NCLEX PN Comprehensive 2024 Exam Questions and Answers, Exams of Nursing

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The nurse is preparing to irrigate a client's sigmoid colostomy. The nurse would plan for which intervention to perform this procedure?

1. Instilling 500 to 1000 mL of lukewarm tap water through the stoma
2. Advises the client to hold the breath if cramping occurs during instillation of the solution
3. Hanging the irrigation solution so that the bottom of the bag is 18 inches above the client's torso.
4. Inserting the irrigation tube with a small amount of force and a twisting motion into the stoma and unclamps the tubing to allow the solution to flow into the stoma - CORRECT ANSWERS 1. Instilling 500 to 1000 mL of lukewarm tap water through the stoma The nurse is teaching a client with a urinary stoma about how to change the collection bag and appliance at home. Which of the following client statements indicate an understanding of the procedure?
5. "The stoma needs to be cleaned with only water."
6. "The best time to change the appliance is at night."
7. "The pouch needs to be changed every 5 to 7 days."
8. "I'll cut the skin barrier 10 millimeters larger than the stoma." - CORRECT ANSWERS 3. "The pouch needs to be changed every 5 to 7 days." A nurse caring for a 2-month-old febrile infant is asked to collect a urine specimen for a culture and sensitivity. The nurse collects the specimen by performing which action?
9. Catheterizing the infant using the smallest available straight catheter
10. Attaching a urinary collection device to the infant's perineum for collection
11. Place cotton balls in the diaper and then after the infant voids aspirating the urine with a syringe
12. Noting the time of the next expected voiding and preparing to collect the specimen into a cup when the infant voids - CORRECT ANSWERS 1. Catheterizing the infant using the smallest available straight catheter

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The nurse has a prescription to give ear drops to a 2-year-old child. To administer the drops, the nurse would pull the pinna of the ear in which direction?

1. Upward and outward
2. Upward and backward
3. Downward and outward
4. Downward and backward - CORRECT ANSWERS 4. Downward and backward A licensed practical nurse (LPN) is administering medications to a client who has difficulty swallowing. A time-released film-coated medication is prescribed and the client is unable to swallow the pill. Which action by the LPN is most appropriate?
5. Skip the dose and try again at a later time.
6. Crush the tablet and mix it with applesauce.
7. Give the client a large glass of water to aid in swallowing.
8. Consult with the registered nurse (RN) about contacting the primary health care provider (PHCP) regarding a medication change. - CORRECT ANSWERS 4. Consult with the registered nurse (RN) about contacting the primary health care provider (PHCP) regarding a medication change. A licensed practical nurse is explaining the appropriate methods for measuring an accurate temperature to an assistive personnel (AP). Which method, if noted by the AP as being an appropriate method, indicates the need for further teaching?
9. Taking a rectal temperature for a client who has undergone nasal surgery
10. Taking an oral temperature for a client with a cough and nasal congestion
11. Taking an axillary temperature on a client who has just consumed hot coffee
12. Taking a temporal temperature on the neck behind the ear on a client who is diaphoretic - CORRECT ANSWERS 2. Taking an oral temperature for a client with a cough and nasal congestion

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The nurse is caring for a client who takes ibuprofen for pain. The nurse is gathering information on the client's medication history and determines it is necessary to consult with the registered nurse if the client is also taking which medications? Select all that apply. 1.Warfarin 2.Glimepiride 3.Amlodipine 4.Simvastatin 5.Hydrochlorothiazide - CORRECT ANSWERS 1.Warfarin 2.Glimepiride 3.Amlodipine A hospitalized client is a lacto-vegetarian. Which food item would the nurse remove from the meal tray? 1.Eggs 2.Milk 3.Cheese 4.Broccoli - CORRECT ANSWERS 1. Eggs The nurse is providing dietary instructions to a client with gout. The nurse would tell the client to avoid which food item? 1.Scallops 2.Chocolate 3.Cornbread 4.Macaroni products - CORRECT ANSWERS 1. Scallops

