2023-2024 NCLEX Study Guide: Comprehensive Nursing Exam Prep, Exams of Nursing

Download 2023-2024 NCLEX Study Guide: Comprehensive Nursing Exam Prep and more Exams Nursing in PDF only on Docsity! NCLEX Review Study Guide Comprehensive 2023-2024| GRADED A+ NCLEX 2023 EXAM REVIEW STUDY GUIDE COMPREHENSIVE QUESTIONS AND ANSWERS NCLEX Review Study Guide Comprehensive 2023 A client with diabetes mellitus calls the clinic nurse and reports that she has been vomiting during the night and now has diarrhea. Which question does the nurse make a priority of asking the client? - ANSWER "Have you tested your blood glucose?" A client's oral intake of liquids includes 120 mL on the night shift, 800 mL on the day shift, and 650 mL on the evening shift. The client is receiving an intravenous (IV) antibiotic every 12 hours, diluted in 50 mL of normal saline solution. The nurse empties 700 mL of urine from the client's Foley catheter at the end of the day shift. Thereafter, 500 mL of urine is emptied at the end of the evening shift and 325 mL at the end of the night shift. Nasogastric tube drainage totals 155 mL for the 24-hour period, and the total drainage from the Jackson-Pratt device is 175 mL. What is the client's total intake during the 24-hour period? - ANSWER 1670mL A client with heart failure suddenly experiences profound dyspnea, pallor, audible wheezing, and cyanosis, and the nurse suspects pulmonary edema. The nurse would first: - ANSWER Raise the head of the client's bed A client with cervical cancer who is undergoing chemotherapy with cisplatin (Platinol). For which adverse effect of cisplatin will the nurse assess the client? - ANSWER Hearing loss Alendronate (Fosamax) is prescribed for a client with postmenopausal osteoporosis. The nurse provides information on the medication to the client. When does the nurse tell the client to take the alendronate? - ANSWER Every morning before breakfast, with a full glass of water A client with emphysema is receiving theophylline (Theo-24). NCLEX Review Study Guide Comprehensive 2023-2024| GRADED A+ While providing dietary instructions, the nurse tells the client that it is acceptable to consume: - ANSWER Apple juice A nurse is reviewing the record of a client scheduled for electroconvulsive therapy (ECT). Which of the following diagnoses, if noted on the client's record, would indicate a need to contact the physician who is scheduled to perform the ECT? - ANSWER Recent stroke An emergency department nurse is assessing a client with acute closed-angle glaucoma. Which of the following characteristics of the disorder does the nurse NCLEX 2023 EXAM REVIEW STUDY GUIDE COMPREHENSIVE QUESTIONS AND ANSWERS to a client who is wearing a blue shirt, "Boys in blue are fun to do! Boys in blue are fun to do!" What is the appropriate response by the nurse? - ANSWER "Don't say that. If you can't control yourself, we'll help you." A client with HIV infection who has been found to have histoplasmosis is being treated with intravenous amphotericin B (Fungizone). Which parameter does the nurse check to detect the most common adverse effect of this medication? - ANSWER Intake and output A nurse is gathering subjective and objective data from a client with suspected rheumatoid arthritis (RA). Which early manifestations of RA would the nurse expect to note? Select all that apply. - ANSWER Fatigue Low-grade fever Phenelzine sulfate (Nardil) is prescribed for a client with depression. The nurse provides information to the client about the adverse effects of the medication and tells the client to contact the physician immediately if she experiences: - ANSWER Neck stiffness or soreness A client is receiving an intravenous infusion of oxytocin (Pitocin) to stimulate labor. The nurse monitoring the client notes uterine hypertonicity and immediately: - ANSWER Stops the oxytocin infusion A nurse is assessing a pregnant woman for the presence of edema. The nurse places a thumb on the top of the client's foot, then exerts pressure and releases it and notes that the thumb has left a persistent depression. On the basis of this finding, the nurse concludes that: - ANSWER Pitting edema is present A nurse is caring for a client with community-acquired pneumonia who is being treated with levofloxacin (Levaquin). For which of the following findings, indicating an adverse reaction to the medication, does the nurse monitor the client? - ANSWER Fever A client receiving parenteral nutrition (PN) suddenly experiences chest pain and dyspnea, and the nurse suspects an air embolism. The nurse immediately places the client in a lateral Trendelenburg NCLEX 2023 EXAM REVIEW STUDY GUIDE COMPREHENSIVE QUESTIONS AND ANSWERS position, on the left side. What action does the nurse take next? - ANSWER Clamping the intravenous catheter A nurse is preparing a poster for a health fair booth promoting primary prevention of skin cancer. Which of the following recommendations does the nurse include on the poster? Select all that apply. - ANSWER Seek medical advice if you find a skin lesion. NCLEX 2023 EXAM REVIEW STUDY GUIDE COMPREHENSIVE QUESTIONS AND ANSWERS A nurse is providing instructions to a client with glaucoma who will be using acetazolamide (Diamox) daily. Which of the following findings, an adverse effect, does the nurse instruct the client to report to the physician? - ANSWER Dark urine A nurse is providing morning care to a client who has undergone surgery to repair a fractured left hip. Which item is most important for the nurse to use in turning the client from side to side to change the bed linens? - ANSWER Abduction device A nurse is performing an assessment of a client being admitted to the hospital with a diagnosis of multiple sclerosis. The client tells the nurse that she took baclofen (Lioresal) for the past 9 months but completely stopped the medication 2 days ago because it was making her feel weak. On the basis of this information, the nurse notes in the plan of care that the client should be monitored most closely for: - ANSWER Seizure activity A nurse administers nitroglycerin sublingually to a client with angina pectoris who complains of chest pain. The medication is ineffective, so the nurse prepares to administer a second dose. Before administering