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NCLEX Practice Questions with Answers and Rationales: Nursing Fundamentals, Exams of Nursing

A series of nclex-style practice questions covering fundamental nursing concepts. Each question includes the correct answer and a detailed rationale explaining the reasoning behind the choice. The topics covered include medication administration, client assessment, surgical procedures, and infection control. This resource is valuable for nursing students preparing for the nclex exam or for nurses seeking to refresh their knowledge.

Typology: Exams

2024/2025

Available from 12/23/2024

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Download NCLEX Practice Questions with Answers and Rationales: Nursing Fundamentals and more Exams Nursing in PDF only on Docsity!

NCLEX practice Questions with Answers and

Rationales.

The nurse is evaluating dietary education provided to a client diagnosed with cholecystitis. The nurse determines that further teaching is necessary when the client chooses which meal to consume?

  1. Cup of oatmeal, blueberries, soymilk
  2. Whole grain pasta, marinara sauce, baked fish, coffee
  3. Spaghetti with meat sauce, peas, garlic French bread, tea
  4. Lentil soup, vegetable medley, fruit salad, water - Correct Answer 3 - spaghetti with meat sauce, peas, garlic french bread, tea meat is high in fat, french bread is low in fiber and high in fat The nurse is caring for a client taking benazepril. Which symptoms would be important for the nurse to report to the primary healthcare provider?
  5. BP 150/108 decreases to 138/
  6. Weight gain of 5 pounds (2.27 kg) in one week
  7. Serum sodium level of 139 mmol/L
  8. Angioedema
  9. Serum potassium of 5.8 mEq - Correct Answer 2. weight gain of 5 pounds in one week
  10. angioedema
  11. serum potassium of 5. Weight gain of 5 pounds in one week is a s/s of an adverse effect of ACE inhibitor use. Weight gain is a sign of fluid retention. Angioedema is an adverse effect of ACE inhibitors and can be life threatening. This should be reported immediately to the healthcare provider. The potassium level is too high. Hyperkalemia is an adverse effect of an ACE inhibitor and needs to be reported. The nurse is caring for a client who is to receive an IV infusion of heparin. The client's dose is based on a sliding scale prescription. What is the priority lab value to check before initiating the heparin infusion?
  12. PT and/or INR
  13. aPTT
  14. Platelet count
  1. WBC count - Correct Answer 2. aPTT The activated partial thromboplastin time (aPTT) is a lab value used to assess pathways in the clotting cascade and is used to monitor Heparin therapy in clients. To maintain a therapeutic level of Heparin, the aPTT should be maintained at 1.5-2.5 times the normal range. A client who has been on bed rest for several days is ambulating for the first time with assistance. Prioritize the actions the nurse should take by placing them in order from first to last. - Correct Answer Assess the client's orientation. Assist the client to sit on the side of the bed for 1-2 minutes. Apply a gait belt to the client's waist. Have the client stand by the side of the bed for a few seconds. Ambulate in the room. The nurse is caring for a Native American client who has returned to the surgical floor following abdominal surgery. The nurse is concerned about the level of discomfort that the client is experiencing. Which comment is the nurse likely to hear upon assessment?
  2. "The pain is getting worse. I can't stand it."
  3. "I need something for pain as soon as possible."
  4. "I hope that the pain will go away soon."
  5. "I am doing okay. The pain is not bad." - Correct Answer 4 - I am doing okay, the pain is not bad The Native American client is likely to be quiet and less expressive of pain. Native Americans tend to tolerate high levels of pain. The nurse is caring for a client taking spironolactone. Which dietary change should the nurse teach the client to make when starting treatment with this medication?
  6. Eat extra helpings of bananas.
  7. Increase intake of water.
  8. Avoid salt substitutes.
  9. Increase intake of green leafy vegetables. - Correct Answer 3 - avoid salt substitutes Spironolactone is a potassium sparing diuretic. Salt substitutes have potassium instead of sodium and should be avoided.

A staff nurse decides to go to lunch with a friend instead of meeting with a study group for a certification exam. The staff nurse informs the clinical specialist, "Studying more will not do any good anyway." What defense mechanism does the clinical specialist understand that the staff nurse is exhibiting?

  1. Rationalization
  2. Denial
  3. Regression
  4. Reaction formation - Correct Answer 1 - rationalization Rationalization is the mind's way of justifying behavior by offering an explanation other than a truthful response. This is often used to avoid embarrassment. A small community has experienced a severe tornado that hit a shopping mall and caused extreme damage and suspected mass casualties and injuries. Which intervention takes priority?
  5. Triage victims and tag according to injury.
  6. Assess the immediate area for electrical wires on the ground and in vicinity of victims.
  7. Activate the community emergency response team.
  8. Begin attending to injuries as they are encountered. - Correct Answer 3
  • activate the community emergency response team With mass casualties, community response teams are needed. An emergency department (ED) nurse working triage has assessed four clients. Which client should receive the highest priority?
  1. Alert client who fell on the side walk. Skin warm and dry to the touch, with a three inch laceration on the right knee continuously oozing dark red liquid.
  2. Elderly client who moans when the nurse asks, "Can you hear me?" Respirations even/nonlabored. Skin slightly cool to touch with pale nailbeds.
  3. A client who "passed out" but regained consciousness when feet were elevated. Awake and confused, with warm and dry skin.
  4. An alert, responsive client who reports severe abdominal and shoulder pain that began two hours after eating at a local fast food restaurant. Skin is warm and dry. - Correct Answer 2 - elderly client who moans when the

nurse asks "can you hear me?" respirations even/nonlabored. skin slightly cool to touch with pale nailbeds This client is responding to verbal stimuli by moaning and has an open airway; but any client with an altered level of consciousness is at risk for airway obstruction. The skin assessment indicates a circulation problem. The charge nurse on the pediatric unit is reviewing the protocol for blood administration with a staff nurse. Which actions by the staff nurse indicate understanding of blood administration?