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The nurse reinforces instructions to a client to increase the amount of riboflavin in the diet. The nurse would tell the client to select which food item that is high in riboflavin? 1.Milk 2.Tomatoes 3.Citrus fruits 4.Green, leafy vegetables - CORRECT ANSWERS 1.Milk The medication prescribed is hydromorphone hydrochloride 3 mg intramuscularly, every 4 hours as needed. The medication label reads hydromorphone hydrochloride 4 mg/1 mL. The nurse would prepare to administer how many mL to the client? Fill in the blank. - CORRECT ANSWERS 0.75 mL The medication prescribed is digoxin 0.25 mg orally, daily. The medication label reads digoxin 0.125 mg/tablet. The nurse would prepare how many tablet(s) to administer the dose? Fill in the blank. - CORRECT ANSWERS 2 tablets The medication prescribed is heparin 5000 units subcutaneously, every 12 hours. The medication vial reads heparin 10,000 units/mL. The nurse prepares how many milliliters to administer one dose? Fill in the blank. - CORRECT ANSWERS 0.5 mL The medication prescribed is metoclopramide hydrochloride 10 mg intramuscularly times one dose. The medication label reads metoclopramide hydrochloride 5 mg/mL. The nurse prepares how much medication to administer the dose? Fill in the blank. - CORRECT ANSWERS 2 mL The medication prescribed is morphine sulfate 6 mg subcutaneously. The medication label states morphine sulfate 10 mg/1 mL. The nurse plans to prepare how much medication to administer the dose? Fill in the blank. - CORRECT ANSWERS 0.6 mL The medication prescribed is prochlorperazine 5 mg intramuscularly, every 4 hours as needed. The medication label states prochlorperazine 10 mg/mL. The nurse prepares how much medication to administer the dose? Fill in the blank. - CORRECT ANSWERS 0.5 mL

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The medication prescribed is haloperidol, 4 mg intramuscularly, immediately. The medication label states 5 mg/1 mL. The nurse prepares how much medication to administer the dose? Fill in the blank and round the answer to one decimal place. - CORRECT ANSWERS 0.8 mL The medication prescribed is levodopa 1 g orally, daily. The medication label states levodopa, 500-mg tablets. The nurse prepares to administer how many tablets at the evening dose? Fill in the blank. - CORRECT ANSWERS 2 tablets The medication prescribed is zidovudine, 0.2 g orally, three times daily. The medication label states zidovudine, 100-mg tablets. The nurse prepares to administer how many tablets for one dose? Fill in the blank. - CORRECT ANSWERS 2 tablets The medication prescribed is methylprednisolone acetate 60 mg intramuscularly. The medication label states methylprednisolone acetate 40 mg/1 mL. How many milliliters will the nurse prepare to administer to the client? Fill in the blank. - CORRECT ANSWERS 1.5 mL The medication prescription states to administer acetaminophen 650 mg orally for a temperature of more than 38° C. The medication bottle states acetaminophen, 325 mg tablets. The nurse takes the client's temperature and notes that it is 101° F. The nurse plans to take which action? 1.Administer two tablets. 2.Administer three tablets. 3.Do not administer at this time. 4.Check the client's temperature in 30 minutes. - CORRECT ANSWERS 1. Administer two tablets. The medication prescription reads phenytoin 0.2 g orally, twice daily. The medication label states 100-mg capsules. The nurse prepares how many capsule(s) to administer one dose? Fill in the blank. - CORRECT ANSWERS 2 capsules The intravenous prescription is 1000 mL of 0.9% NaCl (normal saline) to run over 12 hours. The drop factor is 15 gtts/1 mL. The nurse plans to adjust the flow rate to how many

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gtts/minute? Fill in the blank and record the answer to the nearest whole number. - CORRECT ANSWERS 21 gtts/min The medication is an intramuscular dose of 400,000 units of penicillin G benzathine. The medication label reads penicillin G benzathine 300,000 units/mL. The nurse prepares how much medication to administer the correct dose? Fill in the blank and record the answer using one decimal place. - CORRECT ANSWERS 1.3 mL The intravenous prescription is 3000 mL of 5% dextrose in water (D5W) to run over a 24- hour period. The drop factor is 10 gtts/1 mL. The nurse plans to adjust the flow rate to how many gtts/minute? Fill in the blank and record the answer to the nearest whole number. - CORRECT ANSWERS 21 gtts/min The nurse is preparing to administer an intermittent tube feeding to a client. The nurse aspirates 90 mL of residual from the tube. What would the nurse do? Select all that apply. 1.Hold the feeding. 2.Document the amount of residual. 3.Place it into a container for laboratory analysis. 4.Reinstill the residual and administer the feeding. 5.Deduct the amount of the residual from the new feeding before administering. - CORRECT ANSWERS 2.Document the amount of residual. 4.Reinstill the residual and administer the feeding. The nurse is inserting an indwelling urinary catheter into a male client. As the catheter is inserted into the urethra, urine begins to flow into the tubing. When would the nurse inflate the balloon? 1.Immediately inflate the balloon. 2.Insert the catheter 2.5 cm to 5 cm and inflate the balloon. 3.Advance the catheter to the bifurcation and inflate the balloon. 4.Insert the catheter until resistance is met and inflate the balloon. - CORRECT ANSWERS 3.Advance the catheter to the bifurcation and inflate the balloon.

