1. The nurse is preparing to administer digoxin, 0.125 mg orally, to a client with heart failure. Which vital sign is most important for the nurse to check before administering the medication? A. H... eart Rate B. Temperature C. Respirations D. Blood Pressure 2. The nurse is performing nasotracheal suctioning of a client. The nurse interprets that the client is adequately tolerating the procedure if which observation is made? A. Skin color becomes cyanotic. B. Secretions are becoming bloody. C. Coughing occurs with suctioning. D. Heart rate decreases from 78 beats/minute to 54 beats/minute. 3. The nursing student is asked to describe the correct steps for performing adult cardiopulmonary resuscitation (CPR). Arrange the steps of adult CPR in the order of priority. All options must be used. A. Determine unconsciousness by shaking the client and asking “Are you ok?” B. Perform chest compression C. Open the client’s airway D. Initiate breathing 4. The nurse monitors a postoperative client who had abdominal surgery for signs of complications. Which signs/symptoms should the nurse determine to be indicative of a potential complication? Select all that apply. A. Increasing restlessness B. A temperature of 98.9° F (37.7° C) C. Unrelieved pain despite receiving analgesics D. Faint bowel sounds heard in all four quadrants E. A blood pressure of 114/66 mm Hg with a pulse of 96 beats per minute 5. The nurse provides medication instructions to an older hypertensive client who is taking 20 mg of lisinopril orally daily. The nurse evaluates the need for further teaching when the client makes which statement? A. "I can skip a dose once a week." B. "I need to change my position slowly." C. "I take the pill after breakfast each day." D. "If I get a bad headache, I should call my health care provider immediately." 6. The nurse is caring for an older client who is on bed rest. The nurse plans which intervention to prevent respiratory complications? A. Decreasing oral fluid intake B. Monitoring the vital signs every shift C. Changing the client's position every 2 hours D. Instructing the client to bear down every hour and to hold his or her breath 7. The nurse assists with preparing a nursing care plan for a child who has Reye's syndrome. Which is the priority nursing intervention? A. Monitoring the output B. Checking pupillary responses C. Changing the body position every 2 hours D. Providing a quiet atmosphere with dimmed lights 8. The nurse is initiating seizure precautions for a child being admitted to the nursing unit. Which items are essential for the nurse to place at the bedside? A. Oxygen and a tongue depressor Module 8 NCLEX Questions B. A suction apparatus and oxygen C. An airway and a tracheotomy set D. An emergency cart and an oxygen mask 9. The nurse is caring for a client after an autograft of a burn wound on the right knee. Which position should the nurse anticipate being prescribed for the client? A. Placing the affected leg flat B. Elevating and immobilizing the affected leg C. Immobilizing the client in a dependent position D. Placing the affected leg in a dependent position 10.The nurse is caring for a client after a mastectomy. Which nursing interventions should assist with preventing lymphedema of the affected arm? Select all that apply. A. Placing cool compresses on the affected arm B. Elevating the affected arm on a pillow above heart level C. Taking no blood pressure measurements in the affected arm D. Avoiding arm exercises during the immediate postoperative period E. Maintaining an intravenous (IV) insertion site below the antecubital area on the affected side 11.A client with cancer is receiving chemotherapy and develops thrombocytopenia. Which intervention is a priority in the nursing plan of care? A. Monitor the client for bleeding. B. Monitor the client's temperature. C. Ambulate the client three times daily. D. Monitor the client for pathological fractures. 12.Megestrol acetate, an antineoplastic medication, is prescribed for the client with metastatic endometrial carcinoma. The nurse reviews the client's history and contacts the registered nurse if which diagnosis is documented in the client's history? A. Gout B. Asthma C. Thrombophlebitis D. Myocardial Infarction 13.The nurse is monitoring the laboratory results of a female client receiving an antineoplastic medication by the intravenous (IV) route. The nurse plans to initiate bleeding precautions if which laboratory result is noted? A. A clotting time of 10 minutes B. A hemoglobin of 11 g/dL (110 mmol/L) C. A platelet count of 40,000 mm3 (40 × 109 /L) D. A white blood cell (WBC) count of 3,000 mm3 (3 × 109 /L) 14.The client with non–Hodgkin's lymphoma is receiving daunorubicin. Which sign/symptom should indicate to the nurse that the client is experiencing a toxic effect related to the medication? A. Fever B. Diarrhea C. Complaints of nausea and vomiting D. Crackle on auscultation of the lungs 15.Which nursing