NCLEX questions new exam questions and answers docs solved (2020) solution

NCLEX questions new exam questions and answers docs solved (2020) solution Question 1 See full question The nurse is assessing a neonate born to a mother with type 1 diabetes. Which finding is expected? Question 2 ...

NCLEX questions new exam questions and answers docs solved (2020) solution Question 1 See full question The nurse is assessing a neonate born to a mother with type 1 diabetes. Which finding is expected? Question 2 See full question A client with chest pain, dyspnea, and an irregular heartbeat comes to the emergency department. An electrocardiogram shows a heart rate of 110 beats/minute (sinus tachycardia) with frequent premature ventricular contractions. Shortly after admission, the client has ventricular tachycardia and becomes unresponsive. After successful resuscitation, the client is taken to the intensive care unit (ICU). Which nursing diagnosis is the priority at this time? Question 3 See full question The nurse is instructing the client on insulin administration. The client is performing a return demonstration for preparing the insulin. The client’s morning dose of insulin is 10 units of regular and 22 units of NPH. The nurse checks the dose accuracy with the client. The nurse determines that the client has prepared the correct dose when the syringe reads how many units? Record your answer using a whole number. Question 4 See full question The nurse is assessing a client during a home health visit. The client reports a severe burning on urination. What is the most important action by the nurse? Question 5 See full question A drug must enter the bloodstream before it can act within the body. Which parenteral administration route places a drug directly into the circulation, requiring no absorption? Question 6 See full question When documenting information in a client's medical record, which of the following should the nurse do consistently for each entry? Question 7 See full question Which of the following measures should a home healthcare nurse implement to minimize the potential for lawsuits? Question 8 See full question A nurse manager of the pediatric unit discovers that she is overbudget on supplies. How could each nurse assigned to the unit help with cost containment? Question 9 See full question A pregnant adolescent admitted with premature uterine contractions was successfully treated with I.V. fluids. She is eager to return to high school to take a math test. The nurse's discharge examination reveals vaginal blood pooling under the adolescent's buttocks that's painless to the client. Which action should the nurse take? Question 10 See full question The nurse is conducting a routine risk assessment at a prenatal visit. Which question would be the best to screen for intimate partner violence? Question 11 See full question Following a simple mastectomy, the nurse is totaling the amount of drainage in 24 hours from a suction drain in the incision. The nurse notes there is 200 mL of serosanguinous drainage for the first 24 hours. The nurse should: Question 12 See full question When assessing an 18-year-old primipara who gave birth to a viable neonate under epidural anesthesia 24 hours ago, the nurse determines that the fundus is firm but to the right of midline. Based on this finding, the nurse should further assesses for: Question 13 See full question Parents of a school-age child with asthma express concern about letting the child participate in sports. What should the nurse tell the parents about the relationship between exercise and asthma? Question 14 See full question The nurse is assessing a client who is in her first trimester of pregnancy. The client states that her nausea has been problematic at times, but says that she is able to partially control it using ginger supplements. What is the nurse's best response? Question 15 See full question During the immediate postpartum period after giving birth to twins, the client experiences uterine atony. What should the nurse do first? Question 16 See full question A nurse is counseling a client at a crisis center after her house burned down and her daughter was killed. Which action by the nurse is a priority? Question 17 See full question A client is suspected of having amyotrophic lateral sclerosis (ALS). To help confirm this disorder, the nurse prepares the client for various diagnostic tests. The nurse expects the physician to order: Question 18 See full question A child with type 1 diabetes is admitted to the emergency department with hot and dry skin, rapid and deep respirations, and a fruity odor to her breath. Which task, when performed by a new-graduate registered nurse (RN), requires the RN preceptor to intervene? Question 19 See full question A client has been hospitalized with pancreatitis for 3 days. The nurse assesses the client and documents the accompanying results. The nurse realizes these findings are a manifestation of what sign? Question 20 See full question A nurse is caring for a client who is exhibiting signs and symptoms characteristic of a myocardial infarction (MI). Which statement describes priorities the nurse should establish while performing the physical assessment? Question 21 See full question A physician performs a bone marrow aspiration from the posterior iliac crest on a client with a platelet count of 80,000 mm3. Which intervention should the nurse perform after the procedure? Question 22 See full question A laboratory assistant who is trying to view the electronic record of a client's personal history gets an error message: "You are not authorized to view this information." What is the reason for this message? Question 23 See full question A client is discharged after an aortic aneurysm repair with a synthetic graft to replace part of the aorta. The nurse should instruct the client to notify the health care provider (HCP) before having: Question 24 See full question The nurse is teaching a client with multiple sclerosis about prevention of urinary tract infection (UTI) and renal calculi. Which of the following nutrition recommendations by the nurse would be the most likely to reduce the risk of these conditions? Question 25 See full question A nurse caring for a client diagnosed with schizophrenia should perform which of the following interventions when the client becomes suspicious and refuses to take his medication? Question 26 See full question A physician admits a client to the health care facility for treatment of an abdominal aortic aneurysm. When planning this