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The prescription of the primary health care provider (PHCP) prescription reads acetaminophen 240 mg orally every 6 hours as needed for relief of pain, for a 5-year-old child. The medication label reads "acetaminophen 160 mg per 5 mL." How many mL per dose would the nurse administer to the child? Fill in the blank. - CORRECT ANSWERS 7.5 mL The primary health care provider (PHCP) has prescribed phenobarbital sodium, 25 mg orally twice daily, for a child with febrile seizures. The medication label reads as follows: "Phenobarbital sodium, 20 mg/5 mL." The nurse has determined that the dose prescribed is a safe dose for the child. How many milliliters per dose would the nurse administer to the child? Fill in the blank. - CORRECT ANSWERS 6.25 mL Sulfisoxazole 1 g orally four times daily is prescribed for an adolescent with a urinary tract infection. The medication label reads, "250-mg tablets." The nurse has determined that the prescribed dose is safe. How many tablets per dose would the nurse administer to the adolescent? Fill in the blank. - CORRECT ANSWERS 4 tablets The primary health care provider (PHCP) has prescribed an antibiotic for a child. The average adult dose is 500 mg. The child has a body surface area (BSA) of 0.63 m2. What is the dose for the child? Fill in the blank. - CORRECT ANSWERS 182 mg The nurse is preparing to administer 35 mg of a prescribed intramuscular (IM) dose of medication to a client. The medication label reads 50 mg/mL. How many milliliters would the nurse administer to the client? Fill in the blank. - CORRECT ANSWERS 0.7 mL The nurse is asked to regulate the flow rate of an intravenous (IV) solution being administered to a client. The IV bag contains 50 mL of solution, and the solution is to be administered over 30 minutes. The administration set has a drop factor of 10 drops (gtts)/mL. The nurse would regulate the roller clamp on the infusion set to deliver how many drops per minute? Fill in the blank. Round answer to the nearest whole number. - CORRECT ANSWERS 17 gtts/min A primary health care provider (PHCP) prescribes potassium chloride (KCl) elixir, 20 mEq orally daily. The medication label states potassium chloride (KCl), 30 mEq/15 mL. How many milliliters should the nurse prepare to administer the dose? Fill in the blank. - CORRECT ANSWERS 10 mL

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The nurse is preparing to administer an enema to an adult client. Which interventions would the nurse plan to perform for this procedure? Select all that apply. 1.Apply disposable gloves. 2.Place the client in the right Sims' position. 3.Lubricate the enema tube and insert it approximately 4 inches. 4.Clamp the tubing if the client expresses discomfort during the procedure. 5.Hang the enema solution container 24 inches above the client's anus. 6.Ensure that the temperature of the solution is between 100°F (37.8°C) and 105°F (40.5°C).

• CORRECT ANSWERS 1.Apply disposable gloves. 3.Lubricate the enema tube and insert it approximately 4 inches. 4.Clamp the tubing if the client expresses discomfort during the procedure. 6.Ensure that the temperature of the solution is between 100°F (37.8°C) and 105°F (40.5°C). A postoperative client has a prescription to receive an intravenous (IV) infusion of 1000 mL normal saline solution over a period of 10 hours. The drop (gtt) factor for the IV infusion set is 15 gtts/mL. The nurse sets the flow rate at how many drops per minute? Fill in the blank. - CORRECT ANSWERS 25 gtts/min The primary health care provider's prescription reads "phenytoin 0.2 g orally, twice daily." The medication label states 100-mg capsules. How many capsule(s) would the nurse plan to administer over a 24-hour period? Fill in the blank. - CORRECT ANSWERS 4 capsules The primary health care provider prescribes 1000 mL of 0.45% NaCl to run over 8 hours. The drop (gtts) factor is 15. The nurse plans to adjust the flow rate to how many gtts/min? Fill in the blank. Round your answer to the nearest whole number. - CORRECT ANSWERS 31 gtts/min Penicillin G procaine, 1,000,000 units given intramuscularly, is prescribed for an adolescent with an infection. The medication label reads as follows: "1,200,000 units/2 mL." The nurse has determined that the prescribed dose is safe. How many milliliters per dose would the nurse administer to the adolescent?

