NCLEX RN Exam # 01

NCLEX RN Exam 150 - 1

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1. A 60-year-old client wanders away during halftime at a football game and is found 48 hours later sleeping on a park bench, 100 miles from home. The client is brought to the emergency department by the police. The client can state the name and address but has no recollection of the past 2 days. What is the priority nursing action?

1. Assess vital signs

2. Contact family members

3. Encourage the client to recall recent events

4. Perform a mental status assessment

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2. The nurse cares for a client who returns from the operating room after a tracheostomy tube placement procedure. Which of the following is the nurse's priority when caring for a client with a new tracheostomy?

2. 3. 4.

1. Changing the inner cannula within the first 8 hours to help prevent mucus plugs

2. Checking the tightness of ties and adjusting if necessary, allowing 1 finger to fit under these ties

3. Deflating and re-inflating the cuff every 4 hours to prevent mucosal tissue damage

4. Performing frequent mouth care every 2 hours to help prevent infection

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3. The nurse is assessing a 4-day-old, term neonate who is breastfed exclusively. Which assessment finding should the nurse report to the health care provider for further assessment regarding possible formula supplementation?

1. 10% weight loss since birth

2. Cracked, peeling skin

3. Feeds every 2-3 hours

4. Runny, seedy, yellow stools

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4. The labor and delivery nurse is caring for a Japanese client who has declined epidural anesthesia. The client has been very stoic and quiet throughout labor. Which nursing action represents the most appropriate care for this client?

1. Complete hourly pain assessments using a numeric pain scale

2. Document that the client appears to be experiencing minimal pain

3. Monitor for nonverbal signs of ineffective coping with labor

4. Recognize that the client's stoicism is ineffective coping with labor

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5. During a routine assessment of a developmentally normal 18-month-old, the parent expresses concern about the small amount of food the child consumes. What is the nurse's priority intervention?

1. Check the child for parasitic infections

2. Consult a pediatric nutritionist for suspected eating disorder

3. Educate the parent about physiologic anorexia

4. Notify the primary health care provider

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6. A 55-year-old male client has a 16-Fr indwelling urethral catheter with a 5-ml balloon inserted to relieve postoperative urinary retention. The nurse observes urine leaking from the insertion site, past the catheter. What is the nurse's first action?

1. Check the urethral catheter and drainage tubing

2. Irrigate the catheter with 30 mL of sterile normal saline

3. Notify the health care provider

4. Remove and reinsert the next-larger-size catheter

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7. A critically ill client receiving vasopressor therapy for hypotension requires continuous blood pressure monitoring via an arterial catheter. The nurse sets up the pressure monitoring system and correctly places the transducer at the phlebostatic axis. Where on the chest does the nurse mark this reference point?

1. 1

2. 2

3. 3

4. 4

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8. A young adult with obesity comes to the free clinic for a 2-week post-antibiotic follow-up visit for a superficial abdominal skin abscess. The client has a history of major depressive disorder and was hospitalized twice in the past 6 months for attempted suicide. The client now reports feeling "emotionally upset, alone, and at the end of my rope, due to difficulty finding a job and inability to qualify for medical insurance. The client is currently prescribed fluoxetine but has not been able to follow up with the prescribing health care provider (HCP). What is the priority nursing diagnosis (ND) at this time

1. Hopelessness

2. Ineffective coping

3. Risk for infection

4. Risk for suicide

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9. The nurse assesses 4 children in the clinic. Which assessment finding requires the nurse's priority action?

1. A 3-month-old with fever, vomiting, high-pitched cry, and irritability

2. A9-month-old with diarrhea who is refusing fluids and cries without tears

3. An 11-month-old with cold symptoms and an abdominal breathing pattern

4. An 18-month-old who cries when the caregiver leaves

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10. The nurse cares for a client with type I diabetes mellitus. Which action, by the nurse, best assesses the chronic complication of autonomic neuropathy?

1. Assess how far the client can walk

2. Check sensation in fingers and toes

3. Inspect extremities for diabetic ulcers

4. Take the blood pressure sitting and standing

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11. An obese 85-year-old client, who is an avid gardener and eats only home-grown fruits, legumes, and vegetables, is admitted to the hospital with pneumonia after having an upper respiratory tract infection for a week. Which factor puts the client at greatest risk for developing pneumonia?

1. Advanced age

2. Environmental exposure

3. Nutritional deficit

4. Obesity

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12. The emergency department nurse is triaging clients. Which neurologic presentation is most concerning for a serious etiology and should be given priority for definitive treatment?

1. History of Bell's palsy with unilateral facial droop and drooling

2. History of multiple sclerosis and reporting recent blurred vision

3. Reports unilateral facial pain when consuming hot foods

4. Temple region hit by ball, loss of consciousness, but Glasgow Coma Scale score is now 14

Epidural hematoma is an accumulation of blood between the skull bone and dura mater. The majority of epidural hematomas are associated with fracture of the temporal bone and subsequent rupture or tear of the middle meningeal artery. The bleed is arterial in origin, and so hematoma develops quickly. The clinical presentation of epidural hematoma is characteristic. The client may lose consciousness at the time of impact. The client then regains consciousness quickly and feels well for some time after the injury. This transient period of well-being is called a lucid interval. It is followed by a quick decline in mental function that can progress into coma and death.

(Option 1) Bell's palsy (peripheral facial paralysis) is an inflammation of the facial nerve (CN VII) in the absence of other disease etiologies, such as stroke. There is flaccidity of the affected side with drooling. This differs from the concerning drooling with epiglottis in which the client's throat is too sore and/or swollen to swallow saliva. Treatment includes steroids, measures to relieve symptoms, and protection of the eye (which may not close tightly), but the condition is not emergent.