the nitroglycerin, which action does the nurse make a priority? - ANSWER Checking the client's blood pressure A nurse provides information to a client with coronary artery disease (CAD) about smoking-cessation measures. Which statement by the client indicates a need for further information? - ANSWER "I should drink a cup of coffee if I feel the urge to smoke." A client with myasthenia gravis who has been taking pyridostigmine bromide (Mestinon) for the treatment of the disorder comes to the emergency department complaining of severe muscle weakness, and cholinergic crisis is diagnosed. Which medication does the nurse prepare for immediate use in treating the crisis? - ANSWERAtropine sulfate A rape victim being treated in the emergency department says to the nurse, "I'm really worried that I've got HIV now." What is the appropriate response by the nurse? - ANSWER "Let's talk about the NCLEX 2023 EXAM REVIEW STUDY GUIDE COMPREHENSIVE QUESTIONS AND ANSWERS biliary ducts Cascara sagrada has been prescribed for a client with diminished colonic motor response as a means of promoting defecation. The nurse provides information to NCLEX 2023 EXAM REVIEW STUDY GUIDE COMPREHENSIVE QUESTIONS AND ANSWERS the client about the medication and tells the client to: - ANSWER Increase fluid intake A nurse provides instruction to a pregnant woman about foods containing folic acid. Which of these foods does the nurse tell the client to consume as sources of folic acid? Select all that apply. - ANSWER Spinach Legumes Whole grains A client with a history of angina pectoris tells the nurse that the chest pain usually occurs with moderate to prolonged exertion and is generally relieved by nitroglycerin or rest. Which type of angina does the nurse recognize in the client's description? - ANSWER Stable A client with myasthenia gravis is taking neostigmine bromide (Prostigmin). The nurse determines that the client is gaining a therapeutic effect from the medication after noting: - ANSWER Improved swallowing function A child is brought to the emergency department by ambulance after swallowing several capsules of acetaminophen (Tylenol). Which medication does the nurse prepare, anticipating that it will be prescribed to treat the child? - ANSWER Acetylcysteine (Mucomyst) A nurse is caring for a client with sarcoidosis. The client is upset because he has missed work and worried about how he will care financially for his wife and three small children. On the basis of the client's concern, which problem does the nurse identify? - ANSWER Anxiety NCLEX 2023 EXAM REVIEW STUDY GUIDE COMPREHENSIVE QUESTIONS AND ANSWERS A male client arrives at the emergency department and reports to the nurse, "I woke up this morning and couldn't move my arms." He also tells the nurse that he works in a factory and witnessed an accident 3 weeks ago in which a fellow NCLEX 2023 EXAM REVIEW STUDY GUIDE COMPREHENSIVE QUESTIONS AND ANSWERS concerns. List them in order of priority, from highest to lowest. - ANSWER 1 Possible infection 2Decreased nutrition 3Fatigue 4Despair An emergency department nurse has a physician's prescription to irrigate a client's ears. List in order of priority the steps that the nurse should take in performing this procedure. - ANSWER 1 Use an otoscope to ensure that the tympanic membrane is intact. 2Warm tap water to body temperature. 3Fill an irrigating syringe with warm water. 4Insert the irrigating solution by directing the solution toward the wall of the ear canal. 5Document the completion of the procedure and how the client tolerated it. The nurse is preparing to administer a tube feeding by way of a nasogastric tube. Which action does the nurse carry out as a priority before starting the flow of the solution? - ANSWER Checking for gastric residual volume and assessing tube placement A client with schizophrenia says to the nurse, "I decided not to take my medication because it can't help. I am the only one who can help me." Which nursing response is therapeutic in this situation? - ANSWER "Your doctor wants you to continue this medication because it's helping you. Do you recall needing to be hospitalized because you stopped your medication?" NCLEX 2023 EXAM REVIEW STUDY GUIDE COMPREHENSIVE QUESTIONS AND ANSWERS A client is brought to the emergency department by ambulance, and diabetic ketoacidosis is suspected. Blood samples are taken, and the nurse obtains supplies that will be needed to treat the client. Which type of insulin does the nurse take NCLEX 2023 EXAM REVIEW STUDY GUIDE COMPREHENSIVE QUESTIONS AND ANSWERS from the medication supply room for intravenous (IV) administration? - ANSWER Regular (Humulin R) A nurse is assessing a client who is experiencing chest pain. Which of the following observations indicates to the nurse that the pain is most likely a result of angina? - ANSWER The pain is relieved by rest and nitroglycerin. While being seen by a physician, a client complains of persistent fever, malaise, and night sweats. On physical examination, the physician palpates enlarged lymph nodes, and the client states that the nodes are painless. Hodgkin's lymphoma is suspected, and several diagnostic studies are performed. Which characteristic of this type of lymphoma does the nurse expect to note while reviewing the results of the diagnostic studies? - ANSWER Reed-Sternberg cells on biopsy of a lymph node A client with chronic renal failure who will require dialysis three times a week for the rest of his life says to the nurse, "Why should I even bother to watch what I eat and drink? It doesn't really matter what I do if I'm never going to get better!" On the basis of the client's statement, the nurse determines that the client is experiencing which problem? - ANSWER Powerlessness Tolbutamide (Orinase) is prescribed to a client whose type 2 diabetes mellitus has not been controlled with diet and exercise alone. The nurse provides instructions to the client about the medication. Which statement by the client indicates a need for further instruction? - ANSWER"I can have a beer or glass of wine as long as I stay within my daily dietary restrictions." A client with adenocarcinoma of the ovary is scheduled to undergo chemotherapy with cyclophosphamide after total