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1. 0.8 mL
2. 1.2 mL
3. 1.44 mL
4. 1.66 mL - CORRECT ANSWERS 4. 1.66 mL The nurse is preparing to administer a continuous tube feeding to a client with a nasogastric tube. The primary health care provider has prescribed an amount of 100 mL/hr. The tube feeding setup is an open system, a bag that has formula added at intervals. How much formula would the nurse plan to add to fill the feeding bag?
5. 400 mL of formula
6. 600 mL of formula
7. 800 mL of formula 4.Enough formula to last for 8 hours - CORRECT ANSWERS 1. 400 mL of formula. The nurse is preparing to administer eardrops to an infant. How would the nurse administer the eardrops?
8. Pull up and back on the ear, and direct the solution onto the eardrum.
9. Pull down and back on the ear, and direct the solution onto the eardrum.
10. Pull down and back on the ear, and direct the solution toward the wall of the canal.
11. Pull up and back on the ear lobe, and direct the solution toward the wall of the canal. - CORRECT ANSWERS 3. Pull down and back on the ear, and direct the solution toward the wall of the canal. The nurse prepares to take a blood pressure (BP) on a school-age child. Where would the nurse place the blood pressure cuff to obtain an accurate measurement?
12. One-half the distance between the antecubital fossa and the shoulder
13. One-third the distance between the antecubital fossa and the shoulder

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3. Two-thirds the distance between the antecubital fossa and the shoulder
4. One-quarter the distance between the antecubital fossa and the shoulder - CORRECT ANSWERS 3. Two-thirds the distance between the antecubital fossa and the shoulder A primary health care provider is planning to administer a skeletal muscle relaxant to a client with a spinal cord injury. The medication is going to be administered intrathecally. Which medication would the nurse expect to be prescribed and administered by this route? 1.Baclofen 2.Chlorzoxazone 3.Dantrolene sodium 4.Cyclobenzaprine hydrochloride - CORRECT ANSWERS 1. Baclofen The nurse is developing a nutritional plan for an assigned client. Which is the most critical piece of data to collect before formulating the plan? 1.A dietary diary 2.Food preferences 3.The presence of food allergies 4.Medical history of conditions related to nutritional deficits - CORRECT ANSWERS 3. The presence of food allergies. The licensed practical nurse employed in the ambulatory clinic is assisting the registered nurse in preparing to administer a dose of intravenous immune globulin (IVIG). The licensed practical nurse would ensure that which medication is readily available before the medication is administered?
5. Epinephrine
6. Phytonadione
7. Acetylcysteine
8. Protamine sulfate - CORRECT ANSWERS 1. Epinephrine

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The nurse has just been told by the primary health care provider that a prescription has been written to administer a heparin injection to a client every 12 hours. The nurse anticipates using which technique to administer the medication? 1.Z-track 2.Using a 20-gauge needle 3.Intramuscular using a 1-inch needle 4.Subcutaneous using the abdomen - CORRECT ANSWERS 4.Subcutaneous using the abdomen A client is to receive medication via patient-controlled analgesia (PCA), and the nursing instructor asks the nursing student caring for the client to describe the use of the PCA. The instructor determines there is a need for further teaching about the PCA when the student makes which statement?

1. "The PCA gives the client greater control over analgesic administration."
2. "Asking the client to rate pain is unnecessary when the client has a PCA."
3. "PCA delivers predetermined amounts of analgesia within preset intervals."
4. "A continuous intravenous (IV) solution is needed to keep the vein open between analgesia infusions." - CORRECT ANSWERS 2. "Asking the client to rate pain is unnecessary when the client has a PCA." The nurse is caring for a client with a diagnosis of chronic kidney disease who is receiving dialysis. Epoetin alfa has been prescribed for the client. How would the nurse prepare to administer the medication?
5. The subcutaneous route
6. Shaking the vial before drawing up the medication
7. Obtaining the medication from the medication freezer
8. Mixing the medication with 0.1 mL of heparin before administration to prevent clotting - CORRECT ANSWERS 1. The subcutaneous route.

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The nurse is administering a medication intramuscularly to an assigned client. The nurse would include which actions in administering the medication? Select all that apply.