(Option 2) Multiple sclerosis is a chronic, relapsing, and remitting degenerative disorder involving the brain, optic nerve, and spinal cord. Optic neuritis is a common presentation but is not life-threatening.

(Option 3) Trigeminal neuralgia (tic douloureux) presents with paroxysms of unilateral excruciating facial pain along the distribution of the trigeminal nerve (CN V) that are often triggered by touch, talking, or hot/cold air or intake. Carbamazepine (Tegretol) is the drug of choice; the condition is not life-threatening.

Educational objective: The classic presentation of intracranial epidural bleed is loss of consciousness to a period of lucidity and then gradual loss of consciousness. The bleed is arterial in origin, and so hematoma develops quickly. Emergent diagnosis and treatment are needed to prevent

Epidural hematoma is an accumulation of blood between the skull bone and dura mater. The majority of epidural hematomas are associated with fracture of the temporal bone and subsequent rupture or tear of the middle meningeal artery. The bleed is arterial in origin, and so hematoma develops quickly. The clinical presentation of epidural hematoma is characteristic. The client may lose consciousness at the time of impact. The client then regains consciousness quickly and feels well for some time after the injury. This transient period of well-being is called a lucid interval. It is followed by a quick decline in mental function that can progress into coma and death.

(Option 1) Bell's palsy (peripheral facial paralysis) is an inflammation of the facial nerve (CN VII) in the absence of other disease etiologies, such as stroke. There is flaccidity of the affected side with drooling. This differs from the concerning drooling with epiglottis in which the client's throat is too sore and/or swollen to swallow saliva. Treatment includes steroids, measures to relieve symptoms, and protection of the eye (which may not close tightly), but the condition is not emergent.

(Option 2) Multiple sclerosis is a chronic, relapsing, and remitting degenerative disorder involving the brain, optic nerve, and spinal cord. Optic neuritis is a common presentation but is not life-threatening.

(Option 3) Trigeminal neuralgia (tic douloureux) presents with paroxysms of unilateral excruciating facial pain along the distribution of the trigeminal nerve (CN V) that are often triggered by touch, talking, or hot/cold air or intake. Carbamazepine (Tegretol) is the drug of choice; the condition is not life-threatening.

Educational objective: The classic presentation of intracranial epidural bleed is loss of consciousness to a period of lucidity and then gradual loss of consciousness. The bleed is arterial in origin, and so hematoma develops quickly. Emergent diagnosis and treatment are needed to prevent

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13. A client with diabetes visits the clinic reporting breast tenderness, vaginal discharge, and urinary frequency. Which action is most important for the nurse to perform?

1. Ask if the client performs breast self-exams

2. Ask the client about characteristics of vaginal discharge

3. Assess the date of the client's last menstrual period

4. Review the client's home blood sugar logs

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14. The nurse accidentally sticks him/herself in the finger with a client's contaminated needle. The client has HIV infection. Place in order the steps the nurse should take. All options must be used

1. Step 1

2. Step 2

3. Step 3

4. Step 4

5. Step 5

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15. A nurse is performing a dressing change for a hospitalized client with an infected surgical incision. Which actions should the nurse take?

1. Have the client remove the existing dressing while the nurse prepares sterile supplies

2. Wear clean gloves for removal and application of a new dressing

3. Wear clean gloves to remove the existing dressing, changing to sterile gloves to apply the new dressing

4. Wear sterile gloves, gown, and goggles to remove the soiled existing dressing

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16. The nurse reviews laboratory data for a client admitted to the emergency department with chest pain. Which serum value requires the most immediate action by the nurse?

1. 2. 3. 4.

1. Glucose 200 mg/dL (11.1 mmol/L)

2. Hematocrit 38% (0.38)

3. Potassium 3.4 mEq/L (3.4 mmol/L)

4. Troponin 0.7 ng/mL (0.7 mcg/L)

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17. The home health nurse prepares to give benztropine to a 70-year-old client with Parkinson disease. Which client statement is most concerning and would warrant health care provider notification?

1. "I am going for repeat testing to confirm glaucoma."

2. "I am not able to exercise as much as I used to."

3. "I started taking esomeprazole for heartbum."

4. "My bowel movements are not regular."

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18. The nurse in the pediatric clinic is triaging telephone messages. The nurse should call the parent of which child first?

1. 2-year-old with bilateral tympanostomy tubes who has a small piece of plastic in the right outer ear

2. 4-year-old post adenotonsillectomy who is now reporting ear pain

3. 6-year-old with strep throat who needs a note to retum to school 24 hours after starting antibiotics

4. 7-year-old 5 days post tonsillectomy who wants to return to soccer practice today

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19. A client with primary hypothyroidism has been taking levothyroxine for a year. Laboratory results today show high levels of TSH. Which statement by the nurse to the client is appropriate?

1. "A new prescription will likely be issued for a decreased dose of levothyroxine."

2. "Dosages of levothyroxine may need to be increased to improve TSH levels."

3. "Levothyroxine should be held, and the TSH levels will be reassessed in 3 months."

4. "Start taking your levothyroxine with dietary fiber or calcium to increase its effectiveness."

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20. The nurse is precepting a new graduate nurse (GN) who is administering a prefilled enoxaparin injection to an obese client. Which action by the GN indicates the need for further education from the nurse preceptor?

1. 2. 3. 4.