client's care, which goal should the nurse keep in mind as she formulates interventions? Question 27 See full question A client with alcohol dependency is started on a regimen of disulfiram. Which statement should the nurse include when teaching the client about the intended effects of the drug? Question 28 See full question Which statement reflects appropriate documentation in the medical record of a hospitalized client? Question 29 See full question A nurse is caring for a client with a fresh postoperative wound following a femoral–popliteal revascularization procedure. The nurse fails to routinely assess the pedal pulses on the affected leg, and missed the warning sign that the blood vessel was becoming occluded. The nurse manager is made aware of the complication and the nurse’s failure to assess the client properly. What action should be taken by the nurse manager? Question 30 See full question A nurse suspects that a child, age 4, is being neglected physically. To best assess the child's nutritional status, the nurse should ask the parents which question? Question 31 See full question An adolescent is diagnosed with iron deficiency anemia. After emphasizing the importance of consuming dietary iron, the nurse asks him to select iron-rich breakfast items from a sample menu. Which selection demonstrates knowledge of dietary iron sources? Question 32 See full question The health care provider (HCP) prescribes IV cefazolin 1 g for a client. In preparing to administer the cefazolin, the nurse notes that the client is allergic to penicillin. Based on this information, what is an appropriate action for the nurse to take? Question 33 See full question A primigravida, currently about 8 weeks pregnant, and her husband ask when they should begin the preparation for childbirth classes that discuss maternal nutrition during pregnancy. Which time would be most appropriate for the nurse to suggest that they begin the classes? Question 34 See full question An elderly client asks the nurse how to treat chronic constipation. What is the best recommendation the nurse can make? Question 35 See full question The nurse is caring for a client with an order for an intravenous infusion of dextrose with 5% normal saline at 1500 mL over 8 hrs. The drip administration is set at 10 drops/mL. How fast will the IV infuse (drops/minute)? Record your answer using a whole number. Question 36 See full question A toddler has a temperature above 101° F (38.3° C). The physician orders acetaminophen, 120 mg suppository, to be administered rectally every 4 to 6 hours. The nurse should question an order to administer the medication rectally if the child has a diagnosis of: Question 37 See full question The nurse is evaluating a parent’s understanding of measuring one tablespoon of medication in a medicine cup. At which level on the medicine cup would the nurse confirm an appropriate dose? Question 38 See full question A client at 36 weeks’ gestation with type 1 diabetes is scheduled for a contraction stress test. After explaining the purpose of the test, the nurse determines that the client understands the instruction when she states that the test is done to detect which problem? Question 39 See full question A new nurse has transferred to the chemical dependency rehabilitation unit. Which action if performed by the new nurse would warrant the change nurse to intervene? Question 40 See full question When developing a teaching plan for a client about the medications prescribed for depression, which component is most important for the nurse to include? Question 41 See full question A new nurse is asked to start an I.V. on an antepartum client. The new nurse has performed the procedure only once and isn't familiar with the I.V. pumps used in this facility. The new nurse should: Question 42 See full question A postpartum client has a nursing diagnosis of risk for impaired urinary elimination related to loss of bladder sensation after childbirth. Which of the following priorities outcome criteria should the client achieve? Question 43 See full question A scrub nurse in the operating room has which responsibility? Question 44 See full question A client with manic episodes is taking lithium. Which electrolyte level should the nurse check before administering this medication? Question 45 See full question The nurse is admitting a hospital client who does not speak English and who is accompanied by the client's school-aged child. The client appears to be in pain, but the nurse is unable to assess the character or history of the client's pain. How should the nurse best communicate with the client? Question 46 See full question The nurse should instruct the client to avoid which drug while taking metoclopramide hydrochloride? Question 47 See full question The risk for injury during an attack of Ménière's disease is high. The nurse should instruct the client to take which immediate action when experiencing vertigo? Question 48 See full question A nurse is caring for a child with intussusception. What is an expected outcome for a goal to relieve acute pain from abdominal cramping? You Selected: Question 49 See full question A client reports difficulty breathing and a sharp pain in the right side of his chest. The respiratory rate measures 40 breaths/minute. The nurse should assign highest priority to which care goal? Question 50 See full question A client with chronic sinusitis comes to the outpatient department complaining of headache, malaise, and a nonproductive cough. When examining the client's paranasal sinuses, the nurse detects tenderness. To evaluate this finding further, the nurse should transilluminate the: Question 51 See full question When teaching a client with newly diagnosed hypertension about the pathophysiology of this disease, the nurse states that arterial baroreceptors, which monitor arterial pressure, are located in the carotid sinus. Which other area should the nurse mention as a site of arterial baroreceptors? Question 52 See full question A pregnant client calls the nurse at 22 weeks gestation to report that she is experiencing some edema of her face and hands, with puffiness in her eyelids in the morning. What is the priority action by the nurse? Question 53 See full question A client with acute asthma is prescribed short-term corticosteroid therapy. Which is the expected outcome for the use of steroids in clients with asthma? Question 54 See full question In the hospital setting, the daughter of a man who is dying tells the nurse, “It is hard to just sit with my father for hours