1. Massage the site after injection.
2. Use a Z-track method for administration.
3. Wear sterile gloves to administer the medication.
4. Hold the syringe as if it is a dart to insert the needle.
5. Select an appropriate injection site such as the ventral gluteus.
6. Cleanse the injection site using a back-and-forth motion with an antiseptic pad. - CORRECT ANSWERS 2. Use a Z-track method for administration.
7. Hold the syringe as if it is a dart to insert the needle.
8. Select an appropriate injection site such as the ventral gluteus. The nurse reinforces teaching a client on how to administer enoxaparin subcutaneously. The nurse determines that the client understands the correct procedure if the client does which on a return demonstration?
9. Uses a 1-inch needle
10. Massages after injection
11. Aspirates before injection
12. Bunches the skin before injection - CORRECT ANSWERS 4. Bunches the skin before injection The nurse is inserting an indwelling urinary catheter in a client and begins to inflate the balloon when the client starts complaining of pain. Which action would the nurse take?
13. Continue to inflate the balloon
14. Deflate the balloon, slightly withdraw the catheter and attempt to reinflate the balloon
15. Deflate the balloon, completely withdraw the catheter and end the procedure to notify the primary health care provider

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4. Stop inflating the balloon, allow the saline solution to drain into the syringe and advance the catheter further before reinflating the balloon - CORRECT ANSWERS 4. Stop inflating the balloon, allow the saline solution to drain into the syringe and advance the catheter further before reinflating the balloon The surgeon asks the nurse to obtain a urinary catheter that will be used for continuous bladder irrigation. Which urinary catheter would be the nurse obtain?
5. A straight catheter
6. A Coudé tip catheter
7. A triple-lumen catheter
8. A double-lumen catheter - CORRECT ANSWERS 3. A triple-lumen catheter A primary health care provider has ordered digital removal of stool for a constipated client. How would the nurse position the client for this procedure?
9. Prone position
10. Lithotomy position
11. Left lateral Sims' position
12. Right lateral Sims' position - CORRECT ANSWERS 3. Left lateral Sims' position The nurse in the delivery room is caring for a newborn delivered 10 minutes ago. The nurse assists in preparing which medications that will be prescribed to be given within the first hour of life? Select all that apply.
13. Naloxone
14. Surfactant
15. Phytonadione
16. Hepatitis A vaccine
17. Hepatitis B vaccine
18. Erythromycin eye drops - CORRECT ANSWERS 3. Phytonadione

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6. Erythromycin eye drops A 1-month old child is hospitalized following a motor vehicle accident in which the parents are seriously injured. The nurse would select which toys for this child? Select all that apply.
7. Large puzzle
8. Nursery mobile
9. Jack-in-the-box
10. Strings of big beads
11. A pastel-colored stuffed animal
12. A mobile that swings and plays music - CORRECT ANSWERS 2. Nursery mobile
13. A mobile that swings and plays music The nurse is reinforcing instructions to a client regarding the administration of lypressin. The nurse instructs the client that the medication will be taken by which routes?
14. Oral
15. Intranasal
16. Subcutaneous
17. Intramuscular - CORRECT ANSWERS 2. Intranasal The nurse is reinforcing instructions to a client regarding epoetin alfa that will be administered subcutaneously by the client at home. The nurse tells the client to do which action?
18. Refrigerate the medication.
19. Freeze the medication before use.
20. Shake the medicine bottle before use.
21. Obtain syringes with 1-inch needles from the pharmacy. - CORRECT ANSWERS 1. Refrigerate the medication.

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The nurse is preparing to perform an abdominal examination. Which step would be taken first?

1. Palpation
2. Inspection
3. Percussion
4. Auscultation - CORRECT ANSWERS 2. Inspection The nurse is assisting with the data collection on a client admitted to the psychiatric unit. After review of the obtained data, the nurse would identify which as a priority concern?
5. The client's report of not eating or sleeping
6. The presence of bruises on the client's body
7. The client's report of self-destructive thoughts
8. The family member's disapproval of the treatment - CORRECT ANSWERS 3. The client's report of self-destructive thoughts A client is admitted to the hospital with a diagnosis of major depression. During the admission interview, the nurse determines that a major concern is the client's poor nutritional intake. Which nursing intervention related to poor nutrition would be the initial choice?
9. Weigh the client three times per week, before breakfast.
10. Explain to the client the importance of a good nutritional intake.
11. Report the nutritional concern to the psychiatrist, and obtain a nutritional consult as soon as possible.
12. Offer the client several small, frequent meals daily, and schedule brief nursing interactions with the client during these times. - CORRECT ANSWERS 4. Offer the client several small, frequent meals daily, and schedule brief nursing interactions with the client during these times.