1. Discourages the client from rubbing the injection site after the injection

2. Ejects the air bubble from the prefilled syringe before administration

3. Inserts the needle and injects the medication at a 90-degree angle

4. Selects an injection site on the left lateral side of the abdomen

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21. A charge nurse suspects that the unlicensed assistive personnel (UAP) is falsifying the documentation of clients' capillary glucose results rather than performing the test. What is the best action by the charge nurse to handle this situation?

1. Ask a client if the UAP has performed the test

2. Discuss the importance of task completion and accurate documentation in a staff meeting

3. Give the UAP a verbal warning not to falsify data

4. Take a client's capillary glucose personally and compare it to the recorded result

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22. An unconscious client is brought to the emergency department by the paramedics after being hit by a car. An emergency craniotomy is required. The client has no identification. What action should be taken next?

1. 2. 3. 4.

1. Contact the national database to see if the client has a healthcare proxy

2. Contact the police to help identify the client and locate family members

3. Obtain a court order for the client's surgical procedure

4. Transport the client to the operating room under implied consent

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23. The nurse is eating lunch in the hospital cafeteria, which is crowded with visitors and other staff. A health care provider approaches the nurse and asks, "How is my client Mrs. Jones in Room 312 doing?" Which response by the nurse is appropriate?

1. "I don't know because I am off duty right now."

2. "Let's step away from the crowd to discuss it."

3. "Mrs. Jones was fine when I last checked on her during rounds."

4. "You will have to talk with the nurse caring for her while I am on break."

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24. A nurse is discussing parallel play with the parent of a 2-year-old. Which statement by the parent indicates understanding of the discussion?

1. "I encourage working in a group to build towers with large blocks."

2. "I have a chalk board available to teach the alphabet and numbers."

3. "I set out a basket of various balls in the backyard when other children come to play."

4. "I try to organize games that involve a team approach."

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25. Which actions are appropriate for the registered nurse to delegate to an experienced licensed practical nurse? Select all that apply

1. Administer heparin continuous infusion to a client with a venous thromboembolism

2. Auscultate bowel sounds 2 days after repair of an inguinal hernia

3. Discuss concerns about last shift's care with an irate family member

4. Monitor flow rate and drainage in a client receiving bladder irrigation

5. Teach Kegel exercises after a client has a catheter removed

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26. The nurse is providing teaching to the parents of a child with Marfan syndrome. Which topic is the priority for the nurse to address?

1. Avoiding participation in contact sports

2. Informing the dentist of the child's condition

3. Monitoring for development of scoliosis

4. Scheduling annual eye examinations

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27. The clinic nurse is caring for a 3-year-old client. Which task, if not observed or reported by the parents as accomplished, will cause the nurse concern?

1. Catches a ball at least 50% of the time

2. Copies a square with a pencil or crayon

3. Eats with a spoon

4. Hops on one foot

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28. A client comes to the emergency department with crushing, substernal chest pain. Temperature is 98.6 F (37 C), blood pressure is 173/84 mm Hg, pulse is 92/min, and respirations are 24/min. Oxygen saturation is 95% on room air. What is the nurse's next priority action?

1. Attach defibrillator pads to the client's chest

2. Check the lipid profile laboratory results

3. Obtain a 12-lead electrocardiogram (ECG)

4. Prepare to administer a heparin drip

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29. A graduate nurse is reinforcing education to a pregnant client with hepatitis B who expresses concern about transmitting the virus to the newborn after birth. Which statement about newbom care made by the graduate nurse should cause the precepting nurse to intervene?

1. "IM injections will be given after the newborn's bath to reduce exposure to bodily fluids during needle sticks."

2. "The newborn will receive both the hepatitis B vaccination and hepatitis B immune globulin injection after birth."

3. "You may safely initiate skin-to-skin contact after birth, which promotes bonding and keeps the newborn warm."

4. "You will need to formula feed your newborn to reduce the risk of transmitting the virus via breast milk."

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30.

1. intramuscular

2. immediately

3. Capsule

4. intravenous

5. Presecription

6. Orally

7. Daily

8. sub-q or subcutaneous

9. twice a day

10. every 2 hours

11. tablet

12. hour of sleep (bedtime)

13. four times a day

14. three times a day

15. as necessary

16. every

17. after meals

18. sterile water injectable

19. sublingual

20. before meals

21. hour

22. kilograms

23. grams

24. milligrams

25. micrograms

26. nanograms

27. litres

28. mililitres

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31. The doctor's order reads, Digoxin 0.125 mg. The drug label reads, Digoxin 0.25 mg. The nurse will prepare tablet(s).

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32. If someone weighs 154 lbs, the correct conversion is kg.

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33. The doctor's order reads: Meperidine 75 - 100 mg IM q4h prn. The patient rates his pain as severe (8 / 10). The nurse decides to give the maximun dose. The ampule label reads: Meperidine 50 mg/ml. The nurse will prepare mL

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34. A person is 5' tall, the correct conversion is cm.

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35. 50 ml = L

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36. The doctor's order reads, "Gentamycin 120 mg IV, q8h". The medication is available in vials labeled, "Gentamycin 80 mg / 2 ml." The directions from the pharmacy read, "Dilute up to 320 mg in 50 ml of NS or D5W, infuse over 30 - 60 minutes." Which of the following is correct?

1. Prepare 4 ml Of Gentamycin, inject into a 50 ml minibag of NS, and administer at 0800, 1800 And 0200

2. Prepare 2 ml Of Gentamyin, inject into a 50 ml minibag of D5W and give at intervals 8 hours apart.

3. Prepare 0.5 ml Of Gentamycin, inject into a 50 ml minibag of NS and give At 0400, 1200 and 2000.

4. Prepare 3 ml of Gentamycin, inject into a 50 ml minibag of NS, and administer at 0600, 1400 and 2200.

5. None of the above

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37. Prednisone is available in 5 mg tablets. Your patient is ordered Prednisone 20 mg. You should give tablets

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38. The doctor's order reads: loratadine 10 mg po. The label reads: loratadine 5 mg/5 ml. The nurse will prepare ml.