and not say or do anything.” As the nurse responds to the daughter’s statement, what issue is most important for the nurse to focus on during their discussion? Question 55 See full question A school nurse assesses that an 8-year-old child is preoccupied with sexual comments and activities. The nurse is concerned that the child may have been sexually abused at home. What is the nurse’s best response to this situation? Question 56 See full question The mother of a client who has a radium implant asks why so many nurses are involved in her daughter’s care. She states, “The doctor said I can be in the room for up to 2 hours each day, but the nurses say they are restricted to 30 minutes.” The nurse explains that this variation is based on the fact that nurses: Question 57 See full question A client admitted to the alcohol detoxification program asks the nurse if there's anything he can take to "stop me from wanting a drink so badly." The nurse should teach the client about: Question 58 See full question A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). The nurse informs the client that the physician will order diuretic therapy and restrict fluid and sodium intake to treat the disorder. If the client doesn't comply with the recommended treatment, which complication may arise? Question 59 See full question The nurse is performing an assessment in the nursery on an infant with a developmental hip dysplasia. Which of the following findings should the nurse anticipate? Question 60 See full question A couple admitted to the labor and birth unit show the nurse their birth plan. The nurse inquires about their specific choices and wishes for the birth of their first baby. Which of the following best describes why the nurse is asking questions about the family’s birth plan? Question 61 See full question A client is receiving streptomycin for the treatment of tuberculosis. The nurse should assess the client for eighth cranial nerve damage by observing the client for: Question 62 See full question A pregnant client’s labor is progressing, but her cervix is still only 5 cm dilated and 100% effaced. Although she appears relaxed, she is aware of labor contractions. At this time, which suggestion would be most helpful for the client’s partner? Question 63 See full question Which is the correct technique when the nurse is instilling eye drops for an adult who is alert? Select all that apply. Question 64 See full question A client’s partner uses the call bell to tell the nurse that the client’s membranes have ruptured and “something is hanging out on the bed!” The nurse visualizes an overt prolapsed umbilical cord. What is the priority nursing action? Question 65 See full question Immediately after birth, a nurse assesses the neonate’s respiratory effort as slow. The neonate is actively moving but grimaces in response to stimulation. His fingers and toes are bluish, and his heart rate is 130 bpm. Which step should the nurse take next? Question 66 See full question Lorazepam is commonly given along with a neuroleptic agent. What is the purpose of administering the drugs together? Question 67 See full question A client develops a facial rash and urticaria after receiving penicillin. Which laboratory value does the nurse expect to be elevated? Question 68 See full question When making rounds on the pediatric neurology unit, the nurse manager notes that, when giving IV medications, many of the staff nurses are disconnecting the flush syringe first and then clamping the intermittent infusion device. The nurse manager is concerned that the nurses do not understand the benefits of positive pressure technique and turbulence flow flush in preventing clots. After discussing the problem with the staff educator, which intervention would be the mosteffective way to improve the nursing practice? Question 69 See full question A 15-year-old unmarried primiparous client is being cared for in the hospital’s birthing center after vaginal birth of a viable neonate. The neonate is being placed for adoption through a social service agency. Four hours postpartum, the client asks if she can feed her baby. Which response would be most appropriate? Question 70 See full question A nurse is caring for a client receiving chemotherapy. Which nursing action is most appropriate for handling chemotherapeutic agents? Question 71 See full question The nurse is admitting a child who has been diagnosed with bacterial meningitis to the pediatric unit. The nurse should implement which type of isolation? Question 72 See full question A 39-year-old client tells the nurse that he wants to undergo gender reassignment surgery because he feels trapped in his male body. What is the priority intervention for this client? Question 73 See full question On her third postpartum day, a client complains of chills and aches. Her chart shows that she has had a temperature of 100.6° F (38.1° C) for the past 2 days. The nurse assesses foul-smelling, yellow lochia. What should the nurse do next? Question 74 See full question After teaching a primiparous client about treatment and self-care of infectious mastitis of the right breast, the nurse determines that the client needs further instruction when she makes which statement? Question 75 See full question A client tells the nurse about having numbness from the back of the left buttock to the dorsum of the foot and big toe. The client is scheduled to undergo a laminectomy, and the operative consent form states “a left lumbar laminectomy of L3–L4.” What should the nurse do next? Question 1 See full question A priority in the first 24 hours after a bilateral adrenalectomy is: Question 2 See full question The terms "judgment" and "insight" are sometimes used incorrectly. Insight is the ability to: Question 3 See full question A client is recovering from an attack of gout. Client teaching should include the need to lose weight because: Question 4 See full question An elderly client has been admitted to the medical-surgical unit from the postanesthesia care unit. While the nurse is off the floor, the client falls out of bed and fractures his right leg and right wrist. The nurse finding him states, "The side rails were down and the bed was in the high position." The client's family files legal charges against the nurse and the hospital. Which charge most accurately reflects the nurse's actions? Question 5 See full question When performing routine health evaluations in school-age children, which finding would alert the school nurse to pediculosis capitis (head lice)? Question 6 See