NGN NCLEX PN Actual Exam: 200 Questions and Answers with Rationales, Exams of Nursing

Download NGN NCLEX PN Actual Exam: 200 Questions and Answers with Rationales and more Exams Nursing in PDF only on Docsity!

NGN NCLEX PN ACTUAL EXAM WITH NGN /PN NCLEX

ACTUAL EXAM (NEXT GENERATION) COMPLETE 200

QUESTIONS AND CORRECT DETAILED ANSWERS

WITH RATIONALES (VERIFIED ANSWERS) |ALREADY

GRADED A+.

A nurse is caring for a client who is scheduled for surgery and is experiencing anxiety. Which of the following interventions should the nurse identify as the priority? - ANSWER >>>Determine the client's understanding of the procedure. A nurse is contributing to the plan of care for a client who has peripheral arterial disease of the lower extremities. Which of the following interventions should the nurse include? - ANSWER

Dangle the extremities off the side of the bed. A nurse is assisting in the plan of care for a client who had a recent left hemispheric stroke. Which of the following actions should the nurse include in the plan? - ANSWER >>>Use simple verbal cues when directing tasks. A nurse is reinforcing teaching with the caregiver of a client who is terminally ill about manifestations of impending death. Which of the following manifestations should the nurse include? - ANSWER Incontinence of the bowel and bladder A nurse is preparing to remove a client's NG tube. Which of the following interventions should the nurse take to decrease the risk for aspiration? - ANSWER >>>Pinch the NG tube. A nurse is caring for a client who is preoperative and is receiving an IV infusion of cefazolin. Ten minutes after beginning the infusion, the client reports intense itching. Which of the following actions should the nurse take first? - ANSWER >>>Stop the medication infusion.

A nurse is reinforcing discharge teaching with a client who has cirrhosis. Which of the following instructions should the nurse include?

• ANSWER >>>"Consume foods that are low in sodium." A nurse is reinforcing teaching with a client who is scheduled for a guaiac fecal occult blood test. Which of the following instructions should the nurse include in the teaching? - ANSWER >>>Avoid eating red meat for 3 days prior to the test. A nurse is preparing to administer phytonadione 7 mg subcutaneously to a client who has an INR of 4. Available is phytonadione 10 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.) - ANSWER >>>0.7 mL A nurse is reinforcing teaching with a client who is taking insulin glargine. Which of the following information should the nurse include in the teaching? - ANSWER >>>"This type of insulin should be given at the same time every day." A nurse is caring for a client who has a methicillin-resistant Staphylococcus aureus (MRSA) infection in a surgical wound. Which of the following information should the nurse plan to share with visitors? - ANSWER >>>Visitors must don a gown and gloves prior to entering the client's room. A nurse is collecting data from a 55-year-old female client who reports vaginal dryness and hot flashes. The client is interested in trying hormone replacement therapy (HRT). Which of the following should the nurse recognize as a contraindication to HRT? - ANSWER

History of treatment for blood clots A nurse is reinforcing teaching about management of constipation with a client who has hypothyroidism. Which of the following instructions should the nurse include in the teaching? - ANSWER >>>Increase intake of fiber-rich foods.

A nurse is reinforcing teaching with a client who has multiple sclerosis and a new prescription for baclofen. Which of the following instructions should the nurse include in the teaching? - ANSWER >>>Avoid stopping this medication suddenly. A nurse is caring for a client who has an area indicating potential breakdown over the sacrum. Which of the following actions should the nurse take? - ANSWER >>>Minimize the time the head of the bed is elevated. A nurse is assisting with the care of a client who is receiving 0.9% sodium chloride by continuous IV infusion. The client reports pain and swelling at the IV site. In which order should the nurse perform the following steps? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) - ANSWER

Check IV site Stop the infusion Withdraw the IV catheter Elevate the affected arm Notify the charge nurse Drag words from the choices below to fill in each blank in the following sentence. During the emergent phase of burn care, the client is at risk for developing____________ and _____________. - ANSWER Hypovolemia Respiratory failure A nurse in an oncology clinic is reinforcing teaching about Mohs surgery with a client who has skin cancer. Which of the following information should the nurse include in the teaching? - ANSWER Mohs surgery is a horizontal shaving of thin layers of the tumor. A nurse is contributing to the plan of care for a client who is postoperative following a total knee arthroplasty. The client is using a continuous passive motion (CPM) machine. Which of the following interventions should the nurse recommend for the plan of care? -