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39. 6.5 g = mg

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40. 200 mcg = mg

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41. A student nurse prepares to change a large wet-to-damp sterile wound dressing and uses a disposable moisture-proof sterile drape to set up the sterile field. The precepting nurse intervenes when the student performs which action?

1. Holds the package 6" (15 cm) above the sterile field and drops the sterile gauze onto the field

2. Opens the sterile gauze package with ungloved hands

3. Places the sterile gauze dressings within 2" (5 cm) from the edge of the sterile drape

4. Pours sterile normal saline solution (NSS) into a sterile basin from a bottle opened 30 hours ago

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42. A client with coronary artery disease is being seen in the clinic for a follow-up examination. During medication reconciliation, the nurse identifies which reported medication as requiring further investigation?

1. 10 mg isosorbide dinitrate twice daily

2. 20 mg atorvastatin once daily

3. 500 mg naproxen twice daily

4. 2,000 mg fish oil once daily

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43. A newborn client is seen in the emergency department for vomiting. Which assessment finding indicates a possible emergency?

1. Frequent vomiting since birth

2. Tiny blood streaks in the vomit

3. Vomit that is green

4. Vomiting through the nose

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44. The nurse taught the caregiver of a child with a ventriculoperitoneal (VP) shunt about when to contact the health care provider (HCP). The caregiver shows understanding of the instructions by contacting the HCP about which symptom?

1. A temperature of 99 F (37 C) that occurs during the evening

2. The child cannot recall items eaten for lunch the previous day

3. The child vomits after awakening from a nap and 1 hour later

4. The VP shunt is palpated along the posterior-lateral portion of the skull

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45. A primigravid woman comes to the clinic for her initial prenatal visit. She is at 32 weeks’ gestation and says that she has just moved from out of state. The client says that she has had periodic headaches during her pregnancy, and that she is continually bumping into things. The nurse notes numerous bruises in various stages of healing around the client’s breasts and abdomen. Vital signs are: BP 120/80, pulse 72, resp 18, and FHT 142. Which of the following responses by the nurse is BEST?

1. “Are you battered by your partner?”

2. “How do you feel about being pregnant?”

3. “Tell me about your headaches.”

4. “You may be more clumsy due to your size.”

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46. The registered nurse supervises a student nurse who is caring for a client newly prescribed lithium for the treatment of bipolar disorder. Which action by the student indicates a need for further teaching?

1. Advises the client to drink 2-3 liters of water each day

2. Instructs the client to limit intake of cola, tea, coffee, and alcohol

3. Shows the client how to carefully check food labels to follow a low-sodium diet

4. Teaches the client that it may take up to several weeks for the drug to be effective

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47. The nurse receives handoff report on 4 clients. Which client should the nurse assess first?

1. Client with chronic anxiety disorder taking buspirone and diphenhydramine who has a dry mouth

2. Client with chronic heart failure taking metoprolol and lisinopril who has dizziness when standing up

3. Client with major depressive disorder taking phenelzine and pseudoephedrine who has a headache

4. Client with type 2 diabetes taking metformin and lovastatin who has stomach upset and nausea

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48. A client with type 2 diabetes, coronary artery disease, and peripheral arterial disease developed hospital-acquired pneumonia (HAP) and has been receiving intravenous (IV) antibiotics for 4 days. Which parameter monitored by the nurse best indicates the effectiveness of treatment?

1. Color of sputum

2. Lung sounds

3. Saturation level

4. White blood cell count (WBC)

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49. A client is diagnosed with a small thoracic aortic aneurysm during a routine chest x-ray and follows up 6 months later with the health care provider (HCP). Which assessment data is most important for the nurse to report to the HCP?

1. Blood pressure (BP) of 140/86 mm Hg

2. Difficulty swallowing

3. Dry, hacking cough

4. Low back pain

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50. The nurse is caring for a client receiving mechanical ventilation via tracheostomy 2 weeks following a tracheotomy. The nurse enters the client's room to address a ventilator alarm and notes the tracheostomy tube dislodged and lying on the client's chest. Which action by the nurse is appropriate? Click on the exhibit button for additional information.

Vital Signs

Heart rate -132/min

Respirations - 40/min

O2 Saturation or SpO2 - 80 %

1. Apply a nonrebreather face mask with 100% oxygen

2. Apply dry, sterile gauze over the stoma and secure with tape

3. Insert a new tracheostomy tube using the bedside obturator

4. Insert a sterile catheter into the stoma and suction the airway

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51. The nurse is caring for an exclusively breastfed, small-for-gestational age, term newborn at 6 hours of life. The newborn has a capillary blood glucose (BG) of 30 mg/dL (1.67 mmol/L) and is asymptomatic. Which action is most appropriate for the nurse to take at this time?

1. Administer IV glucose

2. Allow the newborn to breastfeed

3. Obtain a prescription for formula supplementation

4. Wait for plasma blood sample to confirm BG prior to feeding

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52. The registered nurse is counseling the parent of a child recently diagnosed with attention- deficit hyperactivity disorder (ADHD), combined type. Which statement by the parent requires an intervention?

1. "I should offer a choice between 2 things for my child's clothes or meals."

2. "I will need to advocate for an individualized educational plan for my child."

