NCLEX Exam Test Bank Questions with Answers, Exams of Nursing

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Question 1 What document should be in guiding the care of this client? Advance Directives Question 2 You are the of a health care team that consists of one licensed practical/vocational nurse, one nursing assistant, a nursing student and yourself. To whom is it appropriate to assign complete care for Yourself Question 4 As the nurse takes a history of a 3-year-old with neuroblastoma, what comments by the parents require follow-up and are consistent with the diagnosis? "Clothes are becoming tighter across her abdomen." Question 5 A 16-year-old presents to the emergency department. The triage nurse finds that this teenager is legally married and signed the consent form for treatment. What would be the appropriate INITIAL action by the nurse? Assess and treat in the same manner as any adult client Question 6 A newly admitted elderly client is severely dehydrated. When planning care for this client, which one of the following is an appropriate task for an Unlicensed Assistive Personnel (UAP)? Report output of less than 30 ml/hr Question 7 The nurse is assessing a 4-year-old for possible rheumatic fever. Which of the following would the nurse suspect is related to this diagnosis? Exposure to strep throat in daycare last month Question 8 When the nurse becomes aware of feeling reluctant to interact with a manipulative client, the BEST action by the nurse is to Discuss the feeling of reluctance with an objective peer or supervisor Question 9 A client is being treated for paranoid schizophrenia. When the client became loud and boisterous, the nurse immediately placed him in seclusion as a precautionary measure. The client willingly complied. The nurse's action May result in charges of unlawful seclusion and restraint

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Question 10 A client has been admitted to the Coronary Care Unit with a Myocardial Infarction. Which of the following nursing diagnosis should have PRIORITY? Pain related to ischemia Question 11 The nurse manager who is responsible for hiring professional nursing staff is required to comply with the Americans with Disabilities Act. The provisions of the law require the nurse manager to Provide reasonable accommodations for disabled individuals Question 12 The mother of a school-aged child in a long leg cast asks the nurse how to relieve itching inside the cast. Which of the following is appropriate for the nurse to suggest as a remedy? Applying an over the area of the cast that is affected Question 13 Which of the following BEST describes the application of time management strategies in the role of the nurse manager? Setting daily goals to prioritize work Question 14 The clinic nurse assesses a toddler with a tentative diagnosis of neuroblastoma. Symptoms the nurse observes that suggest this problem include Abdominal mass and weakness Question 15 A fifteen-year-old client has been placed in a Milwaukee Brace. Which one of the following statements from the client indicates the need for additional teaching? "I will only have to wear this for six months." Question 16 The nurse manager has been using a decentralized block scheduling plan to staff the nursing unit. However, staff have asked for many changes and exceptions to the schedule over the past few months. The manager considers self- scheduling knowing that Team morale will improve Question 17 A client is admitted to the emergency room following an acute asthma attack. Which of the following assessments would be expected by the nurse? Diffuse expiratory wheezing

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Question 18 The nurse manager hears a physician loudly criticizing one of the staff nurses in the hearing of others. The employee does not respond to the physician's complaints. The nurse manager's FIRST action should be Request an immediate private meeting with the physician and staff nurse Question 19 A client voluntarily admits herself to the hospital due to suicidal ideation. The client has been on the unit for two days and is now demanding to be released. The MOST appropriate action is for the nurse to Discuss with the client the decision to leave and prepare for her discharge Question 20 A client is admitted with condition? (IE). Which this^ symptom^ would alert^ the nurse^ to^ a complication^ of Heart murmur Question 21 A nurse admits a premature infant who has respiratory distress syndrome. In planning care, nursing actions are based on the fact that the MOST likely cause of this problem stems from the infant's inability to Maintain alveolar surface tension Question 22 An 18-year-old client is admitted to intensive care from the emergency room following a diving accident. The injury is suspected to be at the level of the 2nd cervical vertebrae. The nurse's PRIORITY assessment should be Respiratory function Question 23 The nurse is caring for a client who was successfully resuscitated from a pulseless dysrhythmia. Which of the following assessments is CRITICAL for the nurse to include in the plan of care? Hourly urine output Question 24 The nurse admitting a 5-month-old who vomited nine times in the past six hours should observe for signs of Metabolic alkalosis Question 25 A child is injured on the school playground and appears to have a fractured leg. The FIRST action the school nurse should take is Assess the child and the extent of the injury infective