abdominal hysterectomy with bilateral salpingo-oophorectomy. What does the nurse instruct the client to do during chemotherapy? Select all that NCLEX 2023 EXAM REVIEW STUDY GUIDE COMPREHENSIVE QUESTIONS AND ANSWERS A maternity nurse providing an education session to a group of expectant mothers describes the purpose of the placenta. Which statement by one of the women attending the session indicates a need for further discussion of the purpose of the placenta? - ANSWER "The placenta maintains the body temperature of my baby." A nurse is measuring intraocular pressure by means of tonometry in a client who has just been found to have open-angle glaucoma. Which tonometry reading would the nurse expect to note in this client? - ANSWER 28 mm Hg Iodine solution (Lugol solution) is prescribed to a client who is scheduled for subtotal thyroidectomy. The client calls the nurse at the clinic and complains of a burning sensation in the mouth and soreness of the gums and teeth. The nurse most appropriately tells the client: - ANSWER To contact the physician A client with chronic back pain asks a nurse about the use of complementary and alternative therapies to treat the pain. The nurse would initially: - ANSWER Identify the client's treatment goals A child with growth hormone deficiency will be receiving somatropin (Humatrope). The nurse provides information to the mother about the medication. Which of the following laboratory values does the nurse tell the mother will require monitoring? - ANSWER Thyroid- stimulating hormone (TSH) A client who has sustained an acute myocardial infarction (AMI) is receiving intravenous reteplase (Retavase). For which adverse effect of the medication does the nurse monitor the client? - ANSWER Epistaxis NCLEX 2023 EXAM REVIEW STUDY GUIDE COMPREHENSIVE QUESTIONS AND ANSWERS A client arrives at the clinic for her first prenatal assessment. The client tells the nurse that the first day of her last menstrual period (LMP) was September 25, 2012. Using Nagele's rule, the nurse determines that the estimated date of delivery (EDD) is: - ANSWER July 2, 2013 NCLEX 2023 EXAM REVIEW STUDY GUIDE COMPREHENSIVE QUESTIONS AND ANSWERS A nurse provides instructions to a client who has been prescribed lithium carbonate (Lithobid) for the treatment of bipolar disorder. Which of these statements by the client indicate a need for further instruction? Select all that apply. - ANSWER "I need to avoid salt in my diet." "It's fine to take any over-the-counter medication with the lithium." "Diarrhea and muscle weakness are to be expected, and if these occur I don't need to be concerned." An adult client with an ileostomy is admitted to the hospital with a diagnosis of isotonic dehydration. What findings does the nurse expect to note during the admission assessment? Select all that apply. - ANSWER Skin tenting Flat neck veins Weak peripheral pulses Warfarin sodium (Coumadin) is prescribed for a hospitalized client. While transcribing the physician's prescription, the nurse notes that the client is taking levothyroxine (Synthroid) to treat hypothyroidism. The nurse calls the physician to confirm the prescription for warfarin sodium because: - ANSWER Levothyroxine amplifies the effect of warfarin sodium A nurse caring for a client with preeclampsia prepares for the administration of an intravenous infusion of magnesium sulfate. Which of the following substances does the nurse ensure is available at the client's bedside? - ANSWER Calcium gluconate A client with hypoparathyroidism is taking calcium gluconate to treat hypocalcemia. The client calls the clinic nurse and complains of becoming constipated since starting the medication. The nurse tells the client to: - ANSWER Increase intake of high-fiber foods NCLEX 2023 EXAM REVIEW STUDY GUIDE COMPREHENSIVE QUESTIONS AND ANSWERS A nurse is preparing the room of a client in skeletal traction who will be admitted to the nursing unit. Which item for use by the client does the nurse identify as the most important? - ANSWER Trapeze bar A client has been scheduled for an electronystagmography (ENG), and the nurse provides instructions to the client about the test. Which statement by the client tells the nurse that the client understands the instructions? - ANSWER "I need to not drink coffee before the test." A client calls the emergency department and tells the nurse that he may have come in contact with poison ivy while trimming bushes in his yard. The nurse tells the client to immediately: - ANSWER Get into the shower and rinse the skin for at least 15 minutes A nurse checking the fundus of a postpartum woman notes that it is above the expected level, at the umbilicus, and that it has shifted from the midline position to the right. The nurse's initial action should be: - ANSWER Helping the woman empty her bladder A client is receiving an intravenous infusion of alteplase (tissue plasminogen activator, recombinant; tPA). For which adverse effect of the medication does the nurse monitor the client most closely? - ANSWER Bleeding A nurse is monitoring a client who has undergone subtotal thyroidectomy for signs of postoperative complications. Which of the following findings would be a matter of concern for the nurse as an indication of hypocalcemia? - ANSWER The client complains of a tingling sensation around the mouth. NCLEX 2023 EXAM REVIEW STUDY GUIDE COMPREHENSIVE QUESTIONS AND ANSWERS A nurse has provided information about exercise to a client with a diagnosis of degenerative joint disease (osteoarthritis). Which of the following types of exercise does the nurse tell the client to avoid? - ANSWER High-impact exercise NCLEX 2023 EXAM REVIEW STUDY GUIDE COMPREHENSIVE QUESTIONS AND ANSWERS A nurse is performing an assessment of a client with Ménière disease. Which question does the nurse ask to elicit data about the manifestations of this disease? - ANSWER"Do you have episodes of dizziness?" A client who has undergone knee-replacement surgery will be self- administering enoxaparin sodium (Lovenox) at home. The nurse teaches the client about the medication and tells the client to: - ANSWER Lie down to administer the subcutaneous injection A nurse assessing the wound of a client with a stage 3 pressure ulcer and notes that