ANSWER >>>Keep a sheepskin pad between the client's extremity and the CPM machine. A nurse is reinforcing teaching about joint protection with a client who has an acute exacerbation of rheumatoid arthritis. Which of the following information should the nurse include in the teaching? - ANSWER >>>Apply cold packs to the inflamed joints. A nurse is caring for a client who has difficulty swallowing. Which of the following actions should the nurse implement to prevent aspiration? - ANSWER >>>Give the client liquids with increased viscosity. A nurse is discussing health screening guidelines with an older adult client. Which of the following statements should the nurse include? - ANSWER >>>"You should have a pneumococcal immunization every 10 years." A nurse is planning to implement droplet precautions for a client who has manifestations of pertussis. Which of the following interventions should the nurse include when contributing to the plan of care? - ANSWER >>>Apply a mask on the client if transport is needed. A nurse is contributing to the plan of care for a client who was admitted to the neurological unit following a stroke 3 hr ago. Which of the following interventions should the nurse identify as the priority? - ANSWER >>>Keep the client in a side-lying position. A nurse is caring for a client who has a compound fracture of the femur and was placed in balanced suspension skeletal traction 4 days ago. Which of the following actions should the nurse take? - ANSWER >>>Perform pin site care daily. A nurse is reinforcing discharge teaching about wound care with the caregiver of a client who is postoperative. Which of the following instructions should the nurse include in the teaching? - ANSWER

Report purulent drainage to the provider.

A nurse is collecting data from a client who has hypokalemia. Which of the following findings should the nurse identify as the priority? - ANSWER >>>Dysrhythmia Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress. - ANSWER

Reduce the temperature in the clients room. Limit visitors Hyperthyroidism Increased temperature Weight daily

Apply a mask on the client if transport is needed. A nurse is contributing to the plan of care for a client who was admitted to the neurological unit following a stroke 3 hr ago. Which of the following interventions should the nurse identify as the priority? - ANSWER >>>Keep the client in a side-lying position. A nurse is caring for a client who has a compound fracture of the femur and was placed in balanced suspension skeletal traction 4 days ago. Which of the following actions should the nurse take? - ANSWER >>>Perform pin site care daily. A nurse is reinforcing discharge teaching about wound care with the caregiver of a client who is postoperative. Which of the following instructions should the nurse include in the teaching? - ANSWER >>>Report purulent drainage to the provider. A nurse is collecting data from a client who has hypokalemia. Which of the following findings should the nurse identify as the priority? - ANSWER >>>Dysrhythmia Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress. - ANSWER >>>Reduce the temperature in the clients room. Limit visitors Hyperthyroidism Increased temperature Weight daily A nurse is caring for a client who reports stomatitis. Which of the following dietary recommendations should the nurse make? - ANSWER >>>"Eat soft foods." A nurse is caring for a client who has a history of breast cancer. The client asks the nurse about birth control. Which of the following methods of birth control is contraindicated for this client? - ANSWER Combination oral contraceptives A nurse is collecting data from a client and notices several skin lesions. Which of the following findings should the nurse report as possible melanoma? - ANSWER >>>Irregular borders A nurse is contributing to the plan of care for a client who has COPD and is dyspneic. Which of the following interventions should the nurse include in the plan? - ANSWER >>>Encourage abdominal breathing A nurse is assisting with the care of a client who has a newly-inserted water-seal closed chest tube. Which of the following findings should the nurse report to the provider? - ANSWER >>>Chest drainage is greater than 70 mL/hr.

A nurse is reinforcing teaching with a client who is to begin using an insulin pump. Which of the following instructions should the nurse include? - ANSWER >>>"Use rapid-acting insulin in the infusion device." Which of the following actions should the nurse take? Select all that apply. - ANSWER >>>Instruct the client to splint their abdomen with a pillow when coughing plan to ambulate the client as soon as possible report the client's urinary output to the charge nurse monitor the client's pain level A nurse is caring for a client who is in Buck's traction. Which of the following interventions should the nurse perform to reduce skin breakdown? - ANSWER >>>Keep the skin dry and free of perspiration. A nurse is monitoring a client who is taking acarbose. Which of the following findings should the nurse identify as an adverse effect of the medication? - ANSWER >>>Abdominal cramps A nurse is reinforcing teaching with a client who is on a low-sodium diet and asks about how to improve the taste of bland food. Which of the following foods should the nurse recommend? - ANSWER

Lemon juice A nurse is reinforcing discharge teaching for the caregivers of a client who has Parkinson's disease. Which of the following information should the nurse include in the teaching? - ANSWER >>>Remind the client to avoid watching their feet when walking. A nurse is reinforcing teaching with a client who has systemic lupus erythematosus (SLE) and is to begin taking methylprednisolone orally. Which of the following statements should the nurse include in the teaching? - ANSWER >>>"Limit contact with large groups of people."