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The nurse is checking a dark-skinned client for the presence of petechiae. Which body area is best for the nurse to check in this client?

1. Sclera
2. Oral mucosa
3. Soles of the foot
4. Palms of the hand - CORRECT ANSWERS 2. Oral mucosa The nurse is asked to test the visual acuity of a client using a Snellen chart. The nurse prepares to perform the test, knowing that which procedure accurately identifies this visual acuity test?
5. The right eye is tested, followed by the left eye, and then both eyes are tested.
6. Both eyes are tested together, followed by the testing of the right and then the left eye.
7. The client is asked to stand at a distance of 40 feet from the chart and to read the largest line on the chart.
8. The client is asked to stand at a distance of 40 feet from the chart and to read the line that can be read 200 feet away by an individual with unimpaired vision. - CORRECT ANSWERS 1. The right eye is tested, followed by the left eye, and then both eyes are tested. A client's vision is tested with a Snellen chart. The results of the test are documented as 20/60. How would the nurse interpret this result?
9. The client is legally blind.
10. The client's vision is normal.
11. The client can read at a distance of 60 feet what a client with normal vision can read at 20 feet.
12. The client can read at a distance of 20 feet what a client with normal vision can read at 60 feet. - CORRECT ANSWERS 4. The client can read at a distance of 20 feet what a client with normal vision can read at 60 feet.

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The nurse is preparing the client for eye testing, and the examiner is planning to test the eyes using the confrontational method. What would the nurse tell the client about the purpose of the test?

1. Checks for glaucoma
2. Checks for color blindness
3. Examines pupil constriction
4. Examines visual fields or peripheral vision - CORRECT ANSWERS 4. Examines visual fields or peripheral vision The nursing student is caring for a client scheduled for cataract surgery. The student reviews the preoperative prescriptions with the nursing instructor and notes that cyclopentolate eye drops are prescribed to be administered preoperatively. The unit nurse performed an admission health assessment on the client before surgery. Which condition contraindicates using cyclopentolate?
5. Glaucoma
6. Leukemia
7. Liver disease
8. Diabetes mellitus - CORRECT ANSWERS 1. Glaucoma Which observation indicates that the nurse is performing a whispered voice hearing assessment test procedure correctly?
9. Stands 10 feet away from the client
10. Asks the client to block one ear at a time
11. Conducts the test with back to the client
12. Asks the client to close both eyes during the test - CORRECT ANSWERS 2. Asks the client to block one ear at a time The nurse is preparing to collect client data by examining the abdomen. The nurse should begin the assessment by performing which action first?

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1. Palpating the abdomen
2. Inspecting the abdomen
3. Percussing the abdomen
4. Auscultating the abdomen - CORRECT ANSWERS 2. Inspecting the abdomen The nurse provides information to a client regarding breast self-examination (BSE). Which client statement indicates a need for further teaching regarding BSE?
5. "I examine my breasts in the shower."
6. "I do BSE 7 days after I get my period."
7. "I lie on my back to examine my breasts."
8. "I don't need to do that; I'm too old for that." - CORRECT ANSWERS 4. "I don't need to do that; I'm too old for that." The nurse in the emergency department is preparing to instill fluorescein into the eye of a client with the complaint of eye pain. Fluorescein dye is used to detect which conditions? Select all that apply.
9. Cataracts
10. Glaucoma
11. Foreign object
12. Corneal abrasion
13. Macular degeneration - CORRECT ANSWERS 3. Foreign object
14. Corneal abrasion When checking a child's glossopharyngeal nerve function, the nurse would perform which data collection technique?
15. Have the child shrug the shoulders while applying mild pressure.