the wound bed is pale. The nurse interprets this finding as a possible indication that: - ANSWER The client's hemoglobin level is low A nurse, performing an assessment of a client who has been admitted to the hospital with suspected silicosis, is gathering both subjective and objective data. Which question by the nurse would elicit data specific to the cause of this disorder? - ANSWER "Have you ever worked in a mine?" A nurse is preparing to care for a preschool-age child with sickle cell anemia who is experiencing vasoocclusive pain. Which method of assessing the degree of pain the child is experiencing is most appropriate? - ANSWER Asking the child to point to the face, on a spectrum ranging from smiling to very sad, that best describes the pain A home care nurse prefills syringes containing NPH (Humulin N) and regular (Humulin R) insulin for a client with diabetes mellitus who will be administering his own insulin but has difficulty seeing and accurately preparing doses. The nurse places the medication in the client's refrigerator with the syringes: - ANSWER In NCLEX 2023 EXAM REVIEW STUDY GUIDE COMPREHENSIVE QUESTIONS AND ANSWERS A nurse taking the vital signs of a client immediately after she has delivered a newborn notes that the client's heart rate is 110 beats/min. The nurse would first: - ANSWER Check the uterus and amount of lochia discharge NCLEX 2023 EXAM REVIEW STUDY GUIDE COMPREHENSIVE QUESTIONS AND ANSWERS A nurse is caring for a client who sustained a missed abortion during the second trimester of pregnancy. For which finding indicating the need for further evaluation does the nurse monitor the client? - ANSWER Spontaneous bruising A nurse is performing an assessment of a client with suspected pheochromocytoma. Which clinical manifestation does the nurse expect to note? - ANSWER A blood pressure higher than the normal range A client with acute gouty arthritis is being started on medication therapy with indomethacin (Indocin). The nurse, providing medication instructions, and tells the client to take the medication: - ANSWER With food A nurse is assessing a client who has been taking amantadine hydrochloride (Symmetrel) for the treatment of Parkinson's disease. Which finding from the history and physical examination would cause the nurse to determine that the client may be experiencing an adverse effect of the medication? - ANSWER Bilateral lung wheezes A community health nurse is preparing a poster for a health fair that will include information about the ways to prevent ear infection or ear trauma. Which prevention measures does the nurse include on the poster? Select all that apply. - ANSWER Keep the volume of headphones at the lowest setting. Avoid environmental conditions involving rapid changes in air pressure. Clean the external ear and canal daily in the shower or while washing the hair. The blood serum level of imipramine is determined in a client NCLEX 2023 EXAM REVIEW STUDY GUIDE COMPREHENSIVE QUESTIONS AND ANSWERS who is being treated for depression with Tofranil-PM. The laboratory test indicates a concentration of 250 ng/mL. On the basis of this result, the nurse should: - ANSWER Document the laboratory result in the client's record NCLEX 2023 EXAM REVIEW STUDY GUIDE COMPREHENSIVE QUESTIONS AND ANSWERS A client is brought to the emergency department after sustaining smoke inhalation. Humidified oxygen is administered to the client by way of face mask, and arterial blood gases (ABGs) are measured. ABG analysis indicates arterial oxygenation (Pao2) of less than 60 mm Hg. On the basis of the ABG result, the nurse prepares to: - ANSWER Assist in intubating the client and beginning mechanical ventilation Fluticasone propionate (Advair) and albuterol (Ventolin HFA), administered by inhalation twice daily, are prescribed for a client with asthma. The nurse, providing information to the client about administration of the medication, tells the client to use the: - ANSWER Albuterol several minutes before inhaling the fluticasone propionate A nurse, conducting an assessment of a client being seen in the clinic for symptoms of a sinus infection, asks the client about medications that he is taking. The client tells the nurse that he is taking nefazodone hydrochloride (Serzone). On the basis of this information, the nurse determines that the client most likely has a history of: - ANSWER Depression A female client admitted to the mental health unit tells the nurse that she cannot leave the house without checking to be sure that she has shut off the coffee maker and unplugged her curling iron. The client states that she even leaves the house, gets into her car, and then has to go back into the house to check these appliances again and that these behaviors are interfering with her work and social commitments. With which of the following anxiety disorders does the nurse associate this client's symptoms? - ANSWER Obsessive-compulsive disorder A client who is taking lithium carbonate (Lithobid) complains of mild nausea, voiding in large volumes, and thirst. On assessment, the nurse notes that the client is complaining of mild thirst. On the basis of these findings, the nurse should: - NCLEX 2023 EXAM REVIEW STUDY GUIDE COMPREHENSIVE QUESTIONS AND ANSWERS ANSWER Document the findings A nurse is teaching a client with angina pectoris who is being discharged from the NCLEX 2023 EXAM REVIEW STUDY GUIDE COMPREHENSIVE QUESTIONS AND ANSWERS hospital about managing chest pain at home. Which statement by the client indicates a need for further teaching? - ANSWER "If I get chest pain, I should put 3 nitroglycerin tablets under my tongue and then go to the emergency department if that doesn't work." Although previously well controlled with glyburide (Diabeta), a client's fasting blood glucose has been running 180 to 200 mg/dL. On reviewing the client's record, which medication, recently added to the client's regimen, does the nurse recognize as a possible contributor to the hyperglycemia? - ANSWER Lithium carbonate (Lithobid) Colchicine has been prescribed for a client with a diagnosis of gout, and the nurse provides information to the client about the medication. Which statement by the client indicates to the nurse that the client understands the