  1. The blood infusion time was within 6 hours.
  2. A filter was used when administering the blood.
  3. A second nurse checked the blood compatibility.
  4. A set of vital signs was taken 5 minutes after the blood infusion started.
  5. One form of client identification were obtained prior to infusion. - Correct Answer 2 - a filter was used 3 - a second nurse checked the blood 4 - a set of vital signs was taken 5 min after blood infusion started Filters are used when infusing blood. Two nurses must check the blood product label and blood group. Vital signs are checked frequently during a blood transfusion. For example: A baseline set of vital signs are taken, then again 5 minutes after the initiation of the transfusion, then 15 minutes after transfusion started and every 15 minutes for one hour, then every 30 minutes for one hour, then hourly until infusion is complete. Upon receiving a diagnosis of Stage 4 lung cancer, an elderly client expresses regret for having chosen to smoke. Which response by the nurse would best help the client cope at this time?
  6. "You are lucky to have lived a very long life."
  7. "We have younger clients in worse shape than you."
  8. "The doctor will make sure to treat any pain."
  9. "You are regretting your decision to smoke." - Correct Answer 4 - you are regretting your decision to smoke The nurse responds with an open-ended statement that reflects back what the client has stated. This allows the client to continue expressing concerns and feelings about the diagnosis or past choices. At this time, encouraging the client to verbalize is the best choice to help with coping.

In what order, after initially washing hands, should the nurse change a dressing on an infected abdominal surgical wound that has a Penrose drain and a large amount of purulent drainage? Place in priority order from first to last. - Correct Answer Apply clean gloves. Remove soiled dressings. Discard soiled dressings and clean gloves in red bag. Don sterile gloves. Clean surgical wound with moistened sterile 4x4's. Clean around Penrose drain using a circular pattern inside to outside. Place dry, sterile 4x4's over surgical wound and Penrose drain. Apply abdominal dressing pad. What should the nurse do first when caring for a client who is being admitted with a diagnosis of meningococcal meningitis?

  1. Assess neuro status.
  2. Obtain health history.
  3. Institute droplet precautions.
  4. Orient client to the room and procedures. - Correct Answer 3 - droplet precautions Although all the options are appropriate, the priority is to place the client on droplet precaution to prevent the spread of meningococcal meningitis A nurse is caring for a client who reports fatigue, weight loss, afternoon fevers, night sweats, cough, and hemoptysis. What interventions should the nurse initiate?
  5. Wear an N95 respirator when caring for client.
  6. Restrict fluid intake to 500 mL per day.
  7. Position client in semi-Fowler's position.
  8. Place client in a negative pressure airflow room.
  9. Do not allow visitors for 48 hours. - Correct Answer 1 - N95 respirator 3 - position client in semi fowlers 4 - place client in a negative airflow room The nurse should suspect that the client is suffering from tuberculosis. Early pulmonary TB is asymptomatic. When the bacterial load increases, nonspecific symptoms of fatigue, weight loss, afternoon fevers, and night sweats may set in. As disease advances, cough, sputum production, and hemoptysis may appear. This client has the classic symptoms of TB and should be placed on airborne precautions. N95 respirator ensures that the

nurse does not inhale the TB organism. Placing in a semi-Fowler's position reduces the work of breathing. The nurse is caring for a client with possible hepatic failure. The nurse asks the client to sign a permit for a procedure. The nurse recalls the client's admission signature as legible, but, now observes a jerky, illegible signature. What should the nurse suspect is the cause of this handwriting change?

  1. Fetor
  2. Ataxia
  3. Apraxia
  4. Asterixis - Correct Answer 4 - asterixis Yes, the liver flap, which is an abnormal muscle tremor, is usually found in clients with diseases of the liver. This is an indication that the hepatic failure is worsening and needs to be documented. Which nursing intervention should receive priority after a client has returned from having had eye surgery?
  5. Administer pain medication around the clock.
  6. Maintain head of bed at 35°.
  7. Apply warm compresses.
  8. Instruct on importance of turning, coughing, and deep breathing. - Correct Answer 2 - maintan HOB at 35 degrees Maintaining head of bed in an elevated position will help to decrease intraocular pressure. Do not lie the client supine as this will increase intraocular pressure. If the intraocular pressure increases too much, damage to the eye structures, including the retina and optic nerve, with resulting loss of vision, may result. A primary healthcare provider informs the nurse to prepare for an amniotomy on a client who's labor has not progressed. What should the nurse assess for prior to the primary healthcare provider performing this procedure?
  9. Fetal attitude
  10. Fetal engagement
  11. Fetal lie
  12. Fetal position - Correct Answer 2 - fetal engagement

Fetal engagement is important prior to rupturing the membranes so that the umbilical cord cannot prolapse. Fetal engagement is when the fetus is at station 0 (level of mom's ischial spines). The primary healthcare provider prescribes glycopyrrolate 0.2 mg IM thirty minutes prior to electroconvulsive therapy (ECT). What should be the nurse's response when the client asks why this drug is being given?