full question A child, age 15 months, is admitted to the health care facility. During the initial nursing assessment, which statement by the mother most strongly suggests that the child has a Wilms' tumor? Question 7 See full question A client is scheduled for a prostatectomy, and the anesthetist plans to use a spinal (subarachnoid) block during surgery. In the operating room, the nurse positions the client according to the anesthetist's instructions. Why does the client require special positioning for this type of anesthesia? Question 8 See full question The nurse should inform a young female client that the barrier method providing the best protection against sexually transmitted infections (STIs) is: Question 9 See full question A primigravid client asks the nurse if she can continue to have a glass of wine with dinner during her pregnancy. Which statement would be the nurse's best response? Question 10 See full question The nurse is reflecting on the evaluation step of the nursing process. Which documentation would indicate nursing actions were effective in reducing breathing problems for a client? Select all that apply. Question 11 See full question Which observation by the nurse indicates that the mother of a child receiving home IV nafcillin therapy requires further teaching? The mother: Question 12 See full question A client with diabetes is taking insulin lispro injections. The nurse should advise the client to eat: Question 13 See full question The charge nurse in an acute care setting assigns a client who is on one-on-one suicide precautions to a psychiatric aide. This assignment is considered: Question 14 See full question The nurse should suspect that the client taking disulfiram has ingested alcohol when the client exhibits which symptom? Question 15 See full question After a total hip replacement, the client tells the nurse that the pain in the operative hip has increased. Assessing the hip and leg, the nurse notes that the leg is internally rotated and shorter than the other leg and that the client has difficulty moving the leg. Based on this information, the nurse determines that the client: Question 16 See full question A 10-year-old child presents to the emergency department with dehydration. A physician orders 1 L of normal saline solution be administered at a rate of 60 ml/hour. While preparing the infusion, a nurse notices that the I.V. pump's safety inspection sticker has expired. Which action Question 17 See full question A nurse implements a health care facility's disaster plan. Which action should she perform first? Question 18 See full question A client with early dementia exhibits disturbances in mental awareness and orientation to reality. The nurse should expect to assess a loss of ability in which other area? Question 19 See full question After a stroke, a client develops aphasia. The nurse expects to see which assessment finding? Question 20 See full question When preparing to administer a chemotherapeutic agent to a client, the nurse should: Question 21 See full question A client returned to the recovery room after a dilatation and curettage has the postoperative medication prescriptions shown in the medical record. What should the nurse do next? Question 22 See full question What should a male client older than age 50 do to help ensure early identification of prostate cancer? Question 23 See full question The nurse is caring for a group of clients on a pulmonary unit. The nurse can delegate which task to unlicensed assistive personnel (UAP)? Question 24 See full question A nurse is explaining medication benefits and adverse effects to a client with a history of psychosis. The client's brother tells the nurse that she's wasting her time explaining things to the client. What information about informed consent should the nurse use to respond to the brother's negative statement? Question 25 See full question A client is scheduled for an intravenous pyelogram (IVP). In preparation for the procedure, what should the nurse ask the client? Question 26 See full question A registered nurse (RN) is working with the licensed practical nurse (LPN) to care for a group of clients in a nursing home. How should the RN expect the LPN to communicate changes in the clients' wound status? Question 27 See full question A client is receiving chemotherapy to treat breast cancer. Which assessment finding indicates a chemotherapy-induced complication? Question 28 See full question A woman brings her 6-year-old daughter to the pediatrician's office for evaluation. The child recently started wetting the bed and running a low-grade fever. A urinalysis is positive for bacteria and protein. A urinary tract infection (UTI) is diagnosed, and the child is prescribed antibiotics. Which nursing interventions are appropriate? Select all that apply. Question 29 See full question Before a transesophageal echocardiogram, a nurse gives a client an oral topical anesthetic spray. When the client returns from the procedure, the nurse observes that he has no active gag reflex. In response, the nurse should: Question 30 See full question A nurse is caring for a client with hyperemesis gravidarum who will need close monitoring at home. When should the nurse begin discharge planning? Question 31 See full question A client, 11 weeks pregnant, is admitted to the facility with hyperemesis gravidarum. She tells the nurse she has never known anyone who had such severe morning sickness. The nurse understands that hyperemesis gravidarum results from: Question 32 See full question For the client who is receiving intravenous magnesium sulfate for severe preeclampsia, which assessment findings would alert the nurse to suspect hypermagnesemia? Question 33 See full question A client with end-stage pulmonary hypertension tells the physician he doesn't want any heroic measures should his heart stop, and he doesn't want to be placed on a ventilator. The physician enters a do-not-resuscitate order into the hospital's computer system. Which ethical principle is the nurse upholding by supporting the client's decision? Question 34 See full question The selection of a nursing care delivery system (NCDS) is critical to the success of client care in a nursing area. Which factor is essential to the evaluation of an NCDS? Question 35 See full question A child, age 2, with a history of recurrent ear infections is brought to the clinic with a fever and irritability. To elicit the most pertinent information about the child's ear problems, the nurse should ask the parent: Question 36 See full