information? - ANSWER "I need to stop the medication and call my doctor if I have severe diarrhea." A postoperative client with deep-vein thrombosis is at risk for pulmonary embolism. For which characteristic sign or symptom of this complication does the nurse monitor the client? - ANSWER Pleuritic chest pain A nurse provides dietary instructions to a client with osteoporosis who has sustained a fracture about foods that will promote healing. The nurse tells the client that it is best to consume foods that are high in: - ANSWER Vitamin C Methylergonovine (Methergine) is prescribed for a client to control postpartum bleeding. Which action does the nurse take before administering the medication? - ANSWERChecking the client's blood pressure NCLEX 2023 EXAM REVIEW STUDY GUIDE COMPREHENSIVE QUESTIONS AND ANSWERS A nurse develops a list of home care instructions for a client who is wearing a halo fixation device after sustaining a cervical fracture. Which instructions should the NCLEX 2023 EXAM REVIEW STUDY GUIDE COMPREHENSIVE QUESTIONS AND ANSWERS nurse include? Select all that apply. - ANSWERUse a straw to drink. Use caution when leaning forward or backward. Do not drive, because full range of vision is impaired with the device. A nurse in a physician's office is conducting a 2-week postpartum assessment of a client. During abdominal assessment, the nurse is unable to palpate the uterine fundus. This finding would prompt the nurse to: - ANSWER Document the findings Risperidone (Risperdal) is prescribed for a client hospitalized in the mental health unit for the treatment of a psychotic disorder. Which finding in the client's medical record would prompt the nurse to contact the prescribing physician before administering the medication? - ANSWER The client takes a prescribed antihypertensive. A nurse is monitoring a pregnant woman in labor and notes this finding on the fetal-monitor tracing (see figure). Which of the following actions should the nurse take as a result of this observation? - ANSWER Documenting the finding Ferrous sulfate (Feosol) is prescribed for a client. The nurse tells the client that it is best to take the medication with: - ANSWER Tomato juice A nurse is caring for a client undergoing skeletal traction of the left leg. The client complains of severe pain in the leg. The nurse checks the client's alignment in bed and notes that proper alignment is being maintained. Which of the following actions should the nurse take next? - ANSWER Notifying the physician NCLEX 2023 EXAM REVIEW STUDY GUIDE COMPREHENSIVE QUESTIONS AND ANSWERS A nurse is preparing to insert a nasogastric tube into a client. In which position does the nurse place the client before inserting the tube? - ANSWER Fowler's position NCLEX 2023 EXAM REVIEW STUDY GUIDE COMPREHENSIVE QUESTIONS AND ANSWERS that the condition has not yet resolved? Type the option number that is the correct answer. - ANSWER 1 Captopril (Capoten) is prescribed for a hospitalized client with heart failure. Which action is a priority once the nurse has administered the first dose? - ANSWER Maintaining the client on bed rest for 3 hours A nurse is planning to teach a crutch gait to a client who will be using wooden axillary crutches. The nurse reviews the physician's instructions, understanding that the gait was selected after assessment of the client's: - ANSWER Physical and functional abilities A home care nurse visits a mother who delivered a healthy newborn 4 days ago and assesses how the mother is doing breastfeeding her infant. What does the nurse ask the mother to do to permit assessment of whether the infant is receiving an adequate amount of milk? - ANSWER Count wet diapers to be sure that the infant is having at least six to 10 each day A female client with rheumatoid arthritis is taking 3.6 g of acetylsalicylic acid (aspirin) daily in a divided dose. At the physician's office, the client tells the nurse that she has been experiencing ringing in the ears over the past few days. The nurse tells the client that: - ANSWER The physician will probably withhold the aspirin until the symptoms have subsided, then resume the aspirin at a lower dosage The physician will probably withhold the aspirin until the symptoms have subsided, then resume the aspirin at a lower dosage - ANSWER Notifies the emergency department physician NCLEX 2023 EXAM REVIEW STUDY GUIDE COMPREHENSIVE QUESTIONS AND ANSWERS A nurse reviews the medical record of a client with histoplasmosis. Which clinical manifestation of this infection does the nurse expect to see documented? - ANSWERFlulike pulmonary symptoms NCLEX 2023 EXAM REVIEW STUDY GUIDE COMPREHENSIVE QUESTIONS AND ANSWERS A client who is scheduled to undergo chemotherapy asks the nurse, "Is my hair going to fall out?" The nurse responds by telling the client that: - ANSWER Her hair may fall out but will regrow after the chemotherapy is discontinued A client who was involved in a high-speed motor vehicle crash is brought to the emergency department. Which of the following findings indicates to the nurse that the client has sustained flail chest? - ANSWER Asymmetrical chest movement A client is taking gentamicin sulfate (Genoptic) for the treatment of pelvic inflammatory disease. What does the nurse ask the client during assessment for adverse effects of the medication? - ANSWER "Are you having any difficulty hearing?" A client with advanced chronic renal failure (CRF) and oliguria has been taught about sodium and potassium restriction between dialysis treatments. The nurse determines that the client understands this restriction if the client states that it is acceptable to use: - ANSWER Herbs and spices A postpartum nurse provides information to a client who has delivered a healthy newborn about normal and abnormal characteristics of lochia. Which of the following findings does the nurse tells the client to report to the physician? - ANSWER Reddish lochia on postpartum day 8 The nurse is performing a sterile change of an abdominal dressing. Once the dressing has been removed and discarded in a waterproof bag, which action should the nurse take next? - NCLEX 2023 EXAM REVIEW STUDY GUIDE COMPREHENSIVE QUESTIONS AND ANSWERS A nurse provides instructions to a client who will