  1. "The action of the medication is complex."
  2. "This drug will prevent you from having a seizure."
  3. "This medication will relax your muscles so that you do not break a bone."
  4. "Glycopyrrolate will decrease stomach secretions." - Correct Answer 4
  • decreases stomach secretions Glycopyrrolate is an anticholinergic. Glycopyrrolate blocks the activity of acetylcholine which reduces secretions in the mouth, throat, airway, and stomach. It is used prior to procedures to decrease the risk of aspiration. A case manager is evaluating a client diagnosed with hemiplegia due to a cerebral vascular accident who will need assistive devices upon discharge. Which devices should the case manager include for this client?
  1. Dinner plate food guards
  2. Transfer belt
  3. Raised toilet seat
  4. Long handled shoe horn
  5. Wide grip eating utensils
  6. Button closures on clothes - Correct Answer 1- The goal is to promote self-care by the client as much as possible. The case manager should evaluate the need for assistive devices to help with eating, bathing, dressing, and ambulating. The dinner plate food guard will prevent food from being pushed off the plate. The transfer belt will provide safety for the client to get into a chair or back in bed. A raised toilet seat makes it easier for the client to sit on the toilet without falling. The long- handled shoe horn allows the client to put on shoes without assistance. Wide grip utensils accommodate a weak grip. Following surgery, a client refuses to ambulate as prescribed. What action should the nurse take?
  7. Notify the primary health care provider of client's refusal to ambulate.
  1. Offer the client pain medication.
  2. Explain complications associated with bed rest.
  3. Perform passive range of motion exercises. - Correct Answer 3 - explain complications associated with bed rest The nurse should educate the client about complications that can be prevented with ambulation, such as constipation, pneumonia, or deep vein thrombosis (DVT). The nurse assesses a multigravida who is four hours postpartum. Findings include that fundus is firm, 1 centimeter above the umbilicus, and deviated to the right side. The lochia is moderately heavy and bright red. Which nursing intervention has priority?
  4. Massage the fundus.
  5. Administer intravenous oxytocin.
  6. Document these normal findings.
  7. Assist the client up to void. - Correct Answer 4 - assist the client up to void These findings are caused by a full bladder, which prevents the uterus from contracting down and achieving homeostasis. Once the bladder is empty, the fundus will contract adequately and return to its normal location at level of umbilicus or 1 finger breadth below the umbilicus and in the midline. A distended bladder will displace the uterus, usually to the right. A home health nurse is assessing the home environment for safety issues concerning ambulation. Which finding would require the nurse to counsel the client and family?
  8. Dim hall lighting
  9. Grab bar in bath tub
  10. Nonskid strips on outside steps
  11. Throw rug at front entrance to home
  12. Waxed linoleum kitchen floor - Correct Answer 1 - dim lighting 4 - throw rug at front entrance to home 5 - waxed linoleum kitchen floor Rooms and hallways should have adequate lighting so client can see while ambulating and see any objects which may be in the way. Throw rugs (rugs that are not secured) can slide and cause a fall. Slippery floors will contribute to falls.

The home health nurse is caring for a client with a neurological urinary tract dysfunction. What information should be included when teaching the client how to perform intermittent self catheterization?

  1. Performed in an emergency department (ED).
  2. Prevents urinary catheter infections.
  3. Perform as a clean procedure.
  4. Requires using sterile gloves. - Correct Answer 3 - perform as a clean procedure Home intermittent catheterization is a clean, not sterile technique when performed in the home environment. Home intermittent catheterization is preferred over continuous use of an indwelling catheter, as an indwelling catheter increases client risk of urinary tract infection (UTI). A client, admitted to the medical unit with persistent vomiting, reports weakness and leg cramps. The spouse states that the client is irritable. The primary healthcare provider has prescribed lab work and blood gases. Based on this assessment, the nurse anticipates which acid/base imbalance?
  5. Respiratory acidosis
  6. Respiratory alkalosis
  7. Metabolic acidosis
  8. Metabolic alkalosis - Correct Answer 4 - metabolic alkalosis Symptoms of alkalosis are often due to associated potassium loss and may include irritability, weakness, and cramping. Excessive vomiting eliminates gastric acid and potassium, leading to metabolic alkalosis. Which statement by a student nurse indicates to the nurse educator that teaching regarding witnessing consent signatures has been successful?
  9. "Two people must witness a consent signature."
  10. "A RN must witness a consent signature."
  11. "Signing as a witness implies that the client willingly signed the consent."
  12. "A witness must be over the age of 21." - Correct Answer 3 - signing as a witness implies that the client willingly signed the contract Signing as a witness implies that the witness has observed the client personally signing the consent form with no coercion.

What should the nurse include when providing teaching to a female client prescribed doxycycline for the treatment of acne?