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Question 26 As the nurse interviews the parents of a child with asthma, it is a PRIORITY to ask about Household pets Question 27 An 80-year-old client was admitted with a diagnosis of possible cerebral vascular accident. Blood pressure has ranged from 180/110 to 160/100. Over the past several hours, the nurse noted increasing lethargy. Which of the following assessments should the nurse report IMMEDIATELY to the physician? Slurred speech Question 28 A 3-year-old child is brought to the clinic by his grandmother to be seen for "scratching his bottom and wetting the bed at night." Based on these complaints, the nurse would INITIALLY assess for Pinworms Question 29 A 72-year-old client with osteomyelitis requires a six-week course of intravenous antibiotics. In planning for home care, the MOST important action by the nurse is Assessing the client's ability to participate in self-care and/or the reliability of a caregiver Question 30 The mother of a child with a neural tube defect asks the nurse what she can do to decrease the chances of having another baby with a neural tube defect. The BEST response by the nurse is "Folic acid should be taken before and after conception." Question 31 The nurse is caring for a newborn with a neural tube defect. The BEST covering for the lesion is Moist sterile nonadherent dressing Question 32 A nurse is providing a parenting class to individuals living in a community of older homes. In discussing formula preparation, which of the following is most important to prevent lead poisoning? Let tap water run for 2 minutes before adding to concentrate Question 33 A client is admitted to the rehabilitation unit following a CVA and mild dysphagia. The MOST appropriate intervention for this client is Position client in upright position while eating Question 34

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The nurse explains an autograft to a client scheduled for excision of a skin tumor. The nurse knows the client understands the procedure when the client says, "I will receive tissue from my thigh.” Question 35 The nurse is caring for a newborn with tracheoesophageal fistula. Which of the following nursing diagnoses is a PRIORITY? Ineffective airway clearance Question 36 A client has been hospitalized after an automobile accident. A full leg cast was applied in the emergency room. The MOST important reason for the nurse to elevate the casted leg is to Improve venous return Question 37 A nurse is working with family members of a newly diagnosed client with Alzheimer's disease. Which of the following interventions is MOST helpful? Suggesting communication strategies Question 38 The nurse is teaching a client with non-insulin dependent diabetes mellitus about the prescribed diet. The nurse should teach the client to Keep a regular schedule of meals and snacks Question 39 The mother of a two-month-old baby calls the nurse at a well-baby clinic two days after the first DTaP immunization. She reports that the baby feels very warm, has cried inconsolably for as long as three hours, and has had several shaking spells. The response of the nurse should be to instruct the mother to call 911 for an ambulance to transport the infant Question 40 The nurse is teaching a class on HIV prevention. Which of the following should be emphasized as increasing risk? Unprotected sex Question 41 A 6-year-old child is seen for the first time in the clinic. Upon assessment, the nurse finds that the child has short palpebral fissures, thinned upper lip, and hypoplastic philtrum of the upper lip. The mother states that the child seems to have problems in learning to count and recognizing basic colors. Based on this data, the nurse suspects that the child is MOST likely showing the effects of Fetal alcohol syndrome Question 42

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The nurse is performing the admission assessment of a client with an acute episode of asthma. Which of the following assessments would the nurse anticipate finding? Expiratory wheezes Question 43 The nurse is planning a meal plan that would provide the most iron for a child with anemia. Which of the following dinner menus would be BEST? Ground beef patty, lima beans, wheat roll, raisins, milk Question 44 A ten-year-old client is recovering from a splenectomy following a traumatic injury. The client’s laboratory results show a hemoglobin of 9 g/dL and a hematocrit of 28 percent. The BEST approach for the nurse to use is to Plan nursing care around lengthy rest periods Question 45 The nurse planning care for a 12-year-old child with sickle cell disease in a vaso-occlusive crisis of the elbow should include which one of the following as a PRIORITY? Client controlled analgesia Question 46 As the nurse provides discharge teaching to the parents of a 15-month-old child with Kawasaki Disease who has received immunoglobulin therapy, which one of the following instructions would be MOST appropriate? The measles, mumps and rubella vaccine should be delayed Question 47 The nurse is giving instructions to the parents of a child with Cystic Fibrosis. The nurse would emphasize that pancreatic enzymes should be taken With each meal or snack Question 48 The nurse is assessing an eight-month-old infant with a malfunctioning ventriculoperitoneal shunt. Which one of the following manifestations would the infant be MOST likely to exhibit? Irritability Question 49 The nurse is performing a physical assessment on a toddler. Which of the following should be the FIRST action? Use minimal physical contact Question 50