be taking levothyroxine (Synthroid) for hypothyroidism. The nurse tells the client that it is best to take the medication: - ANSWER In the morning, before breakfast NCLEX 2023 EXAM REVIEW STUDY GUIDE COMPREHENSIVE QUESTIONS AND ANSWERS Cyclobenzaprine (Flexeril) is prescribed to a client with multiple sclerosis for the treatment of muscle spasms. For which common side effect of this medication does the nurse monitor the client? - ANSWER Drowsiness A nurse admitting a newborn to the nursery notes that the physician has documented that the newborn has a gastroschisis. The nurse performs an assessment, expecting to note that the viscera are: - ANSWER Outside the abdominal cavity, not covered with a sac The mother of an adolescent with type 1 diabetes mellitus tells the nurse that her child is a member of the school soccer team and expresses concern about her child's participation in sports. The nurse, after providing information to the mother about diet, exercise, insulin, and blood glucose control, tells the mother: - ANSWER That the child should eat a carbohydrate snack about a half-hour before each soccer game A child with a diagnosis of Wilms' tumor is being admitted to the pediatric unit. The nurse prepares the room for the child and places a sign at the child's bedside that tells staff to avoid: - ANSWER Palpating the abdomen A nurse is performing an assessment of a newborn with a diagnosis of esophageal atresia (EA) and tracheoesophageal fistula (TEF). Which findings does the nurse expect to note in the infant? Select all that apply. - ANSWER Drooling Excessive oral secretions A nurse provides information to a client with peripheral vascular disease about ways to limit the disease's progression. Which of the following measures does the nurse tell the client to take? Select all that apply. - ANSWER -Engaging in NCLEX 2023 EXAM REVIEW STUDY GUIDE COMPREHENSIVE QUESTIONS AND ANSWERS exercise such as walking on a daily basis -Washing the feet daily with a mild soap and drying them well NCLEX 2023 EXAM REVIEW STUDY GUIDE COMPREHENSIVE QUESTIONS AND ANSWERS A nurse is preparing a pregnant client in the third trimester for an amniocentesis. The nurse explains to the client that amniocentesis is often performed during the third trimester to determine: - ANSWER The degree of fetal lung maturity Empyema develops in a client with an infected pleural effusion, and the nurse prepares the client for thoracentesis. What characteristics of the fluid removed during thoracentesis should the nurse, assisting the physician with the procedure, expect to note? - ANSWER Thick and opaque A client with depression is anorexic. Which measure does the nurse take to assist the client in meeting nutritional needs? - ANSWER Offering high-calorie and high-protein foods and fluids frequently throughout the day Oral prednisone 10 mg/day is prescribed for a client with an acute exacerbation of rheumatoid arthritis. The nurse, providing information to the client about the medication, tells the client that it is best to take it: - ANSWER In the morning, before 9:00 a.m. A client who recently underwent coronary artery bypass graft surgery comes to the physician's office for a follow-up visit. On assessment, the client tells the nurse that he is feeling depressed. Which response by the nurse is therapeutic? - ANSWER "Tell me more about what you're feeling." A nurse in the cardiac care unit is told that a client with a diagnosis of myocardial infarction will be admitted from the emergency department. Which item does the nurse give priority to placing at the client's bedside? - ANSWER Oxygen cannula and flowmeter NCLEX 2023 EXAM REVIEW STUDY GUIDE COMPREHENSIVE QUESTIONS AND ANSWERS A client being seen in the clinic complains of fatigue and weakness. Laboratory studies are performed because the physician suspects iron-deficiency anemia. NCLEX 2023 EXAM REVIEW STUDY GUIDE COMPREHENSIVE QUESTIONS AND ANSWERS Which finding indicative of this type of anemia does the nurse expect to find on reviewing the laboratory results? - ANSWER Microcytic red blood cells (RBCs) A nurse provides home care instructions to a client with mild preeclampsia. The nurse tells the client that: - ANSWER Urine output must be measured and that the physician should be notified if output is less than 500 mL in a 24-hour period A nurse reviews the results of a total serum calcium determination in a client with renal failure. The results indicate a level of 12.0 mg/dL. In light of this result, which finding does the nurse expect to note during assessment? - ANSWER Bounding, full peripheral pulses A client on the mental health unit says to the nurse, "Everything is contaminated." The client scrubs her hands if she is forced to touch any object. While planning care, the nurse remembers that compulsive behavior: - ANSWER Temporarily eases anxiety in the client A client says to the nurse, "My doctor just left. He told me that my abdominal scan showed a mass in my pancreas and that it's probably cancer. Does this mean I'm going to die?" The nurse interprets the client's initial reaction as: - ANSWER Fear A client has been given a prescription for lovastatin (Mevacor). Which of the following foods does the nurse instruct the client to limit consumption of while taking this medication? - ANSWER Steak NCLEX 2023 EXAM REVIEW STUDY GUIDE COMPREHENSIVE QUESTIONS AND ANSWERS a.m. and 3 p.m.? Type your answer in the space provided. - ANSWER 350mL NCLEX 2023 EXAM REVIEW STUDY GUIDE COMPREHENSIVE QUESTIONS AND ANSWERS A physician writes a prescription for 1000 mL of 0.9% normal saline solution to be administered intravenously (IV) to a client over 10 hours. The drop factor for the infusion set is 15 gtt/mL. At what drip rate does the nurse set the infusion? - ANSWER25 gtt/min A nurse is reviewing the medical record of an infant in whom hypertrophic pyloric stenosis (HPS) is suspected. Which characteristics associated with the disorder does the nurse expects see documented in the infant's medical record? Select all that apply. - ANSWER Weight loss Projectile vomiting Distended upper abdomen A nurse in a physician's office is reviewing the medical record of a child with a diagnosis of lactose intolerance. Which of the following