  1. Take this medication with food to maximize absorption.
  2. Use a non-hormone method of birth control while taking this medication.
  3. Wear protective clothing when outside.
  4. Drink plenty of fluids while taking this medication.
  5. Iron and calcium supplements can be taken with this medication. - Correct Answer 2 - use non-hormone method of birth control 3 - wear protective clothing outside 4 - drink plenty of fluids Doxycycline is a tetracycline antibiotic. Doxycycline can make birth control pills less effective. A non-hormone method of birth control (such as a condom, diaphragm, spermicide) should be used to prevent pregnancy while using doxycycline. Avoid exposure to sunlight or tanning beds. Doxycycline can make you sunburn more easily. Wear protective clothing and use sunscreen (SPF 30 or higher) when outdoors. Take doxycycline with a full glass of water. Drink plenty of liquids while taking this medicine. The nurse is assigned to care for a client who has developed intestinal obstruction and has had an NG tube inserted to low suction. Blood gases are pH 7.54, pCO2 52, HCO3 35. Assessment of the client by the nurse reveals that the client is weak, shaky, and reporting tingling of the fingers. The nurse determines that this client is in which acid/base imbalance?
  6. Respiratory acidosis
  7. Respiratory alkalosis
  8. Metabolic acidosis
  9. Metabolic alkalosis - Correct Answer 4 - metabolic alkalosis Metabolic alkalosis occurs from gastric losses via vomiting, NG tubes to suction, or lavage, and potent diuretics. Signs and symptoms include n/v, sensorium changes, tremors, convulsions. pH > 7.45, pCO2 > 45, HCO3 > 27 The nurse is providing post-operative care to the craniotomy client. Hourly urinary output increases from 100 mL last hour to 500 mL this hour. What action by the nurse takes priority?
  10. Elevate HOB 90 degrees
  11. Auscultate apical pulse
  1. Obtain a blood pressure
  2. Assess Glasgow Coma Score - Correct Answer 3 - obtain a BP This is the best answer because we are "worried" this client is going into SHOCK due to diabetes insipidus. So, you better be checking a BP. This is a time where checking the BP is appropriate. If we "assume the worst" I better check a blood pressure. It could have dropped out the bottom. Following a total hip replacement, the nurse provides discharge teaching to the client. The nurse knows that teaching was effective when the client states which activities are safe to perform?
  3. Using an abduction pillow while sleeping
  4. Crossing the legs
  5. Using a toilet extender
  6. Showering rather than taking a bath
  7. Tying shoes - Correct Answer 1 - abduction pillow 3 - toilet extender 4 - shower instead of bath The client should use an abduction pillow to keep hip in proper alignment and prevent hip dislocation. A toilet extender keeps the hip in proper alignment and prevents hip dislocation. Showering rather than sitting in a tub will prevent flexion of the hip. The oncoming nurse has just received report and is preparing to make initial rounds. Which postpartum client should the nurse see first?
  8. A primipara 6 hours postpartum saturating one peripad every two hours
  9. A multigravida 1 hour postpartum and reporting intense perineal pain
  10. A primigravida 12 hours postpartum with the uterine fundus at the umbilicus
  11. A multigravida 72 hours postpartum with a brownish pink lochia discharge. - Correct Answer 2 - multigravida 1 hr postpartum and reporting intense perineal pain Intense perineal pain is a symptom of a perineal hematoma which is a medical emergency. The nurse notes that a client has impaired swallowing as a result of a cerebrovascular accident (CVA). Which interventions are appropriate for the nurse to include in the plan of care?
  1. Sit the client up at a 90° angle during meals.
  2. Assist the client to hyperextend the head when preparing to swallow.
  3. Encourage the client to sit up for 30 minutes after eating.
  4. Educate a family member on the Heimlich maneuver.
  5. Start the client on a thin liquid diet. - Correct Answer 1 - sit the client up at 90 for meals 3 - encourage the client to sit up for 30 min after eating 4 - educate a family member on the heimlich maneuver This is the optimal position for chewing and swallowing without aspirating. Sitting up 30 minutes after completing a meal will prevent regurgitation of food. In case of choking, family members should know how to perform emergency measures such as the Heimlich maneuver. Which assignment would be most appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)?
  6. Obtaining a sterile urine specimen from an indwelling catheter.
  7. Inserting an in-and-out catheter on a client postpartum.
  8. Taking vital signs on a client 12 hours postpartum.
  9. Removing an indwelling catheter on a client postpartum.
  10. Perform perineal care on a client with an episiotomy. - Correct Answer 3 - taking vital signs on a client 12 hours postpartum 5 - perform perineal care on a client with an episiotomy Taking vital signs is within the scope of practice for the UAP, but the nurse is responsible for evaluating the vital signs. Performing perineal care is within the scope of practice for the UAP. The nurse is responsible for assessing the episiotomy and confirming that perineal care is done properly. The nurse recognizes that treatment has been successful in resolving fluid volume excess based on which assessment findings?
  11. Continued lethargy
  12. Heart rate 112/min
  13. Decreasing shortness of breath
  14. BP 114/
  15. Increased thirst - Correct Answer 3 - decreased SOB 4 - BP 114/

Urinary output should increase with decreasing shortness of breath as hydration is corrected, and BP should be normal. A nurse is preparing a lecture about suicide. Which target audience would be most appropriate?