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A client has been tentatively diagnosed with Graves' disease (hyperthyroidism). Which of the following symptoms noted on the initial nursing assessment is expected? Protruding eyeballs Question 51 When assessing a client admitted to the hospital for diabetic acidosis, which of the following clinical manifestations would the nurse expect? Blood pH level below 7. Question 52 The nurse is explaining the proper use of syrup of ipecac to a group of parents. For which of the following accidental poisonings is the treatment appropriate? Chewable vitamins Question 53 A two-year-old child is brought to the pediatrician's office with a chief complaint of mild diarrhea for two days. Nutritional counseling by the nurse should include which one of the following statements? Continue with the regular diet and include oral rehydration fluids Question 54 The nurse is teaching an elderly client how to use MDI's (multi-dose inhalers). The nurse is concerned that the client is unable to coordinate the release of the medication with the inhalation phase. The nurse's BEST recommendation for the client is Adding a spacer device to the MDI canister Question 55 Which of the following manifestations observed by the school nurse confirms the presence of pediculosis capitis in students? Whitish oval specks sticking to the hair Question 56 When parents call the emergency room to report that a toddler has swallowed drain cleaner, the nurse instructs them to call for emergency transport to the hospital. While waiting for an ambulance, the BEST action the nurse would suggest to the parents is Offer small amounts of water Question 57 A client is scheduled for an IVP (Intravenous Pyelogram). Which of the following data from the client's history indicate a potential hazard for this test? Allergic to shellfish

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Question 58 A high school nurse is advising a class of unwed pregnant students that the MOST important action they can perform to deliver a healthy child is Maintaining good nutrition Question 59 The nurse is preparing a handout on infant feeding to be distributed to families visiting the clinic. Which of the following should be included in the teaching materials? Solid foods are introduced one at a time beginning with cereal Question 60 The nurse is caring for a client with sickle cell disease who is scheduled to receive a unit of packed red blood cells. Which of the following is an appropriate action for the nurse when administering the infusion? Limit the infusion time of each of the unit to a maximum of four hours Question 61 A client with a documented pulmonary embolism has the following arterial blood gases: PO2 - 70 mm hg, PCO2 - 32 mm hg, pH - 7.45, SaO2 - 87%, HCO3 - 22. Based on this data, what is the FIRST nursing action? Administer oxygen Question 62 A client diagnosed with hepatitis C discusses his health history with the admitting nurse. The nurse should recognize which of the following as the MOST important data? Blood transfusion 15 years ago Question 63 A client is recovering from a thyroidectomy. While monitoring the client's initial post operative condition, which of the following should the nurse report immediately? Tetany and paresthesia Question 64 A client is admitted with a right upper lobe infiltrate, and also to rule out tuberculosis. The isolation precautions the nurse would institute include Particulate respirator mask Question 65 A client had 20 mg of Lasix (furosemide) PO at 10 AM. Which would be essential for the nurse to include at the change of shift report? The client's urine output was 1500 cc in five hours

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Question 66 The nurse is caring for a client with a colostomy. During a teaching session, the nurse recommends that the pouch be emptied When it is one third to one half full Question 67 A couple asks the nurse about risks of several birth control methods. The MOST appropriate response by the nurse would be Oral contraceptives should not be used by smokers Question 68 Lactulose (Chronulac) has been prescribed for a client with advanced liver disease. Which of the following assessments would the nurse use to evaluate the effectiveness of this treatment? A decrease in lethargy Question 69 The mother of a 3-month-old infant tells the nurse that she wants to change from formula to whole milk and add cereal and meats to the diet. What should be emphasized as the nurse teaches about infant nutrition? Whole milk is difficult for a young infant to digest Question 70 The nurse is assessing a 55-year-old female client who is scheduled for abdominal surgery. Which of the following information would indicate that the client is at risk for thrombus formation in the post-operative period? Estrogen replacement therapy Question 71 The nurse is planning discharge for a 90-year-old client with musculo-skeletal weakness. Which of the following interventions would be MOST effective in preventing falls? Place nightlights in bedroom Question 72 While obtaining the history of a two-week-old infant during the well-baby exam, the nurse finds that the neonatal screening for phenylketonuria (PKU) was done when the infant was less than 24 hours- old. It is a PRIORITY for the nurse to Obtain a repeat blood test at this point Question 73 Two hours after the normal spontaneous vaginal delivery of a woman who is gravida 4 para 4, the nurse notes that the fundus is boggy and displaced slightly above and to the left of the umbilicus. The appropriate INITIAL nursing action is to