question A client is admitted to the psychiatric unit exhibiting extreme agitation, disorientation, and incoherence of speech with frantic and aimless physical activity and grandiose delusions. Which of the following would the highest priority goal in planning nursing interventions? Question 37 See full question An adult male client with lymphoma reports cough, difficulty swallowing, and shortness of breath. On physical exam his face and neck are swollen and his upper extremities are cyanotic. Which of the following is the nurse’s best course of action? Question 38 See full question A 70-year-old client asks the nurse if she needs to have a mammogram. Which is the nurse's bestresponse? Question 39 See full question The client with tuberculosis is to be discharged home with nursing follow-up. Which aspect of nursing care will have the highest priority? Question 40 See full question Which indicator is the best for determining whether a client with Addison's disease is receiving the correct amount of glucocorticoid replacement? Question 41 See full question A nurse is preparing a client for bronchoscopy. Which of the following instructions is appropriate for the nurse to give to the client? Question 42 See full question A client is prescribed an intravenous solution of 1,000 ml to be infused from 0800 to 2000. The nurse will use an infusion pump that delivers the solution in milliliters per hour. At what rate would the nurse set the pump to deliver the solution? Record your answer using a whole number. (For example: 62) Question 43 See full question The nurse administers a tap water enema to a client. While the solution is being infused, the client has abdominal cramping. What should the nurse do first? Question 44 See full question When developing a teaching plan for the parents of a 1 1/2-month-old infant about how to administer levothyroxine, what should the nurse suggest as most appropriate for dissolving and mixing the medication? Question 45 See full question A physician has ordered a heating pad for an elderly client's lower back pain. Which item would be most important for a nurse to assess before applying the heating pad? Question 46 See full question The client with rapid-cycling bipolar disorder who is about to receive his 1700 hours dose of carbamazepine tells the nurse he has a sore throat and chills. What should the nurse do next? Question 47 See full question A graduate nurse is reviewing the procedure for removing a peripherally inserted central catheter (PICC) with her preceptor. Which planned action by the graduate nurse should the preceptor correct? Question 48 See full question A 15-year-old client gives birth to a healthy neonate. The neonate's adolescent father arrives on the unit demanding to see his baby. Both sets of grandparents are also present and asking to see their grandchild. The newly hired nurse assigned to the nursery should take which action? Question 49 See full question A male neonate underwent circumcision. What nursing intervention is part of the initial care of a circumcised neonate? Question 50 See full question Bacterial conjunctivitis has affected several children at a local day care center. A nurse should advise which measure to minimize the risk of infection? Question 51 See full question The nurse sees a client walking in the hallway who begins to have a seizure. What should the nurse do in order of priority from first to last? All options must be used. Question 52 See full question A nurse is teaching a client about tricyclic antidepressants. The nurse determines that teaching has been effective when the client states: Question 53 See full question A mother is visiting her neonate in the neonatal intensive care unit. Her baby is fussy and the mother wants to know what to do. In order to quiet a sick neonate, what can the nurse teach the mother to do? Question 54 See full question For a client with newly diagnosed cancer, the nurse formulates a nursing diagnosis of Anxiety related to the threat of death secondary to cancer diagnosis. Which expected outcome is appropriate for this client? Question 55 See full question The nurse is administering penicillian V potasium to a child with cellulitis. The child weighs 27.5 lb (12.5 kg). The order reads penicillian V potasium 40 mg/kg/day po divided every six hours. How many milligrams of antibiotics should this child receive with each dose? Record your answer using a whole number. Question 56 See full question The fire alarm sounds on the maternal-neonatal unit at 0200. How can a nurse best care for her clients during a fire alarm? Question 57 See full question A 10-year-old child hospitalized with acute poststreptococcal glomerulonephritis during the acute stage has elevated blood pressure and low urine output for 14 hours. The nurse should next: Question 58 See full question To prevent development of peripheral neuropathies associated with isoniazid administration, the nurse should teach the client to: Question 59 See full question The nurse is caring for a young child on the oncology unit who has developed thrombocytopenia after cancer treatment. What is the priority action for the nurse to implement when caring for this client? Question 60 See full question During a preparation for parenting class, one of the participants asks the nurse, “How will I know if I am really in labor?” What should the nurse tell the participant about true labor contractions? Question 61 See full question A client with thrombocytopenia has developed a hemorrhage. The nurse should assess the client for which finding? Question 62 See full question An adult with appendicitis has severe abdominal pain. Which action will be the most effective to assist the client to manage pain prior to surgery? Question 63 See full question On a crisis shelter hotline, the nurse talks to two 11-year-old boys who think a friend sniffs glue. They say his breath sometimes smells like glue and he acts drunk. They say they are afraid to tell their parents about the friend. When formulating a reply, what is the most important factor for the nurse to consider? Question 64 See full question The parents of a child with rheumatic fever express concern that their other children will develop the disease. Which response from the nurse is best? Question 65 See full question The nurse enters the nondiabetic client’s room shortly after a group of health care providers has made rounds. The client asks, “Why did the doctor tell the others that I am not compliant with my diabetes regimen?” The nurse is aware that which ethical