  1. High school teachers
  2. Girl Scout leaders
  3. Support group of divorced parents
  4. Hispanic immigrant farm workers - Correct Answer 1 - high school teachers Among those who commit suicide, young men between the ages of 15- are more likely to commit suicide than young girls and women. The best line of defense is to teach about the warning signs of suicide to high school teachers, students, and parents of teens and young adults, particularly male A client is reporting pain rated an 8 out of 10 on the numeric pain scale. The nurse administers an oral pain medication to the client and starts a CD of the client's favorite relaxing music. Fifteen minutes later, the client rates the pain as 2 out of 10 on the numeric pain scale. What type of nonpharmacologic pain relief intervention has the nurse used?
  5. Distraction
  6. Biofeedback
  7. Progressive relaxation
  8. Cutaneous stimulation - Correct Answer 1 - distraction The nurse uses distraction in the form of music while the oral analgesic takes effect. A client has been prescribed vancomycin 1 gram IV every 12 hours for the treatment of methicillin-resistant staphylococcus aureus (MRSA). Which action by a new nurse when administering this medication would require intervention by the charge nurse?
  9. Dilutes medication in NS 100 mL.
  10. Delivers medication via an IV pump.
  11. Calculates infusion rate at 30 minutes.
  12. Monitors IV site every 30 minutes during infusion. - Correct Answer 3 - calculates infusion rate at 30 min

This dose of medication should be delivered over at least 60 minutes to prevent hypotension and ototoxicity. The nurse is performing CPR on an adult client with facial and neck trauma. Following the administration of rescue breaths, where is the best location for the nurse to assess for a pulse in this client?

  1. Apical area
  2. Carotid artery
  3. Femoral artery
  4. Radial artery - Correct Answer 3 - femoral artery Pulses that are best palpated are large and close to the trunk of the body. The femoral artery is large and at the trunk (proximal) of the body. A nurse attaches a client to continuous cardiac monitoring due to a potassium level of 2.8 mEq (2.8 mmol). The nurse should monitor for which dysrhythmia?
  5. Third degree heart block
  6. Atrial fibrillation
  7. Premature atrial contractions
  8. Premature ventricular contractions - Correct Answer 4 - premature ventricular contractions Hypokalemia is reflected by the EKG. The earliest EKG change is often premature ventricular contractions (PVCs) which can deteriorate into ventricular tachycardia or fibrillation (VT/VF) without appropriate potassium replacement. What should the nurse include when providing education to a client receiving tetracycline?
  9. Wear long sleeves when going outside.
  10. Take tetracycline on a full stomach.
  11. Wait at least two hours after taking tetracycline prior to taking iron supplements.
  12. Tetracycline can decrease the effectiveness of birth control pills.
  13. Do not take this medicine after the expiration date on the label has passed. - Correct Answer 1 - wear long sleeves when going outside 3 - wait at least two hours after taking tetracycline prior to taking iron supplements 4 - tetra can decrease the effectiveness of birth control pills

5 - do not take this medication after the expiration date on the label has passed Avoid exposure to sunlight or artificial UV rays (sunlamps or tanning beds). Tetracycline can make your skin more sensitive to sunlight and sunburn may result. Use a sunscreen (minimum SPF 15) and wear protective clothing if you must be out in the sun. Take tetracycline on an empty stomach and do not take iron supplements, multivitamins, calcium supplements, antacids, or laxatives within 2 hours before or after taking tetracycline. These products can make this medicine less effective. Tetracycline can make birth control pills less effective. Use a second method of birth control while you are taking this medicine to keep from getting pregnant. Throw away any unused tetracycline when it expires or when it is no longer needed. Do not take this medicine after the expiration date on the label has passed. Expired tetracycline can cause a dangerous syndrome resulting in damage to the kidneys. What risk factors should the nurse include when conducting a class about type 2 diabetes mellitus?

  1. Fat distribution greater in abdomen than in hips.
  2. Being underweight.
  3. Having type 1 diabetes as a child increases risk for type 2 diabetes.
  4. Caucasians are more likely to develop type 2 diabetes than Hispanics.
  5. Polycystic ovary syndrome. - Correct Answer 1 - fat distribution greater in abdomen than in hips 5 - polycystic ovary syndrome If the body stores fat primarily in the abdomen, risk of type 2 diabetes is greater than if body stores fat elsewhere, such as hips and thighs. Women with polycystic ovary syndrome have increased risk of diabetes. Post cataract removal a client reports nausea and severe pain in the operative eye. Which nursing intervention takes priority?
  6. Administer morphine and ondansetron.
  7. Reposition client to non-operative side.
  8. Massage the canthus to unblock the lacrimal duct.
  9. Notify the primary healthcare provider. - Correct Answer 4 - notify healthcare provider

Severe pain with nausea indicates an increase in intraocular pressure and needs to be reported at once. Eye damage can result if not resolved quickly. The primary healthcare provider may prescribe medications or take the client back to surgery. A client being treated for osteoporosis with alendronate reports experiencing slight heartburn after taking the medicine. What should the nurse suggest to reduce this side effect?