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Ask the woman to empty her bladder Question 74 An 8-year-old client is admitted to the hospital for surgery. The child's parent reports several allergies. Which of the following should all health care personnel be aware of? Balloons Question 75 The nurse is caring for a client who is post-op following a thoracotomy. The client has two chest tubes in place, connected to one chest drain. The nursing assessment reveals bubbling in the water seal chamber when the client coughs. What is the MOST appropriate nursing action? Continue to monitor the client to see if the bubbling increases Question 76 The nurse is reinforcing teaching to a 24-year-old woman receiving acyclovir (Zovirax) for a Herpes Simplex Virus type 2 infection. The nurse should instruct the client to Begin treatment with acyclovir at the onset of symptoms of recurrence Question 77 An eight-year-old child is hospitalized during the edema phase of minimal change nephrotic syndrome. The nurse is assisting in choosing the lunch menu. Which one of the following is the BEST choice? Chicken strips, corn on the cob, milk Question 78 The nurse is teaching parents about accidental poisoning in children. Which of the following should be emphasized? Empty the child's mouth in any case of possible poisoning Question 79 Which of the following symptoms contraindicate the use of haloperidol (Haldol) and warrant withholding the dose? Rash, blood dyscrasias, severe depression Question 80 The nurse is planning care for a 14-year-old client returning from scoliosis corrective surgery. Which of the following actions should receive PRIORITY in the plan? Assess movement and sensation of extremities Question 81 A three-year-old child diagnosed as having celiac disease attends a day care center. Which of the following would be an appropriate snack?

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Potato chips Question 82 The nurse is caring for a 14-month-old just diagnosed with Cystic Fibrosis. The parents state this is the first child in either family with this disease and ask about the risk to future children. The BEST response by the nurse is based on the knowledge that there is a 1 in 4 risk for each child to have the disease Question 83 A client with moderate persistent asthma is admitted for a minor surgical procedure. On admission the peak flow meter is measured at 480 liters/minute. Post-operatively the client is complaining of chest tightness. The peak flow has dropped to 200 liters/minute. What should the nurse do FIRST? Administer the prn dose of Albuterol Question 84 What nursing observation signifies that a client has attained the stage of concrete operations (Piaget)? Makes the moral judgment that "stealing is wrong" Question 85 The nurse is caring for a 17-month-old with acetaminophen poisoning. Which of the following lab reports should the nurse review FIRST? Liver enzymes (AST and ALT) Question 86 The nurse is teaching parents about diet for a 4-month-old infant with gastroenteritis and mild dehydration. In addition to oral rehydration fluids, the diet should include Formula or breast milk Question 87 The nurse instructs the client taking dexamethasone (Decadron) to take it with food or milk because this medication Stimulates hydrochloric acid production Question 88 The nurse is planning care for a 3-month-old infant immediately postoperative following placement of a ventriculoperitoneal shunt for hydrocephalus. The nurse needs to Assess for abdominal distention Question 89 The mother of a two-year-old hospitalized child asks the nurse's advice about the child's screaming every time the mother gets ready to leave the hospital room. The BEST response of the nurse would be to

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Help the mother understand this is a normal response to hospitalization Question 90 When caring for a client receiving warfarin sodium (Coumadin), the nurse would monitor the results of the client's Prothrombin time Question 91 The nurse is caring for a four-year-old two hours after tonsillectomy and adenoidectomy. Which of the following assessments must be reported IMMEDIATELY? Increased restlessness Question 92 The nurse admits a 7-year-old to the emergency room following a leg injury. X-rays show that there is a femur fracture near the epiphysis. The nurse should be aware that at this age, the injury MOST likely will Result in retarded bone growth Question 93 A client receiving chlorpromazine HCL (Thorazine) is in psychiatric home care. During a home visit the nurse observes the client smacking her lips alternately with grinding her teeth. The nurse assesses this as Tardive dyskinesia Question 94 While the nurse assesses a 2-month-old infant, the mother expresses concern because a flat pink birthmark on the baby's forehead and eyelid has not gone away. The nurse should tell the parents that Telangiectatic nevi are normal and will disappear as the baby grows Question 95 A client has returned to the unit following a renal biopsy. Which of the following nursing interventions is appropriate? Monitor vital signs Question 96 The nurse assessing a newborn notices that the breasts are enlarged bilaterally with a white, thin discharge. The INITIAL action of the nurse should be to Record the findings as "normal" Question 97 A client has been admitted with a fractured femur and has been placed in skeletal traction. Which of the following nursing interventions should receive PRIORITY? Frequent neurovascular assessments of the affected leg