principle has been violated? Question 66 See full question A parent calls the pediatric clinic to express concern over her child's eating habits. She says the child eats very little and consumes only a single type of food for weeks on end. The nurse knows that this behavior is characteristic of: Question 67 See full question A client with diabetes mellitus has had declining renal function over the past several years. Which diet regimen should the nurse recommend to the client on days between dialysis? Question 68 See full question Which has the highest priority in the care of a client with chronic renal failure? Question 69 See full question On a medical-surgical floor, a nurse is caring for a cluster of clients with diabetes mellitus. Which client should the nurse assess first? Question 70 See full question On the second day after surgery, the nurse assesses an elderly client and finds the following: • blood pressure, 148/92 mm Hg; heart rate, 98 bpm; respirations 32 breaths/min • O2 saturation of 88 on 4 L/min of oxygen administered by nasal cannula • breath sounds are coarse and wet bilaterally with a loose, productive cough • client voided 100 mL very dark, concentrated urine during the last 4 hours • bilateral pitting pedal edema Using the SBAR method to notify the health care provider (HCP) of current assessment findings, the nurse should recommend that the HCP write a prescription for a(n): Question 71 See full question What question would the nurse ask to assess coping abilities of a family dealing with a chronic illness? Question 72 See full question Two hours ago, a multigravid client was admitted in active labor with her cervix dilated at 5 cm and completely effaced and the fetus at 0 station. Currently, the client is experiencing nausea and vomiting, a slight chill with perspiration beads on her lip, and extreme irritability. The nurse should first: Question 73 See full question A client on short-term mental health disability leave undergoes required psychiatric evaluation and counseling. He requests that his evaluation and counseling records be e-mailed to his Human Resources representative. How should the nurse respond? Question 74 See full question When a client has a tearing of tissue with irregular wound edges, the nurse should document this as: Question 75 See full question The client with acute renal failure asks the nurse for a snack. Because the client's potassium level is elevated, which snack is most appropriate? Question 1 See full question When assessing a neonate 1 hour after delivery, the nurse measures an axillary temperature of 95.6° F (35.3° C), an apical pulse of 110 beats/minute, and a respiratory rate of 64 breaths/minute. Which nursing diagnosis is the priority at this time? Question 2 See full question A hospitalized client with a fracture of the tibia and fibula of the left leg is reporting increased pain at the site. What signs must the nurse be alert to that would indicate compromised circulation to the leg? Question 3 See full question For almost an hour after birth, a neonate was awake, alert, and startled and cried easily. Respirations rose to 70 breaths/minute, and heart rate on two occasions was 160 beats/minute. After sleeping quietly for about 2 hours, the neonate then awoke with a start, cried, extended and flexed all four extremities, and then choked, gagged, and regurgitated some thick mucus. What should the nurse do next? Question 4 See full question A 57-year-old woman with breast cancer who does not speak English is admitted for a lumpectomy. Her daughter, who speaks English, accompanies her. In order to obtain admission information from the client, what should the nurse do? Question 5 See full question A nurse is assessing a 10-year-old girl. The girl's mother informs the nurse that she's concerned about her daughter's breasts. The nurse assesses the breasts and notes the areola and nipple protrude slightly. Which statement by the nurse is an appropriate response? Question 6 See full question Which item in the care plan for a toddler with a seizure disorder should a nurse revise? Question 7 See full question A nurse is teaching a client with type 1 diabetes how to treat adverse reactions to insulin. To reverse hypoglycemia, the client ideally should ingest an oral carbohydrate. However, this treatment isn't always possible or safe. Therefore, the nurse should advise the client to keep which alternate treatment on hand? Question 8 See full question Which statement indicates that a client with diabetes mellitus understands proper foot care? Question 9 See full question After a plane crash, a client is brought to the emergency department with severe burns and respiratory difficulty. The nurse helps to secure a patent airway and attends to the client's immediate needs, then prepares to perform an initial neurologic assessment. The nurse should perform an: Question 10 See full question When assessing a client's I.V. insertion site, a nurse notes normal color and temperature at the site and no swelling. However, the I.V. solutions haven't infused at the ordered rate; the flow rate is slow even with the roller clamp wide open. When the nurse lowers the I.V. fluid bag, no blood returns to the tubing. What should the nurse do first? Question 11 See full question A nurse is providing health teaching focusing on urinary tract infections to a group of adolescent girls. One of the girls tells the nurse that she has heard of a condition called honeymoon cystitis and wants to know what it is. Which statement by the nurse is the most appropriate response? Question 12 See full question A nurse is planning postoperative care for a client who has received a general anesthetic. During the immediate postoperative period, which nursing assessment should the nurse be most concerned about? Question 13 See full question When bandaging a client's ankle, the nurse should use which technique? Question 14 See full question During hospitalization, a client with bulimia stops purging but becomes fearful that she will gain weight. She tells the nurse, “I cannot gain weight. I am fat enough as it is. I will be really disgusting if I get fatter.” When responding to this client, which response by the nurse would be mosttherapeutic? Question 15 See full question A 16-year-old client is admitted to the emergency department following an accident. The client sustained a head injury, is unconscious, and has compound fractures of the right tibia and fibula. No family members accompanied the client and none can be reached by phone. The surgeon