findings does the nurse expect to see documented in the child's record? - ANSWER Episodes of cramping abdominal pain and excessive flatus A client is found to have posttraumatic stress disorder (PTSD) after witnessing a terrorist attack that caused the deaths of hundreds of people. The nurse, developing a plan of care for the client, identifies posttrauma syndrome as a concern and identifies a client outcome that states, "The client will cope effectively with thoughts and feelings of the event." Which nursing interventions will assist the client in achieving this outcome? Select all that apply. - ANSWER Being honest, nonjudgmental, and empathetic Assessing the immediate posttraumatic reaction Encouraging the client to keep a journal focused on the trauma Asking the client about the use of alcohol and drugs before and since the event NCLEX 2023 EXAM REVIEW STUDY GUIDE COMPREHENSIVE QUESTIONS AND ANSWERS A client who has been undergoing long-term therapy with an antipsychotic medication is admitted to the inpatient mental health unit. Which of the following findings does the nurse, knowing that long-term use of an antipsychotic NCLEX 2023 EXAM REVIEW STUDY GUIDE COMPREHENSIVE QUESTIONS AND ANSWERS Oral prednisone 5 mg/day has been prescribed for a client with a chronic respiratory disorder, and the nurse provides instructions to the client about the medication. The nurse tells the client to: - ANSWER Call the physician if a fever, sore throat, or muscle aches develop The nurse, auscultating the breath sounds of a client, hears these sounds. What are they? - ANSWER Wheezes Laboratory studies are performed on a client with suspected sickle cell disease, and electrophoresis reveals a large percentage of hemoglobin S (HbS). Which additional laboratory finding will the nurse expect to note that is a characteristic of this disease? - ANSWER Increased white blood cell (WBC) count A client is found to have hypoxemic respiratory failure. Which finding does the nurse expect to note on review of the results of the client's arterial blood gas analysis? - ANSWER Pao2 of 49 mm Hg, Paco2 of 32 mm Hg A nurse is monitoring a client who was brought to the emergency department in an unresponsive state and is now being treated for hyperglycemic hyperosmolar nonketotic syndrome (HHNS). Which of the following findings indicates to the nurse that fluid replacement is inadequate? - ANSWER Level of consciousness remains unchanged A nurse is providing dietary instructions to a client who is taking tranylcypromine sulfate (Parnate). Which of the following foods does the nurse tell the client to avoid while she is taking this medication? Select all that apply. - ANSWER Beer Yogurt Pickled herring NCLEX 2023 EXAM REVIEW STUDY GUIDE COMPREHENSIVE QUESTIONS AND ANSWERS An emergency department nurse assessing a client with Bell's palsy collects subjective and objective data. Which of the following findings does the nurse expect to note? - ANSWER Complaints of inability to close the eye on the affected side A nurse provides information to a client with chronic obstructive pulmonary disease (COPD) about methods of alleviating shortness of breath while the client is eating. Which statement by the client indicates a need for further instruction? - ANSWER "I should eat three meals a day, and the biggest meal should be at suppertime." A nurse is providing morning care to a client in end-stage renal failure. The client is reluctant to talk and shows little interest in participating in hygiene care. Which statement by the nurse would be therapeutic? - ANSWER "What are your feelings right now?" A nurse provides information about activity and exercise to the wife of a client with Parkinson's disease. Which statement by the spouse indicates a need for further instruction? - ANSWER "I should encourage him to keep his hands hanging at his side when he walks." A nurse is providing home care instructions to a client with coronary artery disease (CAD) who will be discharged home and will be taking 1 aspirin daily. The nurse tells the client: - ANSWERThe answer for this question should be something relating to toxicity that may present itself as tinnitus, ie., ringing in the ears. A client who has undergone extensive gastrointestinal surgery is receiving intermittent enteral tube feedings that will be continued after he is discharged home. When the nurse tells the client that he will be taught how to administer the feedings, the client states, "I don't think I'll be able to do these feedings by myself." Which response by the nurse is appropriate? - ANSWER "Tell me more NCLEX 2023 EXAM REVIEW STUDY GUIDE COMPREHENSIVE QUESTIONS AND ANSWERS about your concerns regarding the tube feedings." NCLEX 2023 EXAM REVIEW STUDY GUIDE COMPREHENSIVE QUESTIONS AND ANSWERS the nurse provides instructions to the client about the medication. For which of the following occurrences does the nurse tells the client to contact the physician? - ANSWER Sore throat A pediatric nurse is caring for a hospitalized toddler. Which of the following activities does the nurse deem the most appropriate for the toddler? - ANSWER Large building blocks A registered nurse is planning client assisgnments for the day. There is a licensed practical nurse and a nursing assistant on the team. Which client is the appropriate choice for the nursing assistant? - ANSWER A client with rheumatoid arthritis who needs assistance with feeding and ambulation Aneurysm precautions are prescribed for a client with a cerebral aneurysm. Which interventions does the nurse implement? Select all that apply. - ANSWER Keeping the room slightly darkened Monitoring the client for changes in alertness or mental status Restricting visits to close family members and significant others and keeping visits short A nurse is monitoring a client receiving terbutaline (Brethine) by intravenous infusion to stop preterm labor. The nurse notes that the client's heart rate is 120 beats/min and that the fetal heart rate is 170 beats/min. The appropriate action by the nurse is: - ANSWER Contacting the physician Lorazepam (Ativan) 1 mg by way of intravenous (IV) injection (IV push) is prescribed for a client for the management of anxiety. The nurse prepares the medication as