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Question 98 The nurse is teaching a client newly diagnosed with asthma how to use the metered-dose inhaler (MDI). The client asks when they will know the canister is empty. The BEST response is Drop the canister in water to observe floating Question 99 While teaching the family of a child who will take phenytoin (Dilantin) regularly for seizure control, it is MOST important for the nurse to teach them to Maintain good oral hygiene and dental care Question 100 A two-year-old child has just been diagnosed with Cystic Fibrosis. The child's father asks the nurse "What are the chances that another child of ours will have Cystic Fibrosis?" Which of the following is the BEST response? "Each of your children have a 25% chance of having Cystic Fibrosis." Question 101 A 7-month pregnant woman is admitted with complaints of painless vaginal bleeding over several hours. The nurse should prepare the client for an immediate Abdominal ultrasound Question 102 The nurse is assessing a 17-year-old female client with bulimia. Which of the following laboratory reports would the nurse anticipate? Decreased potassium Question 103 An 80-year-old client on digitalis (Lanoxin) reports nausea, vomiting, abdominal cramps and halo vision. Which of the following laboratory results should the nurse analyze FIRST? Potassium levels Question 104 A mother telephones the clinic and tells the nurse she is concerned because her breastfed 1 month-old has soft, yellow stools after each feeding. The nurse's BEST response would be based on the knowledge that This type of stool is normal for breast fed infants Question 105 The nurse caring for a 9-year-old child with a fractured femur is told that a medication error occurred. The child received twice the ordered dose of morphine an hour ago. Which of the following nursing diagnoses is a PRIORITY at this time? Ineffective breathing patterns related to central nervous system depression

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Question 106 A pregnant client asks the nurse about the scheduled blood test for alpha-fetoprotein (AFP). The nurse's BEST explanation i "Possible neurological defects may be identified." Question 107 The nurse notes that a 2-year-old child recovering from a tonsillectomy has an temperature of 98. degrees F at 8:00 AM. At 10:00 AM the child's mother reports that the child "feels very warm" to touch. The FIRST action by the nurse should be to Reassess the child's temperature Question 108 The nurse is assessing an eight-month-old child. The nurse would anticipate that the child would be able to Sit without support Question 109 The nurse is teaching a newly diagnosed asthma client on how to use a peak flow meter. The nurse explains that this should be used to Measure forced expiratory volume Question 110 The nurse is performing a pre-kindergarten physical on a five-year-old. The last series of vaccines will be administered. What is the preferred site for injection by the nurse? Vastus lateralis Question 111 A client experienced the loss of a seven-month fetus. The nurse planning for discharge should emphasize Discussing feelings with support persons Question 112 The parents of a 4-year-old hospitalized child tell the nurse they will leave for a time and return at 6 PM. When the child asks when the parents will come again, the nurse can BEST respond by saying "They will be back right after supper." Question 113 The nurse is providing instructions for a client with asthma. Which of the following should the client monitor on a daily basis? Peak air flow volumes Question 114

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Therapeutic nurse-client interaction occurs when the nurse Assists the client to clarify the meaning of what the client is communicating Question 115 A 14-month-old child ingested half a bottle of aspirin tablets. Which of the following would the nurse expect to see in the child? Epistaxis Question 116 The nurse is caring for a client with a distal tibia fracture. The client has had a closed reduction and application of a toe to groin cast. Thirty-six hours after surgery, the client suddenly becomes confused, short of breath and spikes a temperature of 103 degrees F. The FIRST assessment the nurse should perform is Pulse oximetry Question 117 Which nursing intervention will be MOST effective in helping a withdrawn client to develop relationship skills? Offer the client frequent opportunities to interact with you Question 118 The nurse is assessing a client with a stage 2 skin ulcer. Which of the following treatments is most effective to promote healing? Applying a transparent film cover Question 119 A female client is admitted for a breast biopsy. She says, tearfully to the nurse, "If this turns out to be cancer and I have to have my breast removed, my husband will never come near me." The nurse's BEST response would be "Are you worried that the surgery will change you?" Question 120 When teaching suicide prevention to the parents of a 15-year-old who recently attempted suicide, the nurse describes the following behavioral cue Giving away valued personal items Question 121 The nurse is caring for a 4-year-old admitted after receiving burns to more than 50% of his body. Which laboratory data should be reviewed by the nurse as a PRIORITY in the first 24 hours? Blood urea nitrogen Question 122

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The nurse is caring for a client in a Coronary Care Unit two days following a Myocardial Infarction. The client has many questions about his condition. The nurse should focus teaching about Immediate needs and concerns Question 123 The nurse is preparing a client with a deep vein thrombosis (DVT) for a Venous Doppler evaluation. Which of the following would be necessary for preparing the client for this test? No special preparation is necessary Question 124 While interviewing a client, the nurse notices that the client is shifting positions, wringing her hands, and avoiding eye contact. It is important for the nurse to Ask the client what she is feeling Question 125 Parents of a 4-year-old boy have just been informed that their son has a congenital neurologic demyelinating disorder that is terminal. The nurse evaluates their reaction as which phase of the crisis process? Impact phase Question 126 A postpartum mother is unwilling to allow the father to participate in the newborn's care, although he is interested in doing so. She states, "I am afraid the baby will be confused about who the mother is. Baby raising is for mothers, not fathers." The nurse's BEST initial intervention is to Help the mother to express her feelings and concerns Question 127 Which of the following statements made by a female client indicate to the nurse that she may have a thought disorder? "I can't find my 'mesmer' shoes. Have you seen them?" Question 128 The nurse is aware that which of the following psychosocial needs are BEST described in the adolescent when hospitalized? Privacy, autonomy, peer interactions Question 129 The nurse is observing a client with an obsessive-compulsive disorder in an in-patient setting. Which of the following behaviors is consistent with this diagnosis? Repeatedly checking that the door is locked Question 130