instructs the nurse to take the client to the operating room immediately. Which of the following actions should the nurse take regarding informed consent? Question 16 See full question After instructing the client in techniques of pushing to use during the second stage of labor, the nurse determines that the client needs further instructions when she says she will need to do which action? Question 17 See full question Which of the following is an example of social interaction, rather than a therapeutic professional nursing interaction, between a nurse and a client? Question 18 See full question The nurse is planning care for an infant with bronchiolitis. What is the nurse’s priority intervention for this child? Question 19 See full question Which finding is an expected outcome for an elderly client following treatment for bacterial pneumonia? Question 20 See full question At what age is an individual most at risk for acquiring acute lymphocytic leukemia (ALL)? Question 21 See full question A client has been severely depressed since her husband died 6 months earlier. Her physician orders amitriptyline hydrochloride, 50 mg by mouth daily. Before administering amitriptyline, the nurse reviews the client's medical history. Which preexisting condition requires cautious use of this drug? Question 22 See full question The nurse is caring for a client who is confused about time and place. The client has intravenous fluid infusing. The nurse attempts to reorient the client, but the client remains unable to demonstrate appropriate use of the call light. In order to maintain client safety, what should the nurse do first? Question 23 See full question A client with peripheral vascular disease has undergone a right femoral-popliteal bypass graft. The blood pressure has decreased from 124/80 mm Hg to 88/62 mm Hg. What should the nurse assess first? Question 24 See full question A client is frustrated and embarrassed by urinary incontinence. Which measure should the nurse include in a bladder retraining program? Question 25 See full question The health care provider (HCP) prescribes ampicillin 100 mg/kg/dose for a newly admitted neonate. The neonate weighs 1,350 g. How many milligrams should the nurse administer? Record your answer using a whole number. Question 26 See full question A school nurse is examining a student at an elementary school. Which findings would lead the nurse to suspect impetigo? Question 27 See full question One hour before a client is to undergo abdominal surgery, the physician orders atropine, 0.6 mg I.M. The client asks the nurse why this drug must be administered. How should the nurse respond? Question 28 See full question Which goal is a priority after surgical repair of a cleft lip? Question 29 See full question When prioritizing a client's care plan based on Maslow's hierarchy of needs, a nurse's first priority would be: Question 30 See full question A nurse works with a client diagnosed with bulimia. What is the most appropriate long-term client goal for this client? Question 31 See full question The labor and birth nurse is assigned to triage for the day. There are four clients already in rooms, and the following reports have been received about each of these clients. To provide the safest care and best manage time, the nurse should plan to see which client first? Question 32 See full question A nurse recognizes that labor is divided into how many stages? Question 33 See full question A 14-year-old is using glargine and lispro to manage type 1 diabetes. The prescription for sliding scale lispro reads as follows: Lispro subcutaneous give units according to sliding scale: Blood glucose: 70–150 mg/dL (3.9 to 8.3 mmol/L) = 0 units 151–200 mg/dL (8.4 to 11.1 mmol/L) = 1 unit 201–250 mg/dL (11.2 to 13.9 mmol/L) = 2 units 251–300 mg/dL (13.9 to 16.7 mmol/L) = 3 units 301–350 mg/dL (17 to 19.4 mmol/L) = 4 units Call for Blood glucose > 350 mg/dL (19.4 mmol/L) In addition give 1 unit for every 15 g of carbohydrate. The morning blood glucose is 202 mg/dL (11.2 mmol/L), and the client is going to eat two carbohydrate exchanges. The nurse has the client administer how many units of lispro? Record your answer using a whole number. Each carbohydrate food exchange has 15 g of carbohydrate. Two units are needed to cover the current blood glucose and 2 units are needed to cover the anticipated carbohydrate intake. Question 34 See full question The client has a latex allergy. What should the nurse teach the client to do before having surgery? Select all that apply. Question 35 See full question When completing the preoperative checklist on the nursing unit, the nurse discovers an allergy that the client has not reported. What should the nurse do first? Question 36 See full question The triage nurse in the emergency department must prioritize the care of children waiting to be seen. Which child is in the greatest need of emergency medical treatment? Question 37 See full question The nurse is assessing a client for heroin addiction. Which finding indicates the client has used heroin? Question 38 See full question A severe acute respiratory syndrome (SARS) epidemic is suspected in a community of 10,000 people. As clients with SARS are admitted to the hospital, what type of precautions should the nurse institute? Question 39 See full question Following an epidural and placement of internal monitors, a client's labor is augmented. Contractions are lasting greater than 90 seconds and occurring every 1½ minutes. The uterine resting tone is greater than 20 mm Hg with an atypical fetal heart rate and pattern. Which action should the nurse take first? Question 40 See full question The health care provider (HCP) prescribes mirtazapine 30 mg PO at bedtime for a client diagnosed with depression. The nurse should:. Question 41 See full question Which action should the nurse take to provide the most effective emergency care at the accident site for a victim with a heat burn? Question 42 See full question A client comes to the clinic for a routine checkup. To assess the client's gag reflex, the nurse should use which method Question 43 See full question A nurse is assessing a client who's 29 weeks pregnant. What is the most cost-effective method for assessing fetal well-being? Question 44 See full question Which of the following actions most clearly demonstrates a nurse’s commitment to social justice? Question 45 See full question The nurse is evaluating the effectiveness of antipsychotic medications in a client with severe Alzheimer's disease. Which of the following changes