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2. Have the child follow a light in the 6 cardinal positions of gaze.
3. Test sense of sour or bitter taste on the posterior segment of the tongue.
4. Test sense of sweet or salty taste on the anterior section of the tongue. - CORRECT ANSWERS 3. Test sense of sour or bitter taste on the posterior segment of the tongue. To assess for the presence of the posterior tibialis pulse, the nurse would palpate which areas?
5. In the groove just below the inguinal ligament
6. Behind the knee and lateral to the medial tendon
7. Lateral to and parallel with the extensor tendon of the big toe
8. In the groove behind the medial malleolus and the Achilles tendon - CORRECT ANSWERS
9. In the groove behind the medial malleolus and the Achilles tendon The nurse is teaching a mother how to administer eardrops to an infant. The nurse determines the mother understands instructions if the mother demonstrates pulling the ear in which manner?
10. Up and back and directing the solution onto the eardrum
11. Down and back and directing the solution onto the eardrum
12. Up and back and directing the solution toward the wall of the canal
13. Down and back and directing the solution toward the wall of the canal - CORRECT ANSWERS 4. Down and back and directing the solution toward the wall of the canal The nurse is presenting a lecture on disasters and posttraumatic stress disorder (PTSD) to a group of new assistive personnel (AP). Which statements by the AP indicate that teaching has been effective? Select all that apply.
14. "I will never experience PTSD."
15. "PTSD can potentially last a lifetime."
16. "Clients can be easily startled and have difficulty sleeping."

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4. "Flashbacks occur, causing the client to relive the experience."
5. "PTSD only occurs in clients who already have a history of depression." - CORRECT ANSWERS 2. "PTSD can potentially last a lifetime."
6. "Clients can be easily startled and have difficulty sleeping."
7. "Flashbacks occur, causing the client to relive the experience." The nurse is auscultating bowel sounds. Which are appropriate data collection methods and actions? Select all that apply.
8. Divide the abdomen into four quadrants at the umbilicus.
9. Do not feed the client if no sounds are audible in 5 minutes.
10. Listen in each quadrant for gurgling sounds indicating movement.
11. If no sounds are audible in 2 minutes, notify the registered nurse.
12. If 20 sounds are noted within 1 minute, notify the registered nurse. - CORRECT ANSWERS
13. Divide the abdomen into four quadrants at the umbilicus.
14. Do not feed the client if no sounds are audible in 5 minutes.
15. Listen in each quadrant for gurgling sounds indicating movement. A client has died, and the nurse asks a family member about the funeral arrangements. The family member refuses to discuss the issue. Which is the appropriate nursing action?
16. Show acceptance of feelings.
17. Provide information needed for decision making.
18. Suggest a referral to a mental health professional.
19. Remain with the family member without discussing funeral arrangements. - CORRECT ANSWERS 4. Remain with the family member without discussing funeral arrangements. The parents of an 8-year-old child tell the nurse that they are concerned about the child because the child seems to be more attentive to friends than anyone else. Which is the appropriate nursing response?

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1."You need to be concerned."

2. "You need to monitor the child's behavior closely."
3. "You need to praise the child more often to stop this behavior."
4. "At this age, the child is developing his or her own personality." - CORRECT ANSWERS 4. "At this age, the child is developing his or her own personality." The nurse is providing instructions to a new parent regarding the psychosocial development of the infant. Using Erikson's psychosocial development theory, which instruction would the nurse reinforce to the parents?
5. Allow the infant to signal a need.
6. Anticipate all of the needs of the infant.
7. Attend to the crying infant immediately.
8. Avoid the infant during the first 10 minutes of crying. - CORRECT ANSWERS 1. Allow the infant to signal a need. The parent of a 3-year-old tells the nurse that the child is constantly rebelling and having temper tantrums. Which instruction would the nurse reinforce to the parent?
9. Set limits on the child's behavior.
10. Ignore the child when this behavior occurs.
11. Allow the behavior, because this is normal at this age period.
12. Punish the child every time the child says "no" to change the behavior. - CORRECT ANSWERS 1. Set limits on the child's behavior. The nurse is caring for an older client who is reminiscing about past life experiences in a positive manner. The nurse plans care with the understanding that this behavior indicates which?
13. A mental status alteration
14. A normal psychosocial response