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A young adult seeks treatment in an out-patient mental health center. The client tells the nurse he is a government official being followed by spies. On further questioning, he reveals that his warnings must be heeded to prevent nuclear war. What is the MOST therapeutic approach by the nurse? Listen quietly without comment Question 131 The client's self-esteem is MOST damaged by the nurse's Indifference Question 132 An 8-year-old client is admitted to the child mental health unit for evaluation. Following his mother's departure, the client cries and refuses his dinner. The BEST approach by the nurse is to Offer to play with him Question 133 A client is admitted to a psychiatric unit with delusions. The nurse can expect which of the following signs and symptoms? Suspiciousness and resistance to therapy Question 134 A client states, "People think I'm no good, you know what I mean?" Which of the following nursing responses would be MOST therapeutic for this client? "I'm not sure what you mean. Tell me a bit more about that." Question 135 A client who is a former actress enters the day room wearing a sheer nightgown, high heels, numerous bracelets, bright red lipstick and heavily rouged cheeks. Which of the following is the BEST nursing action in response to the client's attire? Directly assist client to her room for appropriate apparel Question 136 An appropriate goal for a client with anxiety would be to Learn self-help techniques for reducing anxiety Question 137 Handshaking is the preferred form of touch or contact used with clients in a psychiatric setting. The rationale behind this limited touch practice is that Some clients misconstrue hugs as an invitation to sexual advances Question 138

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A client with paranoid delusions stares at the nurse for several days. The client suddenly walks up to the nurse and shouts "You think you're so perfect and pure and good." An appropriate response for the nurse is "You are angry right now." Question 139 A client being treated for hypertension returns to the clinic for follow up.He says, "I know these pills are important, but I just can't take these water pills anymore. I drive a truck for a living, and I can't be stopping every 20 minutes to go to the bathroom." The MOST appropriate nursing diagnosis would be Noncompliance related to medication side effects Question 140 A spouse is concerned because the client frequently daydreams about moving to Arizona to get away from the pollution and crowding in southern California. The nurse explains that Such fantasies can gratify unconscious wishes or prepare for anticipated future events Question 141 An important goal in the development of a therapeutic in-patient milieu is Providing a testing ground for new patterns of behavior while the client takes responsibility for his or her own actions Question 142 The nurse's PRIMARY intervention for a client who is experiencing a panic attack is to Maintain safety for the client Question 143 A 64-year-old client scheduled for surgery with a general anesthetic refuses to remove her dentures prior to leaving the unit for the operating room. The MOST appropriate intervention by the nurse is Ask the client if she would prefer removing the dentures in the operating room receiving area Question 144 Which of the following interventions BEST demonstrates the nurse's sensitivity to a 16-year-old’s appropriate need for autonomy? Provides opportunity to discuss concerns without presence of parents Question 145 A client with anorexia is hospitalized on a medical unit due to electrolyte imbalance and cardiac dysrhythmias. Additional assessment findings that the nurse would expect to observe are Brittle hair, lanugo, amenorrhea Question 146

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A depressed client in an assisted living facility tells the nurse that "life isn't worth living anymore." What is the BEST response to this statement? "Have you thought about hurting yourself?" Question 147 A client, recovering from alcoholism, asks the nurse, "What can I do when I start recognizing relapse triggers within myself?" How might the nurse BEST respond? "Identify your relapse triggers as part of getting better." Question 148 A client was admitted to the eating disorder unit with bulimia nervosa. When the nurse assesses for a history of complications of this disorder, the following are expected Dental erosion, parotid gland enlargement Question 149 A nurse entering the room of a postpartum mother observes the baby lying at the edge of the bed while the woman sits in a chair. The mother states," This is not my baby, and I do not want it." The nurse's BEST response is "You seem upset; tell me what the pregnancy and birth were like for you." Question 150 Which of the following times is a depressed client at highest risk for attempting suicide? 7 to 14 days after initiation of antidepressant medication and psychotherapy when energy increases Question 1 The nurse manager informs the nursing staff at morning report that the clinical nurse specialist will be conducting a research study on staff attitudes toward client care. All staff are invited to participate in the study if they wish. This affirms the ethical principle of Autonomy Individuals must be free to make independent decisions about participation in research without coercion from others. Question 2 The nurse is preparing to take a toddler's blood pressure for the first time. Which of the following actions should the nurse do FIRST? Permit handling the equipment before putting the cuff in place Question 3 The nurse must know that the MOST accurate oxygen delivery system available is The venturi mask Question 4