  1. Stop taking the medication and call the primary healthcare provider.
  2. Drink plenty of water with the medication.
  3. Take the medication before bedtime.
  4. Take antacids when taking the medication. - Correct Answer 2- drink plenty of water with the med Increased heartburn can be reduced or prevented by drinking plenty of water, sitting upright following the administration of the medication, and avoiding sucking on the tablet. The nurse determines that a client does not have an advance directive. The daughter is designated to make healthcare decisions in the event that the client becomes incapacitated or unable to make informed decisions. Which nursing actions are appropriate for this client?
  5. Document the client's statement in the client's own words.
  6. Provide information on advance directives to the client.
  7. Inform the client that personnel are available to assist with completing an advance directive.
  8. Avoid inquiring about a client's advance directive as this could cause the client anxiety and concern.
  9. Ask the daughter if she agrees with her mother's decision. - Correct Answer 1 - document the clients statement in the clients own words 2 - provide info on advance directives 3 - inform the client that personnel are available to assist with completing an advance directive The nurse should document the client's statement in the client's own words. The nurse should provide the client with information on advance directives and assurance that there are hospital personnel to assist with completing the advance directive.

A client has been on the mental health unit for three days and is requesting to leave against medical advice (AMA). It has been determined that the client is not suicidal. What should the nurse do?

  1. Inform the primary healthcare provider that the client wishes to leave.
  2. Make arrangements for a commitment hearing, as soon as possible.
  3. Tell the client the primary healthcare provider must discharge the client prior to leaving.
  4. Call the primary healthcare provider and request a discharge order. - Correct Answer 1 - inform the primary healthcare provider Protocols on the unit must be followed when someone is requesting to leave AMA. The first step is to call the primary healthcare provider about the client's desire to leave AMA. Which instructions should the nurse give the unlicensed assistive personnel (UAP) about care needed to reduce the risk of infection when a client has an indwelling catheter?
  5. Check catheter for kinks in the tubing when the client is in the bed or chair.
  6. Instruct the UAP to disconnect the catheter from the bag when measuring output.
  7. Wash hands before providing personal care to the client.
  8. Ensure that catheter remains secured to the thigh.
  9. Make sure that the drainage bag is always below the level of the bladder. - Correct Answer 1 - check catheter for kinks 3 - wash hands before providing care 4 - ensure catheter remains secured to thigh 5 - keep drainage bag below bladder level Tubing that becomes obstructed cannot allow adequate urine flow. The urine flow occurs by gravity. Adequate handwashing before providing care is one defense against infection. Tension on the tubing may cause irritation and subsequent infection. The bag should be below the level of the bladder so that urine flows appropriately. A nurse invites a friend home one evening. On arrival, the friend sees the nurse's large, white, long-haired cat sitting on the couch and begins to experience palpitations, trembling, nausea, shortness of breath, and a feeling of losing control. What should the nurse do first?
  10. Stay with the friend until the friend feels better.
  1. Have the friend breathe into a paper bag.
  2. Remove the cat from the room.
  3. Dim the lights in the room. - Correct Answer 3 - remove the cat from the room Remove the source of the panic attack first, then continue to assess the person for symptoms. Removing the cat "fixes" the problem A hysterical college student arrives in the emergency department in bloody soiled clothing. The nursing assessment reveals facial bruising and multiple contusions consistent with the client's report of being raped. Which initial nursing intervention takes priority at this time?
  4. Notify police of the alleged rape.
  5. Allow the client privacy to wash self.
  6. Remove clothing and bag for evidence.
  7. Encourage client to express fears and anxiety. - Correct Answer 4 - encourage client to express fears and anxiety Although there are specific protocols that must be followed when dealing with rape clients, it is important to remember that this client had all control taken away during the attack. The emotional effects of rape are as traumatizing as the physical injuries. Allowing the client to first express emotions, such as fear or anxiety, returns a small amount of control to a situation in which the client has little or none. The nurse is caring for a client with decreased cardiac output secondary to heart failure with fluid volume overload. Which signs/symptoms are an indication to the nurse that treatment goals have not been met?
  8. Diuresis
  9. Dyspnea on exertion
  10. Persistent cough
  11. Warm, dry skin
  12. Heart rate irregular at 118/min
  13. Alert and oriented - Correct Answer 2 - dyspnea on exertion 3 - persistant cough 5 - heart rate irregular at 118/min When the cardiac output decreases, renal perfusion decreases, which leads to decreased urine output and fluid retention. This leads to difficulty breathing. Tachycardiac and rhythm irregularity are signs of fluid volume

excess (FVE) and decreased output. Persistent cough, wheezing, and pink blood tinged sputum are all signs that the client is still sick. A nurse drops a bottle of IV fluid, which shatters on the floor in the hallway. What action should the nurse take?