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3. A need for psychiatric consultation
4. A sensory deficit requiring social activities - CORRECT ANSWERS 2. A normal psychosocial response The nurse is observing a parent and child interacting in the clinic waiting room. The child begins to bounce on the couch. The parent removes the child from the couch stating firmly, "Couches are for sitting, not for jumping." The parent then gives the child a toy to play with on the carpet. The child plays with the toy until called by the nurse. The nurse determines the child is acting within which Kohlberg stage of moral development?
5. Egocentric judgment
6. Law-and-order orientation
7. Punishment-obedience stage
8. Good boy-nice girl orientation - CORRECT ANSWERS 3. Punishment-obedience stage The nurse determines a child is in the "preoperational" phase of Piaget's cognitive developmental theory when the child makes which statement?
9. "I know all of my multiplication tables by memory".
10. "The ball is gone," when a ball disappears out of sight.
11. "I'll use a map to help me find my way in a new town".
12. "The moon follows me, and goes to bed when I go to bed". - CORRECT ANSWERS 4. "The moon follows me, and goes to bed when I go to bed" A child remarks, "I share my toys and snacks with my friends so they will like me more." The nurse determines the child is in which stage of moral development?
13. Egocentric judgment
14. Law-and-order orientation
15. Good boy-nice girl orientation
16. Social contract and legalistic orientation - CORRECT ANSWERS 3. Good boy-nice girl orientation

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The nursing student is preparing a conference on Freud's psychosexual stages of development, specifically the anal stage. Which appropriately relates to this stage?

1. Gratification of self
2. Beginning of toilet training
3. Tapering off of conscious biological and sexual urges
4. Association with pleasurable and conflicting feelings about the genital organs - CORRECT ANSWERS 2. Beginning of toilet training The parents of a 16-year-old child tell the nurse that they are concerned because the child sleeps until noon every weekend. Which is the most appropriate nursing response?
5. "Adolescents love to sleep late in the morning."
6. "The child shouldn't be staying up so late at night."
7. "If the child eats properly, that shouldn't be happening."
8. "The child should have a blood test to check for anemia." - CORRECT ANSWERS 1. "Adolescents love to sleep late in the morning." A 16-year-old child is admitted to the hospital for acute appendicitis, and an appendectomy is performed. Which intervention is most appropriate to facilitate normal growth and development?
9. Encourage the child to rest and read.
10. Encourage the parents to room-in with the child.
11. Allow the family to bring in favorite computer games.
12. Allow the child to participate in activities with other individuals in the same age group when the condition permits. - CORRECT ANSWERS 4. Allow the child to participate in activities with other individuals in the same age group when the condition permits. Which interventions are appropriate for the care of an infant? Select all that apply.

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1. Provide swaddling.
2. Talk in a loud voice.
3. Provide the infant with a bottle of juice at naptime.
4. Hang mobiles with black-and-white contrast designs.
5. Caress the infant while bathing or during diaper changes. Allow the infant to cry for at least 10 minutes before responding. - CORRECT ANSWERS 1. Provide swaddling
6. Hang mobiles with black-and-white contrast designs.
7. Caress the infant while bathing or during diaper changes. The nurse is preparing to care for a dying client, and several family members are at the client's bedside. Which therapeutic techniques would the nurse use when communicating with the family? Select all that apply.
8. Discourage reminiscing.
9. Make the decisions for the family.
10. Encourage expression of feelings, concerns, and fears.
11. Explain everything that is happening to all family members.
12. Touch and hold the client's or family member's hand if appropriate.
13. Be honest and let the client and family know that they will not be abandoned by the nurse. - CORRECT ANSWERS 3. Encourage expression of feelings, concerns, and fears.
14. Touch and hold the client's or family member's hand if appropriate.
15. Be honest and let the client and family know that they will not be abandoned by the nurse. The parents of a 2-year-old arrive at the hospital to visit their child. The child is in the play room and ignores the parents during the visit. The nurse tells the parents that this behavior in a 2-year-old child indicates which characteristic about the child?
16. The child is withdrawn.

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2. The child is upset with the parents.
3. The child is exhibiting a normal pattern.
4. The child has adjusted to the hospitalized setting. - CORRECT ANSWERS 3. The child is exhibiting a normal pattern. When caring for a 3-year-old child, the nurse would provide which toy for the child? 1.A puzzle
5. A wagon
6. A golf set
7. A miniature farm set - CORRECT ANSWERS 2. A wagon Upon palpation of the fontanel of a 3-month-old newborn, the nurse notes that the anterior fontanel has not closed and is soft and flat. Which action would the nurse take?
8. Increase oral fluids.
9. Document the findings.
10. Notify the registered nurse.
11. Elevate the head of the bed to 90 degrees. - CORRECT ANSWERS 2. Document the findings. The nurse is caring for a 5-year-old child who has been placed in traction after a fracture of the femur. Which is the most appropriate activity for this child?
12. Blocks
13. A music video
14. A 10-piece puzzle
15. Large picture books - CORRECT ANSWERS 3. A 10-piece puzzle