prescribed and administers the medication over a period of: - ANSWER 3 minutes NCLEX 2023 EXAM REVIEW STUDY GUIDE COMPREHENSIVE QUESTIONS AND ANSWERS A nurse is conducting a preoperative psychosocial assessment of a client who is NCLEX 2023 EXAM REVIEW STUDY GUIDE COMPREHENSIVE QUESTIONS AND ANSWERS scheduled for a mastectomy. Which of the following findings would cause the nurse to conclude that the client is at risk for poor sexual adjustment after the mastectomy? - ANSWER The client reports a history of sexual abuse by her father A child who has just been found to have scoliosis will need to wear a thoracolumbosacral orthotic (TLSO) brace, and the nurse provides information to the mother about the brace. Which statement by the mother indicates a need for further information? - ANSWER "Wearing the brace is really important in curing the scoliosis." A nurse is monitoring a client with pheochromocytoma who is receiving an intravenous (IV) infusion of phentolamine. Which vital sign does the nurse monitor most closely during the infusion? - ANSWER Blood pressure A nurse is preparing to care for a client who was admitted to the antepartum unit at 34 weeks' gestation after an episode of vaginal bleeding resulting from total placenta previa. In report, the nurse is told that the client's vital signs are stable, that the fetal heart rate is 140 beats/min with a reassuring pattern, and that both the client and her husband are anxious about the condition of the fetus. On reviewing the client's plan of care, which client concern does the nurse identify as the priority at this time? - ANSWER Anxiety A client is admitted to the nursing unit with a diagnosis of avoidant personality disorder. Which of the following behaviors is a characteristic of the disorder? - ANSWER Hypersensitivity to negative evaluation Disulfiram (Antabuse) is prescribed to a client with an alcohol abuse problem. The nurse provides information about the medication and tells the client: - ANSWER That the medication cannot be started until at least 12 hours has elapsed since the client's last ingestion of NCLEX 2023 EXAM REVIEW STUDY GUIDE COMPREHENSIVE QUESTIONS AND ANSWERS A nurse is transcribing a physician's prescription for oral prednisone 5 mg/day that was written in the chart of a client with type 2 diabetes mellitus who is already taking an oral hypoglycemic medication. The nurse contacts the physician to ask about the prescription because: - ANSWER Prednisone can increase the blood NCLEX 2023 EXAM REVIEW STUDY GUIDE COMPREHENSIVE QUESTIONS AND ANSWERS glucose level A nurse is caring for a client who is immobilized in skeletal traction after sustaining a leg fracture in a motor vehicle crash. The nurse notes that the client is restless, and the client complains of being bored. Which problem does the nurse identify on the basis of this information? - ANSWER Lack of adequate diversional activity Testing of the plasma theophylline level in a client who is receiving a continuous intravenous infusion of theophylline reveals a level of 20 mcg/mL. The nurse interprets this result as: - ANSWER At the top of the therapeutic range A nurse notes documentation in the client's medical record indicating that the client has a stage II pressure ulcer. On the basis of this information, which of the following findings does the nurse expect to note? - ANSWER A diagram of ulcers, stage II ulcer is characterized by nonintact skin. There is partial-thickness skin loss, and the wound may appear as an abrasion, a shallow crater, or a blister. A client in labor experiences spontaneous rupture of the membranes. The nurse immediately counts the fetal heart rate (FHR) for 1 full minute and then checks the amniotic fluid. The nurse notes that the fluid is yellow and has a strong odor. Which of the following actions should be the nurse's priority? - ANSWER Contacting the physician A nurse is assessing a client with hepatitis for signs of jaundice. Which area does the nurse check, knowing that it will provide the best data regarding the presence of jaundice? - ANSWER Mucous membranes NCLEX 2023 EXAM REVIEW STUDY GUIDE COMPREHENSIVE QUESTIONS AND ANSWERS A client is scheduled to undergo an upper gastrointestinal (GI) series, and the nurse provides instructions to the client about the test. Which statement by the client indicates a need for further instruction? - ANSWER "I need to drink citrate of magnesia the night before the test and give myself a Fleet enema on the NCLEX 2023 EXAM REVIEW STUDY GUIDE COMPREHENSIVE QUESTIONS AND ANSWERS A nurse caring for a client 24 hours after a radical neck dissection notes the presence of serosanguineous drainage in the portable wound suction device attached to the surgical site. On the basis of this finding, the nurse should: - ANSWER Document the findings Alprazolam (Xanax) is prescribed for a client to treat an anxiety disorder. Which side effect does the nurse warn the client of? - ANSWER Lightheadedness A nurse is caring for a client who has undergone transsphenoidal hypophysectomy to remove a microadenoma of the pituitary gland. Which of these findings would be of greatest concern to the nurse? - ANSWER Urinary specific gravity is low A nurse is teaching a client with left-side weakness how to walk with the use of a quad-cane. The nurse ensures that: - ANSWER 30-degree flexion of the client's elbow is maintained when the client is holding the cane A client is brought to the emergency department after sustaining smoke inhalation injury during a fire in the client's home. The nurse plans to first: - ANSWERProvide the client with 100% oxygen by mask A nurse is providing dietary instructions to the mother of a child with celiac disease. The nurse tells the mother that it is acceptable to give the child: - ANSWER Boiled rice A nurse discovers that a client receiving heparin sodium by way of continuous intravenous (IV) infusion has removed the IV tubing from the infusion pump to change his hospital gown. After assessing the client and placing the tubing back in the infusion pump, which medication does the nurse check NCLEX 2023 EXAM REVIEW STUDY GUIDE COMPREHENSIVE QUESTIONS AND ANSWERS for in the medication room in case a heparin overdose has occurred? - ANSWER Protamine sulfate