3. "My child will outgrow this disorder around age 20."

4. "When talking with my child, I should not be multi-tasking."

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53. A client is taking morphine sulfate for acute pain. Which statement will best assist the client worried about nausea and vomiting while taking this medication?

1. "Nausea and vomiting rarely occur with this medication."

2. "Nausea and vomiting rarely occur when you are up and walking."

3. "Take the medication on an empty stomach."

4. "Tolerance develops quickly and persistent nausea is rare."

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54. The public health nurse conducts a program at the community senior citizen center about preventing falls at home. Which statement made by a participant indicates that further education is needed?

1. "I bought a new nightlight for the hallway to the bathroom."

2. "I feel so much more secure wearing my electronic fall alert device."

3. "I walk in my stockings at home because it helps to relieve my bunion pain."

4. "My daughter helped me secure the small, thin rug in my kitchen with strong tape."

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55.

1. "I do not want to get pregnant, so I restarted my oral contraceptive last month."

2. "I have been taking my medications with breakfast every morning."

3. "I should alert my health care provider if I notice yellowing of my skin."

4. Since I started this medicine, my saliva has become a red-orange color."

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56. A nurse is caring for a client on a mechanical ventilator. The ventilator is sounding an alarm and displaying an alert about low tidal volumes. The nurse has checked all connections and the endotracheal tube, but the alarm persists and the client's oxygen saturation is dropping. What should the nurse do next?

1. Call the respiratory therapist to the bedside to troubleshoot

2. Elevate the head of the bed and apply a nonrebreather mask

3. Increase the oxygen delivery on the ventilator to 100%

4. Manually ventilate with a resuscitation bag device attached to the endotracheal tube

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57. The nurse receives report on several postpartum clients who gave birth at term gestation. Which client should the nurse assess first?

1. Client, G_{1} P_{11} who is 24 hours postcesarean birth with cramping and foul-smelling lochia

2. Client, G_{11} P_{11} who is 72 hours postvaginal birth, on bed rest, and taking enoxaparin for a deep venous thrombosis

3. Client, G_{4} P_{3} who is 72 hours postcesarean birth with a temperature of 100.8 F (38.2 C) and a red, swollen breast

4. Client, G_{5} P_{5} who is 12 hours postvaginal birth and saturating perineal pads every hour for 2 hours with lochia rubra

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58. The health care provider has just informed a client who has diabetes and chronic kidney disease of the need to start dialysis. The client tearfully says to the nurse, "I don't know what I'm going to do; everything was so overwhelming before, and now there is this." How should the nurse respond?

. 2. 3. 4.

1. "You can cry and get it all out; I will stay with you."

2. "You have dealt with diabetes; you can conquer dialysis."

3. "You sound very discouraged and frightened."

4. "You still have a lot to live for; think about your family."

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59. During shift change, the night nurse notices that the graduate nurse administered IV dopamine instead of the prescribed norepinephrine for a client with sepsis. What should the night nurse do first?

1. 2. 3. 4.

1. Administer the correct medication and obtain current vital signs

2. Alert the graduate nurse and complete an incident report

3. Assess the client and notify the health care provider

4. Discontinue the dopamine and inform the nursing supervisor

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60. In working with a rape victim, which of the following is most important?

1. Continuing to encourage the client to report the rape to the legal authorities.

2. Recommending that the client resume sexual relations with her partner as soon as possible.

3. Periodically reminding the client that she did not deserve and did not cause the rape.

4. Telling the client that the rapist will eventually be caught, put on trial, and jailed.

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61. A client tells the nurse that she has been raped but has not reported it to the police. After determining whether the client was injured, whether it is still possible to collect evidence, and whether to file a report, the nurse's next priority is to offer which of the following to the client?

1. Legal assistance.

2. Crisis intervention.

3. A rape support group.

4. Medication for disturbed sleep.

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62. When caring for a client who was a victim of a crime, the nurse is aware that recovery from any crime can be a long and difficult process depending on the meaning it has for the client. Which of the following should the nurse establish as a victim's ultimate goal in reconstructing his or her life?
1.
2.
3.
4.

1. Getting through the shock and confusion.

2. Carrying out home and work routines.

3. Resolving grief over any losses.

4. Regaining a sense of security and safety.

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63. The mother of a school-aged child tells the nurse that, “For most of the past year, my husband was unemployed and I worked a second job. Twice during the year I spanked my son repeatedly when he refused to obey. It has not happened again. Our family is back to normal.” After assessing the family, the nurse decides that the child is still at risk for abuse. Which of the following observations best supports this conclusion?

1. The parents say they are taking away privileges when their son refuses to obey.

2. The child has talked about family activities with the nurse.

3. The parent's are less negative toward the nurse.

4. The child wears long-sleeved shirts and long pants, even in warm weather.

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64. A third-grade child is referred to the mental health clinic by the school nurse because he is fearful, anxious, and socially isolated. After meeting with the client, the nurse talks with his mother, who says, “It's that school nurse again. She's done nothing but try to make trouble for our family since my son started school. And now you're in on it.” The nurse should respond by saying:

1. “The school nurse is concerned about your son and is only doing her job.”

2. “We see a number of children who go to your son's school. He isn't the only one.”

3. “You sound pretty angry with the school nurse. Tell me what has happened.”

4. “Let me tell you why your son was referred, and then you can tell me about your concerns.”

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65. After months of counseling, a client abused by her husband tells the nurse that she has decided to stop treatment. There has been no abuse during this time, and she feels better able to cope with the needs of her husband and children. In discussing this decision with the client, the nurse should:
1.
2.
3.
4.