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The nurse is assessing a comatose client receiving gastric tube feedings. Which of the following assessments requires an IMMEDIATE response from the nurse? Decreased breath sounds in right lower lobe Question 5 A pregnant client who is at 34 weeks gestation is diagnosed with a pulmonary embolism (PE). The nurse would anticipate the physician ordering Heparin by subcutaneous injection to maintain the PTT at 1.5 times the control value Review Information Question 6 Which of the following BEST describes the goal of total quality management or continuous quality improvement in a health care setting? Improving processes in a proactive, preventive mode Question 7 A new nurse manager is responsible for interviewing applicants for a staff nurse position. Which of the following interview strategies is the BEST? Develop an interview guide for consistency in interviewing each candidate Question 8 The nurse is caring for a client who has altered cerebral tissue perfusion related to a subarachnoid hemorrhage. To reduce the risk of rebleeding, the nurse should plan to Restrict visitors to immediate family Question 9 The nurse is caring for a client with renal calculi. Which physician order would be a PRIORITY? Morphine sulfate as client-controlled analgesia Question 10 The nurse is teaching parents of a 7-month-old about adding table foods. Which of the following is an APPROPRIATE finger food? Sliced bananas Question 11 While assessing the vital signs in children, the nurse should know that the apical heart rate is preferred until the radial pulse can be accurately assessed at about Two years of age Question 12 A newborn weighed 7 pounds 2 ounces at birth. The nurse assesses her at home two days later and finds the weight to be 6 pounds 7 ounces. When the parents question this loss, the nurse explains that

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The loss is within normal limits Question 13 A five-year-old has been rushed to the emergency room several hours after acetaminophen poisoning. Which of the following laboratory results should receive PRIORITY attention by the nurse? Bilirubin Question 14 An 18-month-old child is on peritoneal dialysis in preparation for a renal transplant in the near future. When the nurse obtains the child's health history, the mother indicates that the child has not had the first measles, mumps, rubella (MMR) immunization. The PRIORITY nursing action is based on the understanding that The MMR vaccine should be given now, prior to the transplant Question 15 The nurse working with clients from many different cultures recognizes that it is a PRIORITY to Recognize personal attitudes and biases Question 16 When teaching a client about the use of sublingual nitroglycerin, the nurse should emphasize that the MOST common side effect is Headache Question 17 The nurse is planning care for an 8-year-old child. Which of the following should be included in the plan of care? Encourage child to engage in activities in the playroom Question 18 The nurse is preparing to administer a tube feeding to a post-operative client. To accurately assess for a gastostomy tube placement, the PRIORITY is to Auscultate the abdomen while instilling 10 cc of air into the tube Question 19 You are caring for a client with Parkinson's disease who has developed hallucinations. Which of the following medications that the client is receiving may have been a contributing factor? L-Dopa Question 20 A nurse admits a client transferred from the emergency room. The client, diagnosed with a myocardial infarction, is complaining of substernal chest pain, diaphoresis, and nausea. The FIRST action by the nurse should be Administer pain medication as ordered

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Question 21 Decentralized scheduling is used on a nursing unit. A CHIEF advantage of this management strategy is that it Considers client and staff needs Question 22 A client with angina has been instructed about the use of sublingual nitroglycerin. Which of the following statements made to the nurse indicates a need for FURTHER teaching? "I can take 2-3 tablets at once if I have severe pain." Question 23 The nurse is talking with the family of an 18-month-old newly diagnosed with retinoblastoma. A PRIORITY in communicating with the parents is Discussing the need for genetic counseling Question 24 The nurse is teaching a client about precautions with Coumadin. The nurse should instruct the client to avoid foods with excessive amounts of Vitamin K Question 25 The clinic nurse is counseling a substance-abusing post-partum client on the risks of continued cocaine use. In order to provide continuity of care, which of the following is a PRIORITY nursing diagnosis? Altered parenting Question 26 As a part of a 9-pound newborn's assessment, the nurse performs a dextro-stick at one hour. The blood glucose level is 45 mg/dl. What FIRST action by the nurse is appropriate? Repeat the test in 2 hours Question 27 A client with atrial fibrillation is receiving digoxin (Lanoxin). It is MOST important for the nurse to Measure apical pulse prior to administration Question 28 A client is brought to the emergency room following a motor vehicle accident. When assessing the client one-half hour after admission, the nurse notes several physical changes. Which of the following changes would require the nurse's IMMEDIATE attention? Tracheal deviation Question 29