action would be appropriate to implement when a client has a diagnosis of pheochromocytoma? A. Weigh the client Module 8 NCLEX Questions B. Test the client’s urine for glucose C. Monitor the client’s blood pressure D. Palpate the client’s skin to determine warmth 16.The nurse is caring for a client with pheochromocytoma. Which data are indicative of a potential complication associated with this disorder? A. A urinary output of 50 mL/hr B. A congestion heard on auscultation of the lungs C. A blood urea nitrogen (BUN) level of 20 mg/dL 17.The nurse is caring for a client after a thyroidectomy and monitoring for signs of thyroid storm. The nurse determines that which sign/symptom is indicative that a thyroid storm may be occurring? A. Constipation B. Temperature of 96.6F C. Blood pressure of 80/60 mm Hg D. Heart rate of 44 beats per minute 18.A client with acquired immunodeficiency syndrome (AIDS) has histoplasmosis. Which sign/symptom should the nurse expect the client to experience? A. Dyspnea B. Headache C. Weight gain D. Hypothermia 19.The nurse is taking the nursing history of a client with silicosis. The nurse checks whether the client wears which item during periods of exposure to silica particles? A. Mask B. Gown C. Gloves D. Eye Protection 20.The nurse is assisting in planning care for a client scheduled for insertion of a tracheostomy. Which equipment should the nurse plan to have at the bedside when the client returns from surgery? A. Obturator B. Oral Airway C. Epinephrine D. Tracheostomy tube with the next larger size 21.The nurse is caring for a client with an endotracheal tube attached to a ventilator. The high-pressure alarm sounds on the ventilator. The nurse prepares to perform which priority nursing intervention? A. Suction the client. B. Check for a disconnection C. Notify the respiratory therapist D. Evaluate the tube cuff for a leak 22.The nurse is preparing to obtain a sputum specimen from the client. Which nursing action is essential in obtaining a proper specimen? A. Have the client take three deep breaths. B. Limit fluids before obtaining the specimen. C. Ask the client to obtain the specimen after eating. D. Ask the client to spit into the collection container. Module 8 NCLEX Questions 23.The emergency department nurse is caring for a client who sustained a blunt injury to the chest wall. Which sign noted in the client indicates the presence of a pneumothorax? A. Bradypnea B. Shortness of breath C. A low respiratory rate D. The presence of a barrel chest 24.The nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease (COPD). Which should the nurse expect to note? A. Hypcapnia B. Hyperinflated lungs on chest x-ray C. Increased oxygen saturation with exercise D. A widened diaphragm noted on chest x-ray 25.The nurse has a prescription to give a client albuterol (two puffs) and beclomethasone dipropionate (two puffs) by metered-dose inhaler. How much time should the nurse place between administering the albuterol and then the beclomethasone dipropionate? A. 1 minute B. 2 minutes C. 5 minutes D. Administer immediately 26.A client with a prescription to take theophylline daily has been given medication instructions by the nurse. The nurse determines that the client needs further teaching about the medication if the client makes which statement? A. "I will take the daily dose at bedtime." B. "I will drink at least 2 L of fluid per day." C. "I will avoid over-the-counter (OTC) cough and cold medications unless approved by the PHCP." D. "I will avoid changing brands of the medication without primary health care provider (PHCP) approval." 27.A client has an Unna boot applied for treatment of a venous stasis leg ulcer. The nurse notes that the client's toes are mottled and cool, and the client verbalizes some numbness and tingling of the foot. Which interpretation should the nurse make of these findings? A. The boot has not yet dried. B. The boot is controlling leg edema. C. The boot is impairing venous return. D. The boot has been applied too tightly. 28.A client has been diagnosed with Prinzmetal's angina. The nurse reviews the medical record and notes which accompanying characteristics? Select all that apply. A. Relieved by rest B. Occurs after exercise C. Prolonged severe pain D. Nitroglycerine relieves the pain E. Happens at the same time each day 29.The nurse is assisting in monitoring the condition of a client after pericardiocentesis for cardiac tamponade. Which observation indicates that the procedure was unsuccessful? Module 8 NCLEX Questions A. Clear breath sounds B. Client expressions of relief C. Clearly audible heart sounds D. Distant and muffled heart sounds 30.The nurse is monitoring a client with an abdominal aortic aneurysm (AAA). Which finding is probably unrelated to the AAA? A. Pulsatile abdominal mass B. Hyperactive bowel sounds in the area C. Systolic bruit over the a [Show More]
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