1. Tell the client that this is a bad decision that she will regret in the future.

2. Find out more about the client's rationale for her decision to stop treatment.

3. Warn the client that abuse commonly stops when one partner is in treatment, only to begin again later.

4. Remind the client of her duty to protect her children by continuing treatment.

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66. When planning the care for a client who is being abused, which of the following measures is most important to include?

1. Being compassionate and empathetic.

2. Teaching the client about abuse and the cycle of violence.

3. Explaining to the client about the client's personal and legal rights.

4. Helping the client develop a safety plan.

67 / 150

67. A client with suspected abuse describes her husband as a good man who works hard and provides well for his family. She does not work outside the home and states that she is proud to be a wife and mother just like her own mother. The nurse interprets the family pattern described by the client as best illustrating which of the following as characteristic of abusive families?

1. Tight, impermeable boundaries.

2. Unbalanced power ratio.

3. Role stereotyping.

4. Dysfunctional feeling tone

68 / 150

68. A married female client has been referred to the mental health center because she is depressed. The nurse notices bruises on her upper arms and asks about them. After denying any problems, the client starts to cry and says, “He didn't really mean to hurt me, but I hate for the kids to see this. I'm so worried about them.” Which of the following is the most crucial information for the nurse to determine?

1. The type and extent of abuse occurring in the family.

2. The potential of immediate danger to the client and her children.

3. The resources available to the client.

4. Whether the client wants to be separated from her husband.

69 / 150

69. The nurse is providing first aid at an outdoor festival when a client reports dizziness and weakness. The client is flushed, sweating, nauseated, and slightly tachycardic. Which action is most appropriate at this time?

1. Call emergency medical services and place ice packs on the client's axilla and groin

2. Encourage the client to leave the venue to visit a health care provider

3. Evaluate whether the client may be intoxicated

4. Move the client to an air-conditioned booth and provide a cool sports drink

70 / 150

70. A legally blind client is being prepared to ambulate 1 day after an appendectomy. What is the most appropriate action by the nurse?

1. Arrange for the client's service dog to come to the health care facility as soon as possible

2. Describe the environment in detail so the client can ambulate safely with a cane

3. Instruct the unlicensed assistive personnel to walk beside the client and lead by the hand

4. Walk slightly ahead of the client with the client's hand resting on the nurse's elbow

71 / 150

71. A client with latent tuberculosis has been taking oral isoniazid (INH) 300 mg daily for 2 months. The client tells the nurse that for the past week she has had numbness, a burning sensation, and tingling in her hands and feet. Additional intake of which of the following would most likely have prevented this?

1. Folic acid 2. Vitamin B 3. 4.

1. Folic acid

2. Vitamin B 3

3. Vitamin B12

4. Vitamin D

72 / 150

72. The nurse is conducting a health-screening clinic at an industrial work site. The nurse should be most concerned about which client's risk for metabolic syndrome?

1. 27-year-old woman with triglycerides of 210 mg/dL (2.4 mmol/L), blood pressure of 128/82 mm Hg, and fasting blood glucose of 98 mg/dL (5.4 mmol/L)

2. 45-year-old man with waist circumference of 38 inches (96.5 cm), high-density lipoprotein of 49 mg/dL (1.3 mmol/L), and fasting blood glucose of 118 mg/dL (6.6 mmol/L)

3. 55-year-old woman with waist circumference of 37 inches (94 cm), triglycerides of 190 mg/dL (2.2 mmol/L), and fasting blood glucose of 120 mg/dL (6.7 mmol/L)

4. 82-year-old man with high-density lipoprotein of 45 mg/dL (1.2 mmol/L), blood pressure of 148/88 mm Hg, and fasting blood glucose of 104 mg/dL (5.8 mmol/L)

73 / 150

73. A client with massive trauma and possible spinal cord injury is admitted to the emergency department following a motorcycle collision. Which assessment finding leads the nurse to suspect neurogenic shock?

1. Apical heart rate 48/min

2. Blood pressure 186/92 mm Hg

3. Cool, clammy skin

4. Temperature 100 F (37.8 C)

74 / 150

74. A client's lab results show a blood urea nitrogen (BUN) level of 25 mg/dL and a creatinine level of 1.8 mg/dL. What do these findings suggest?

1. Liver failure

2. Renal impairment

3. Normal kidney function

4. D.

75 / 150

75. A client’s lab results indicate a white blood cell (WBC) count of 15,000/mm³. What might this lab value suggest?

1. Leukopenia

2. Normal WBC count

3. Infection

4. Anemia

76 / 150

76. The nurse notes that a client's platelet count is 90,000/µL. Which is the most appropriate intervention?

1. Administer platelet transfusion immediately.

2. Monitor the client for signs of bleeding.

3. Encourage the client to increase physical activity

4. Prepare the client for hemodialysis

77 / 150

77. A client's laboratory results show a fasting blood glucose level of 130 mg/dL. What condition does this value indicate?

1. Hypoglycemia

2. Normal fasting glucose

3. Prediabetes

4. Diabetic ketoacidosis

78 / 150

78. The nurse is assessing a client with a calcium level of 6.5 mg/dL. Which symptom should the nurse expect to find?

1. Polyuria

2. Muscle twitching

3. Constipation

4. Lethargy

79 / 150

79. A client has an INR of 4.5 while on warfarin therapy. Which action should the nurse take?

1. Administer the next dose of warfarin as scheduled

2. Prepare to administer vitamin K

3. Encourage the client to eat green leafy vegetables

4. Instruct the client to avoid foods high in vitamin K

80 / 150

80. A client’s complete blood count (CBC) shows a hemoglobin level of 7.8 g/dL. Which clinical manifestation should the nurse anticipate?