WITH ANSWERS A+

A 42-year-old male client refuses to take propranolol hydrochloride (Inderal) as prescribed. Which of the following client statements from the assessment data is likely to explain his noncompliance? "I have diminished sexual function." Question 30 The nurse is instructing a client with moderate persistent asthma on the proper method for using MDI's (multi-dose inhalers). Which medication should be administered FIRST? Beta agonist Question 31 A nurse assessing the newborn of a diabetic mother understands that hypoglycemia is related to Disruption of fetal glucose supply Question 32 The nurse is administering an intravenous piggyback infusion of penicillin. Which of the following client statements would require the nurse's IMMEDIATE attention? "I am itching all over." Question 33 A 16-year-old boy is admitted for Ewing's sarcoma of the tibia. In discussing his care with the parents, the nurse understands that the initial treatment MOST often includes Radiation and chemotherapy Question 34 A client is receiving dexamethasone (Decadron) therapy. The nurse plans to monitor the client's Blood glucose levels every twelve hours Question 35 When managing a client's pain, which of the following statements BEST describes the ethical considerations of the nurse? The client's self-report is the most important consideration Question 36 The nurse is performing an assessment of the motor function in a client with a head injury. The BEST technique is Gentle pressure on eye orbit Question 37 A 3-year-old child has tympanostomy tubes in place. The child's mother asks the nurse if he can swim in the family pool. The BEST response from the nurse is "Your child may swim if he wears ear plugs."

WITH ANSWERS A+

Question 38 The nurse is caring for a 2-year-old who is being treated with chelation therapy, calcium disodium edetate, for lead poisoning. The nurse should be alert for which of the following side effects? Nephrotoxicity Question 39 The nurse admits a two-year-old child who has had a seizure. Which of the following statement by the child's parent would be important in determining the etiology of the seizure? "He has had an ear infection for the past two days." Question 40 The nurse is caring for a client with Hodgkin's disease who will be receiving radiation therapy. The nurse recognizes that, as a result of the radiation therapy, the client is MOST likely to experience Nausea Question 1 The nurse is performing an assessment on a client with pneumococcal pneumonia. Which of the following assessments would the nurse anticipate finding? Bronchial breath sounds in outer lung fields Question 2 In providing care to a 14-year-old adolescent with scoliosis, which of the following will be MOST difficult for this client? Looking different from their peers Question 3 When counseling parents of a child who has recently been diagnosed with hemophilia, the nurse must know that in the offspring of a normal father and a carrier mother There is a 25% chance a daughter will be a carrier Question 4 A three-year-old child is treated in the emergency room after ingesting an ounce of a liquid narcotic. What FIRST action should the nurse take? Assess airway and circulation Question 5 The nurse is caring for a client who is receiving total parenteral nutrition (hyperalimentation and lipids). What is the PRIORITY nursing action on every eight-hour shift? Check urine glucose, acetone and specific gravity Question 6

WITH ANSWERS A+

The nurse walks into a client's room and finds the client lying still and silent on the floor. The nurse should FIRST Establish that the client is unresponsive Question 7 The nurse is teaching a client with asthma about the correct use of the Azmacort (triamcinolone) inhaler. Which of the following statements, if made by the client, would indicate that the teaching was effective? "I should rinse my mouth after using the inhaler." Question 8 The nurse measures the head and chest circumferences of a 20-month-old infant. After comparing the measurements, the nurse finds that they are approximately the same. The appropriate action for the nurse to take would be to Record these normal findings Question 9 A 7-year-old child is hospitalized following a major burn to the lower extremities. A diet high in protein and carbohydrates is recommended. The nurse informs the child and family that the MOST important reason for this diet is to Spare protein catabolism to meet metabolic needs Question 10 The nurse prepares to give a one-year-old child an intramuscular injection. The BEST site for this injection would be in the Vastus lateralis muscle Question 11 A client is unconscious following a tonic-clonic seizure. What should the nurse do FIRST? Place the client in a side-lying position Question 12 The nurse caring for a 14-year-old boy with severe Hemophilia A, who was admitted after a fall while playing basketball. In understanding his behavior and in planning care for this client, the nurse must recognize that adolescents with hemophilia Often take part in active sports Question 13 The nurse is caring for two children who have had surgical repair of congenital heart defects. For which one of the defects is it a PRIORITY to assess for signs of heart conduction disturbance? Ventricular septal defect Question 14