  1. Notify housekeeping to clean up the spill.
  2. Pick up glass with a broom and dustpan and dispose into a puncture resistant sharps container.
  3. Pick up the glass with gloved hands and dispose into a puncture resistant sharps container.
  4. Use a wet mop to collect the glass and dispose of it in the garbage can.
  • Correct Answer 2 - pick up glass with broom and dustpan and dispose of in a puncture resistant sharps container The nurse must not be cut by the broken glass. Proper removal of glass includes using a dustpan and broom to collect the glass and disposing of it into a puncture resistant sharps container. A primary healthcare provider prescribed KCL 40 mEq in 100 mL NS to infuse over 30 minutes. What action should the nurse take?
  1. Administer the KCL through the lowest IV line port.
  2. Clarify the prescription with the primary healthcare provider.
  3. Mix KCL 40 mEq into the present infusing bag of NS when it reaches 100 mL.
  4. Set the infusion pump to 100 mL / hour. - Correct Answer 2 - clarify with provider Potassium chloride should be diluted and administered to infuse no faster than 40 mEq per hour. So this prescription would infuse too quickly and may lead to life threatening arrhythmias. Which task would be appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)?
  5. Check client for signs of skin breakdown.
  6. Check client's vital signs after ambulating.
  7. Administer 8 ounces of polyethylene glycol electrolyte solution every 10 minutes.
  8. Obtain a stool specimen.
  9. Determine what activities the client can do independently - Correct Answer 2 - check vital signs

4 - obtain a stool specimen The nurse is caring for a client who has taken an acetaminophen overdose. Which symptom is the client most likely to exhibit?

  1. Expectorating pink frothy sputum
  2. Sudden onset of mid-sternal chest pain
  3. Jaundiced conjunctiva
  4. Diaphoresis and fever - Correct Answer 3 - jaundiced conjunctiva This is a sign of liver damage, which is caused by an overdose of acetaminophen. Which assessment findings would be of concern to the nurse who is caring for a client who has an arterial line to the radial artery?
  5. Capillary refill: Left hand-2 seconds; Right hand- 4 seconds.
  6. Blue tinged color to finger tips of right hand.
  7. Warm skin to right and left hand.
  8. Left radial pulse-88/min; Right radial pulse-82/min
  9. Blanching to right hand. - Correct Answer 1 - cap refill different 2 - blue tinged color 4 - radial pulses different 5 - blanching on right hand These are all signs of poor circulation to the right hand. The arterial line could be occluding circulation and needs to be removed. the nurse is preparing to administer iron dextran IM. Which injection site would be best for administration?
  10. Ventrogluteal site
  11. Vastus lateralis site
  12. Rectus Femoris site
  13. Deltoid site - Correct Answer 1 - ventrogluteal site This site would be used for Z track IM injections. Iron preparations are administered by the Z track technique, preferably in a large, deep muscle such as the ventrogluteal muscle. Which action by a nurse indicates to the charge nurse that the sterile field has been contaminated?
  14. The sterile field is above the level of the waist.
  1. Sterile gauze dressing within the one inch border of sterile field.
  2. Remains facing the sterile field throughout procedure.
  3. Inspects sterile wrapped instruments for tears. - Correct Answer 2 - sterile dressing within the one inch border of the sterile field No sterile object should be within the one inch border of the sterile field as the object is no longer considered sterile. A client is hospitalized because of severe malnutrition related to anorexia nervosa. What is the most important goal for this client?
  4. Verbalize understanding that eating behaviors are maladaptive.
  5. Verbalize the importance of adequate nutrition.
  6. Achieve at least 80% of expected body weight.
  7. Acknowledge misperception of body image as fat. - Correct Answer 3 - achieve at least 80% of expected body weight Until appropriate weight is gained, the client continues to be at risk for major health complications including hypotension, cardiac arrhythmias, poor muscle tone, increased risk for infection, abnormal liver function, and damaged kidneys. A school nurse educates a group of teachers how to extinguish a fire involving a child whose clothes are on fire. Which statement by the teachers would indicate to the school nurse that the teachers understand what should be done first?
  8. "Someone should be assigned to call 911."
  9. "Lay child flat and roll in a blanket."
  10. "A blanket should be thrown over the child's head and body."
  11. "Use a fire extinguisher to put out the flames." - Correct Answer 2 - lay child flat and roll in a blanket The flames should be extinguished first. The best way to accomplish this it to lay the child flat and roll in a blanket. This is referred to as the drop and roll method, when a blanket is available. Which signs and symptoms, if noted by the nurse, would indicate that the client with hyperthyroidism is experiencing thyroid crisis?
  12. Hyperkinesis
  13. Bradycardia
  14. Hypertension
  1. Restlessness
  2. Confusion - Correct Answer 1 - hyperkinesis 3 - hypertension 4 - restlessness 5 - confusion What should the nurse document after a client has died?
  3. Time of death
  4. Who pronounced the death
  5. Disposition of personal articles
  6. Destination of body
  7. Primary healthcare provider's prescriptions
  8. Time body left facility - Correct Answer 1 - time of death 2 - who pronounced death 3 - disposition of personal articles 4 - destination of body 6 - time body left facility All of these should be documented. Also document consideration of and preparation for organ donation; family notified and decisions made; location of identification tags. A client with heart failure and pulmonary edema is given furosemide intravenously. Which assessment indicates that the furosemide has achieved the desired effect?
  9. Weight has decreased 2 pounds.
  10. Systolic blood pressure has decreased.
  11. Urinary output has increased.
  12. Lungs have fewer rales on auscultation. - Correct Answer 4 - lungs have fewer rales on auscultation The goal for diuretic therapy in this client is to prevent/relieve fluid accumulation in the lungs. This answer addresses the most life-threatening sequelae with HF. The number one thing to worry about in clients with HF is pulmonary edema, because this is what can kill the client. Which nursing action is likely to improve client satisfaction and demonstrate acts of beneficence?
  13. Allowing clients to make their own decisions about care
  14. Answering all questions posed by client in an honest manner
  1. Reporting faulty equipment to the proper departments
  2. Sitting at the bedside and listening to an elderly client - Correct Answer 4 - sitting at the bedside and listening to an elderly client Sitting and listening demonstrates kindness and compassion that are consistent with the ethical term "beneficence." Beneficence is taking positive action to help others and a desire to do good which is the core principle of client advocacy. The nurse is caring for a client diagnosed with type 2 diabetes who was brought to the emergency department in an unresponsive state. A diagnosis of hyperglycemic hyperosmolar nonketotic syndrome (HHNS) is made. The nurse prepares for the administration of which initial therapy?
  3. Oxygen by nasal cannula
  4. Long-acting IV insulin
  5. Normal saline
  6. IV dextran - Correct Answer 3 - normal saline Clients in HHNS diurese due to a high glucose load in the vascular space. The client becomes severely volume depleted and is at risk for developing shock. Therapy is focused on combating shock. A nurse who has never had varicella has been exposed to a client diagnosed with herpes zoster. What actions should the nurse take?
  7. Notify the infection control nurse.
  8. Continue to care for client as varicella and herpes zoster are not related.
  9. Go to the lab to have a Tzanck smear performed.
  10. Obtain herpes zoster vaccine for protection from this exposure.
  11. Receive the varicella-zoster immune globulin within 96 hours of exposure. - Correct Answer 1 - notify infection control nurse 5 - receive the varicella zoster immune globulin within 96 hours Notify the person responsible for infection control to get post-exposure treatment initiated within a timely manner. For persons who are susceptible, the varicella-zoster immune globulin should be given within 96 hours of exposure. The infection of herpes zoster is contagious until the crusts have dried and fallen off the skin. the nurse is caring for a client who has been diagnosed with dissociative identity disorder. What is the most appropriate short term goal?
  1. Recovery of memory deficits.
  2. Demonstration of the ability to perceive stimuli correctly.
  3. Elimination of causative phobia.
  4. Verbal recognition of the existence of multiple personalities. - Correct Answer 4 - verbal recognition of the existence of multiple personalities The client has just returned from electroconvulsive therapy (ECT) and is very drowsy. What is the position of choice for the nurse to place the client in until full consciousness is regained?
  5. Supine
  6. Fowler's
  7. Lateral
  8. High Fowler's - Correct Answer 3 - lateral When someone is very sedated and not fully conscious, we want them on their side so the airway remains open and the secretions can drain. What symptoms would the nurse anticipate in a client being admitted to the hospital with a calcium level of 3.2 mg/dL (0.80 mmol/L)?
  9. Slowed deep tendon reflexes.
  10. Muscle rigidity and cramping.
  11. Hypoactive bowel sounds.
  12. Positive Chvostek's sign.
  13. Seizures
  14. Laryngospasms - Correct Answer 2 - muscle rigidity/cramping 4 - pos chvosteks sign 5 - seizures 6 - laryngospasms Normal serum calcium is 8.7 - 10.3 mg/dL (2.18 - 2.58 mmol/L). The client with a calcium level of 3.2 mg/dL (0.80 mmol/L) is hypocalcemic. With hypocalcemia, the muscle tone is rigid and tight. Therefore, the client may report muscle cramping. A hallmark sign of hypocalcemia is a positive Chvostek's sign, which is a twitching of facial muscles following tapping in the area of the cheekbone, indicative of hyperirritability. The client may be at risk of having seizures due to the neuromuscular irritability. Prolonged contraction of the respiratory and laryngeal muscles causes laryngospasm and stridor and may result in cyanosis.