1. Hypertension

2. Bradycardia

3. Fatigue

4. Cyanosis

81 / 150

81. The nurse is reviewing the lab results of a client with pancreatitis. Which of the following serum amylase levels is consistent with this diagnosis?

1. 50 U/L

2. 120 U/L

3. 300 U/L

4. 450 U/L

82 / 150

82. A client’s laboratory results show a serum sodium level of 128 mEq/L. Which of the following findings should the nurse expect?

1. Increased thirst

2. Hyperactive bowel sounds

3. Confusion and weakness

4. Bradycardia

83 / 150

83. A client with chronic kidney disease has a serum potassium level of 6.2 mEq/L. Which action should the nurse take first?

1. Encourage the client to eat potassium-rich foods

2. Administer a prescribed dose of sodium polystyrene sulfonate

3. Place the client on a cardiac monitor.

4. Administer a prescribed dose of furosemide

84 / 150

84. A client with chronic heart failure developed an intractable cough and an incident of angioedema after starting enalapril. Which prescription does the nurse anticipate for this client?

1. Alprazolam

2. Dextromethorphan

3. Lisinopril

4. Valsartan

85 / 150

85. The nurse assessing a client notices pearly white plaque-like lesions on the mouth mucosa. The nurse understands that which client is at highest risk for oral candidiasis?

1. A client with asthma who uses an albuterol nebulizer once a day

2. A septic client receiving intravenous broad-spectrum antibiotics daily

3. A teenage client with braces who drinks several sugary drinks daily

4. An elderly client with poor oral hygiene and inadequate nutrition

86 / 150

86. The hospital nurse coming on duty notifies the unit of a delay due to a motor vehicle accident. The off-going nurse has an important appointment and must leave on time. How should the off-going nurse handle the situation?

1. Ask another nurse to watch the current assigned clients until the incoming nurse arrives

2. Tape-record a report and leave a cell phone number to call if there are any questions

3. Tell the charge nurse of the impending need to leave and that client coverage is required

4. Write out a report about the clients for the incoming nurse prior to leaving

87 / 150

87. The nurse is teaching a class of expectant parents about infant safety. Which statement by a class participant indicates a need for further instruction?

1. "I will allow my baby to sleep with a pacifier."

2. "I will dress my baby in a sleep sack to prevent my baby from getting cold."

3. "I will make sure there is a firm mattress in the crib."

4. "I will tie bumper pads to the sides of the crib to protect my baby's head."

88 / 150

88. The nurse is conducting a pain assessment on a client with dysuria. Which pain description is most likely associated with pyelonephritis?

1. Constant; increased by pressure over the suprapubic area

2. Dull and continuous; occasional spasms over the suprapubic area

3. Dull flank pain; extending toward the umbilicus

4. Excruciating; sharp flank pain radiating to the groin

89 / 150

89. The student nurse and the registered nurse are caring for a mechanically ventilated client with an acute lung injury. Which statement by the student nurse indicates a need for further education?

1. "I will auscultate the neck to assess for endotracheal cuff leaks."

2. "I will perform endotracheal suctioning routinely after oral care."

3. "I will provide oral care and oral suctioning every 2 hours."

4. "I will reposition the client from side-to-side at least every 2 hours."

90 / 150

90. The parents of a 5-year-old ask the school nurse for advice on how to tell their child about being adopted. Which developmentally appropriate thought about adoption by the child does the nurse counsel the parents to anticipate?

1. Feels responsible for being placed for adoption

2. Imagines what life would be like with a different family

3. Is unable to conceptualize differences between adoptive and biological parents

4. Worries about what peers will say or think

91 / 150

91. A nurse in a pediatric clinic is preparing to administer ear drops to a 5-year-old. Which is an appropriate action by the nurse?

2. 3. 4.

1. Have the child sit upright with the chin tilted down

2. Pull the pinna upward and back

3. Remove the medication from the refrigerator just before use

4. Touch the dropper to the entrance of the ear canal

92 / 150

92. A client with a mandibular fracture who has the upper and lower teeth wired together begins to choke on excessive oral secretions. What is the nurse's immediate action?

1. Cut the wires

2. Elevate the head of the bed

3. Notify the health care provider

4. Suction the mouth and oropharynx

93 / 150

93. The charge nurse is preparing for the admission of an elderly client with delirium and agitation associated with urinary tract infection. To promote client safety, which intervention is most important for the charge nurse to implement?

1. A bed near the nursing station

2. Four-point leather restraints

3. Minimizing environmental stimuli

4. One-on-one supervision from a sitter

94 / 150

94. A client is brought to the emergency department after the spouse finds the client locked in the car inside their garage with the motor running. The spouse says to the nurse, "If I hadn't come home early from work, my spouse would be dead. I can't believe this is happening." What is the best response by the nurse?

1. "Do you have any relatives or close friends who can help you through this?"

2. "Has your spouse seemed depressed lately?"

3. "This has been very overwhelming for you. What are you feeling right now?"

4. "Well, you did find your spouse. You need to focus on helping your spouse get better."

95 / 150

95. The nurse just administered routine immunizations to a healthy 15-month-old. What information should the nurse provide the caregivers before they leave the clinic?