indicates improvement resulting from medications? Question 46 See full question A nurse is caring for a group of pediatric clients. The nurse understands that which age group would most likely identify their pain as punishment for past behavior? Question 47 See full question As a client is being admitted to the facility, her husband asks the nurse why she must sign a statement confirming that she has been told of her rights to communicate her wishes about life support and resuscitation. How should the nurse respond? Question 48 See full question When planning care for a client with hepatitis A, the nurse should review labororatory reports for which laboratory value? Question 49 See full question The nurse is taking care of a client with Clostridium difficile. To prevent the spread of infection, what should the nurse do? Select all that apply. Question 50 See full question A client in the manic phase of bipolar disorder is admitted to the facility. Which agents are appropriate for this client? Question 51 See full question The client who experiences angina has been told to follow a low-cholesterol diet. Which meal would be best? Question 52 See full question A laboring client is restless and moving frequently in the bed. She is uncomfortable but refuses pain medication when offered. Which of the following responses from the nurse is most helpful? Question 53 See full question Which goal would be appropriate for a client with viral hepatitis? The client will: Question 54 See full question A client receiving total parenteral nutrition is ordered a 24-hour urine test. When initiating a 24-hour urine specimen, the collection time should: Question 55 See full question A nurse is caring for a client with a hiatal hernia who states abdominal and sternal pain after eating and when lying down. Which instructions would the nurse recommend when teaching this client? Select all that apply. Question 56 See full question A nurse is caring for a client with suspected diabetes insipidus. Which test does the nurse anticipate the physician will order to confirm the diagnosis? Question 57 See full question A nurse observes that decerebrate posturing is a comatose client's response to painful stimuli. Decerebrate posturing as a response to pain indicates: Question 58 See full question A client who takes ibuprofen for pain tells the nurse, “I have frequent indigestion.” Which of the following actions should the nurse take? Question 59 See full question After surgery to remove a ruptured fallopian tube, a multigravid client receives discharge instructions about potential complications to report to her physician. Which of the following, if stated by the client as a complication, indicates a need for additional teaching? Question 60 See full question To follow standard precautions, the nurse should carry out which measure? Question 61 See full question A 4-year-old, 40-lb (18.1-kg) child is brought to the pediatrician's office. The child has upper respiratory symptoms and has had a fever for 2 days. The physician diagnoses a viral illness, and the mother is instructed to treat the child with rest, fluids, and antipyretics. The nurse is reviewing the orders and questions which of the following? Question 62 See full question A client with a pulmonary embolism is experiencing chest pain and apprehension. What is the nurse’s priority intervention? Question 63 See full question A nurse is preparing to provide contraceptive counseling for a client. What should the nurse plan to do first? Question 64 See full question The nurse is planning care for a client in restraints. Which nursing intervention is most important when restraining a this client? Question 65 See full question A nurse is accompanying a client to the mall to do some shopping. A neighbor of the nurse approaches and tries to engage the nurse in conversation. What would be the most appropriate response by the nurse to the neighbor? Question 66 See full question During a routine prenatal examination, a client who is at 32 weeks’ gestation becomes dizzy, lightheaded, and pale. After placing the client in a supine position, what is the priority nursing action? Question 67 See full question A nurse is planning an education program on breast cancer for a community group of women who are of child-bearing age. The nurse plans to base the discussion on the American Cancer Association and Canadian Cancer Association guidelines. Which of the following should the nurse plan to include in the discussion? Select all that apply. Question 68 See full question Which health education topic is the priority when teaching parents ways to prevent urinary tract infections (UTIs) in their children? Question 69 See full question A 44-lb (20-kg) preschooler is being treated for inflammation. The physician orders 0.2 mg/kg/day of dexamethasone by mouth to be administered every 6 hours. The elixir comes in a strength of 0.5 mg/5 ml. How many teaspoons of dexamethasone should the nurse give this client per dose? Record your answer using a whole number. Question 70 See full question Nurses on a pediatric unit have developed a program to decrease the infection rate on the unit. What is an expected outcome of this quality improvement program? Question 71 See full question A visitor is getting ready to enter the room of a client who has contact precautions for MRSA. The nurse stops the visitor from entering and explains the necessary precautions needed to visit the client. Which statement by the visitor reflects understanding of the contact precautions teaching? Question 72 See full question The family members of a client with mild dementia are asking the nurse about permitting the elderly father to prepare an advance directive. Which information would be essential for the nurse to include in a discussion with this family? Question 73 See full question A client with a spinal cord injury says he has difficulty recognizing the symptoms of a urinary tract infection (UTI). Which assessment finding is an early symptom of UTI in a client with a spinal cord injury? Question 74 See full question A nurse must monitor a client receiving chloramphenicol for adverse drug reactions. What is a toxic reaction to chloramphenicol? Question 75 See full question A client with a history of polysubstance abuse is admitted to the facility. He complains of nausea and vomiting 24 hours after admission. The nurse who assesses the client notes piloerection, pupillary dilation, and lacrimation. The nurse suspects that the client is going through withdrawal from which substance?