The client in the manic phase of bipolar disorder begins climbing onto a table in the dayroom and shouts, "I can fly! I can fly! Watch me fly!" What should be the initial intervention by the nurse?

  1. Leave the client alone and remove clients from the dayroom.
  2. Call for personnel to escort the client out of the day room.
  3. Restrain the client, and notify the primary healthcare provider.
  4. Tell the client that there is no way that a person can fly. - Correct Answer 2 - call for personnel to escort the client out of the room The first priority is the safety of the client. If the client jumps off the table, this action may cause an injury to the client. The nurse may need extra help in case the client becomes violent. The nurse is teaching a diabetic client who has been prescribed Lispro insulin about avoiding hypoglycemia. What administration teaching is priority?
  5. Take insulin 30 minutes before bedtime
  6. Take insulin twice daily in AM and PM
  7. Take insulin one hour before meals
  8. Take insulin with meals - Correct Answer 4 - take insulin with meals Lispro is a rapid-acting insulin that should only be taken with food or within 15 minutes of a meal. Which task should the nurse perform first?
  9. Suctioning the tracheostomy.
  10. Changing a colostomy bag that is leaking.
  11. Performing an admission assessment on a client.
  12. Administering pain medication to a postoperative client. - Correct Answer 1 - suction the trach The tracheostomy tube must be suctioned to keep the client's airway open. Suctioning the tracheostomy should take priority. Remember, airway first. The charge nurse was notified that a client with 2nd degree burns is being admitted to the floor. Which nurse should be assigned this client?
  13. A nurse caring for clients with spina bifida and acute gastroenteritis.
  14. The new nurse, out of orientation for 2 months, caring for clients diagnosed with tonsillitis and anorexia nervosa.