1. Call the office if the toddler's temperature is higher than 100 F (37.7 C)

2. Fussiness and anorexia are common for 1 week after immunizations

3. Redness at the injection sites and a mild fever are common

4. The toddler's activity level should be restricted for 24 hours

96 / 150

96. Yesterday, the client was weaned from the mechanical ventilator and an intravenous infusion of lorazepam. The client has been alert and oriented for 24 hours but is now experiencing confusion. The nurse now evaluates new-onset confusion by assessing the client's sense of place and time, difficulty focusing, short-term memory loss, and increasing lethargy. The nurse suspects which condition in this client?

1. Amnesia

2. Delirium

3. Dementia

4. Psychosis

97 / 150

97. A nurse is teaching a postpartum client about cord care for the newborn. Which statement by the client indicates a need for further teaching?

1. "I can expect the cord to turn black in a few days."

2. "I should let the cord fall off by itself, in about 1-2 weeks."

3. "I should use a cotton swab to gently apply alcohol to the cord."

4. "I will fold the diaper below the cord to allow the cord to dry."

98 / 150

98. A client diagnosed with trigeminal neuralgia is given a prescription of carbamazepine by the health care provider. Which intervention does the nurse add to this client's care plan?

1. Encourage client to drink cold beverages

2. Encourage client to eat a high-fiber diet

3. Encourage client to perform facial massage

4. Encourage client to report any fever or sore throat

99 / 150

99. What is a common symptom of hyperphosphatemia in a patient with TLS?

1. Constipation

2. Itching

3. Muscle cramps

4. Weight loss

100 / 150

100. Which of the following is a key nursing intervention for a patient at risk of TLS?

1. Monitoring blood glucose levels

2. Restricting fluid intake

3. Encouraging a high-calcium diet

4. Close monitoring of electrolyte levels

101 / 150

101. Which medication is used to treat hyperkalemia by shifting potassium into cells?

1. Calcium gluconate

2. Sodium bicarbonate

3. Insulin with dextrose

4. Kayexalate

102 / 150

102. What is the primary purpose of administering IV fluids to a patient with TLS?

1. To prevent dehydration

2. To enhance the excretion of released intracellular contents

3. To manage pain

4. To increase blood pressure

103 / 150

103. The presence of which symptom suggests that a patient with TLS might be experiencing hypocalcemia?

1. Muscle weakness

2. Trousseau's sign

3. Polyuria

4. Hypertension

104 / 150

104. Which laboratory test result is most indicative of TLS?

1. Decreased hemoglobin

2. low blood phosphatase

3. Elevated serum creatinine

4. Low white blood cell count

105 / 150

105. What is the first-line treatment for hyperuricemia in TLS?

1. Allopurinol

2. Rasburicase

3. Methotrexate

4. Furosemide

106 / 150

106. A patient with TLS is at risk for which of the following cardiac complications?

1. Bradycardia

2. Tachycardia

3. Arrhythmias

4. Hypertension

107 / 150

107. Which electrolyte imbalance is most commonly associated with Tumor Lysis Syndrome?

1. Hyperkalemia

2. Hypokalemia

3. Hypophosphatemia

4. Hypernatremia

108 / 150

108. What is the primary cause of Tumor Lysis Syndrome?

1. Chemotherapy-induced tumor cell lysis

2. Radiation therapy

3. Surgical removal of a tumor

4. Long-term use of corticosteroids

109 / 150

109. The nurse notes muffled heart tones in a client with a pericardial effusion. How would the nurse assess for a pulsus paradoxus?

1. Check for variation in amplitude of QRS complexes on the electrocardiogram strip

2. Compare apical and radial pulses for any deficit

3. Measure the difference between Korotkoff sounds auscultated during expiration and throughout the respiratory cycle

4. Multiply diastolic blood pressure (DBP) by 2, add systolic blood pressure (SBP), and divide the result by 3; [(DBP x 2) + (SBP)]/3

Muffled heart tones in a client with pericardial effusion can indicate the development of cardiac tamponade. This results in the build-up of fluid in the pericardial sac, which leads to compression of the heart. Cardiac output begins to fall as cardiac compression increases, resulting in hypotension. Additional signs and symptoms of tamponade include tachypnea, tachycardia, jugular venous distension, narrowed pulse pressure, and the presence of a pulsus paradoxus. Pulsus paradoxus is defined as an exaggerated fall in systemic BP >10 mm Hg during inspiration. The procedure for measurement of pulsus paradoxus is as follows:

1. Place client in semirecumbent position

2. Have client breathe normally

3. Determine the SBP using a manual BP cuff

4. Inflate the BP cuff to at least 20 mm Hg above the previously measured SBP

5. Deflate the cuff slowly, noting the first Korotkoff sound during expiration along with the pressure

6. Continue to slowly deflate the cuff until you hear sounds throughout inspiration and expiration; also note the pressure

7. Determine the difference between the 2 measurements in steps 5 and 6; this equals the amount of paradox

8. The difference is normally <10 mm Hg, but a difference >10 mm Hg may indicate the presence of cardiac tamponade.

(Option 1) Variation in QRS amplitude is termed electrical alternans. It could be present in cardiac tamponade, but it is not how pulsus paradoxus is determined. Electrical alternans is due to the swinging motion of the heart in a fluid-filled pericardial sac.

(Option 2) An apical/radial pulse deficit may be present during certain dysrhythmias, but this is not the procedure for measuring pulsus paradoxus. (Option 4) This is the formula for calculating mean arterial pressure.

Educational objective: The nurse should assess the client for pulsus paradoxus when cardiac tamponade is suspected. The amount of paradox is the difference between the pressure heard at the first Korotkoff sound during expiration and the Korotkoff sounds heard throughout inspiration and expiration. A difference of <10 mm Hg is normal, but if it is >10 mm Hg, this may indicate cardiac tamponade.