is appropriate when communicating with the pacing
client?
Locate the position of the placenta and fetus - CORRECT ANSWERS—
Prior to an amniocentesis, a fetal ultrasound is done in order to
February 27 - CORRECT ANSWERS—
A 25-year-old client believes she may be pregnant with her first child. She schedules
an obstetric examination with the nurse practitioner to determine the status of her
possible pregnancy. Her last menstrual period began May 20, and her estimated date of
confinement using Nagele's rule is:
Gestational diabetes mellitus - CORRECT ANSWERS—
A client is now pregnant for the second time. Her first child weighed 4536 g at delivery.
The client's glucose tolerance test shows elevated blood sugar levels. Because she only
shows signs of diabetes when she is pregnant, she is classified as having:
Vitamin C - CORRECT ANSWERS—
The nurse is assisting a 4th-day postoperative cholecystectomy client in planning her
meals for tomorrow's menu. Which vitamin is the most essential in promoting tissue
healing?
Allowing him to do as much for himself as he is able, including learning to do pin-site
care under supervision - CORRECT ANSWERS—
A 10-year-old client with a pin in the right femur is immobilized in traction. He is
exhibiting behavioral changes including restlessness, difficulty with problem solving,
inability to concentrate on activities, and monotony. Which of the following nursing
implementations would be most effective in helping him cope with immobility?
First trimester - CORRECT ANSWERS—
In client teaching, the nurse should emphasize that fetal damage occurs more
frequently with ingestion of drugs during:
High Fowler - CORRECT ANSWERS—
, On admission, the client has signs and symptoms of pulmonary edema. The nurse
places the client in the most appropriate position for a client in pulmonary edema, which
is:
Respiratory obstruction - CORRECT ANSWERS—
A client has returned to the unit from the recovery room after having a thyroidectomy.
The nurse knows that a major complication after a thyroidectomy is:
Mother calls infant by name. - CORRECT ANSWERS—
The nurse should facilitate bonding during the postpartum period. What should the
nurse expect to observe in the taking-hold phase?
Respect the client's family's wishes. - CORRECT ANSWERS--A female client has just
died. Her family is requesting that all nursing staff leave the room. The family's religious
leader has arrived and is ready to conduct a ceremony for the deceased in the room,
requesting that only family members be present. The nurse assigned to the client
should perform the appropriate nursing action, which might include:
Wear a patch over one eye - CORRECT ANSWERS—
A woman diagnosed with multiple sclerosis is disturbed with diplopia. The nurse will
teach her to
Level of consciousness - CORRECT ANSWERS—
One of the most reliable assessment tools for adequacy of fluid resuscitation in burned
children is:
Urine output - CORRECT ANSWERS—
Which one of the following is considered a reliable indicator for assessing the adequacy
of fluid resuscitation in a 3-year-old child who suffered partial- and fullthickness burns to
25% of her body?
Headache and facial flushing - CORRECT ANSWERS—
A client with a diagnosis of C-4 injury has been stabilized and is ready for discharge.
Because this client is at risk for autonomic dysreflexia, he and his family should be
instructed to assess for and report:
Phenytoin (Dilantin) - CORRECT ANSWERS-
A client states to his nurse that I was told by the doctor not to take one of my drugs
because it seems to have caused decreasing blood cells. Based on this information,
which drug might the nurse expect to be discontinued?
Administer the morning lithium dose as scheduled - CORRECT ANSWERS—
A client has been taking lithium 300 mg po bid for the past two weeks. This morning her
lithium level was 1 mEq/L. The nurse should:
Maintaining an adequate level of hydration - CORRECT ANSWERS—