A nurse is reviewing the laboratory results of a client who is scheduled for a CT scan with an IV contrast agent. Which of the following laboratory findings should the nurse report to the provider prior to the procedure? - ANSWER >>>Creatinine 1.9 mg/dL Complete the following sentence by using the lists of options. After reviewing the findings in the client's medical record, the nurse should first address the client's_____________ followed by the client's ________. - ANSWER >>>Abdominal distention Acute pain The nurse is collecting data on the client For each client finding, click to specify if the finding is consistent with appendicitis, diverticular disease, or Crohn's disease. Each finding may support more than 1 disease process. - ANSWER >>>Blood in the stool - Diverticular disease Drag 1 condition and 1 client finding to fill in each blank in the following sentence. The client has manifestations of ___________ ; therefore, the priority finding for the nurse to report is the __________. - ANSWER

peritonitis laboratory values The nurse is contributing to the plan of care for the client who has peritonitis and Crohn's disease. For each potential intervention, click to specify if the intervention is indicated or contraindicated for the client. - ANSWER >>>Obtain "Limit contact with large groups of people." A nurse is reviewing the laboratory results of a client who is scheduled for a CT scan with an IV contrast agent. Which of the following laboratory findings should the nurse report to the provider prior to the procedure? - ANSWER >>>Creatinine 1.9 mg/dL Complete the following sentence by using the lists of options. After reviewing the findings in the client's medical record, the nurse should first address the client's_____________ followed by the client's ________. - ANSWER >>>Abdominal distention Acute pain The nurse is collecting data on the client For each client finding, click to specify if the finding is consistent with appendicitis, diverticular disease, or Crohn's disease. Each finding may support more than 1 disease process. - ANSWER >>>Blood in the stool - Diverticular disease Drag 1 condition and 1 client finding to fill in each blank in the following sentence. The client has manifestations of ___________ ; therefore, the priority finding for the nurse to report is the __________. - ANSWER >>>peritonitis laboratory values The nurse is contributing to the plan of care for the client who has peritonitis and Crohn's disease. For each potential intervention, click to specify if the intervention is indicated or contraindicated for the client. - ANSWER >>>Obtain blood cultures - indicated obtain the client's vital signs every 15 min - indicated Administer a hypotonic IV solution - contraindicated insert a nasogastric tube - indicated The nurse is assisting with the care of the client who is preoperative for an exploratory laparotomy.

Select the 4 actions the nurse should take. - ANSWER >>>Administer phenytoin with a sip of water on the day of surgery. Assist with the administration of gentamicin 100 mg IV. Assist with the administration of dextrose 5% in lactated Ringer's. Contact the wound, ostomy, and continence nurse. The nurse is reinforcing discharge teaching with the client. Which of the following client statements indicates an understanding of the teaching? Select all that apply. - ANSWER >>>"I should schedule several rest periods throughout the day" "I should notify my provider if my temperature is higher than 101 degrees Fahrenheit". A home health nurse is reinforcing teaching about preventing asthma attacks with a client who has asthma. Which of the following instructions should the nurse include in the teaching? - ANSWER

"Do not allow visitors to smoke cigarettes in your home." A nurse is caring for a client who has a new cast on their left forearm and reports severe pain in the affected arm with numbness in the fingers. The nurse finds the skin is pale and cold with sluggish capillary refill. Which of the following fracture complications should the nurse suspect? - ANSWER >>>compartment syndrome A nurse is contributing to the plan of care for a client who has a methicillin-resistant Staphylococcus aureus (MRSA) infection and is on contact isolation precautions. Which of the following actions should the nurse take? - ANSWER >>>Have a designated stethoscope in the client's room. A nurse is collecting data from a client who has heart failure and is taking digoxin. Which of the following outcomes from the medication should the nurse expect? - ANSWER >>>Decreased shortness of breath.

A nurse is contributing to the plan of care for a client who has a new prescription for nystatin suspension for oral candidiasis. Which of the following interventions should the nurse include in the plan? - ANSWER >>>Instruct the client to swish the medication in their mouth. A nurse is reviewing the laboratory results of a client who has type 2 diabetes mellitus. The nurse should identify that which of the following laboratory values indicates the client is at risk for delayed wound healing? - ANSWER >>>Prealbumin 12 mg/dL A nurse is caring for a client who had an acute ischemic stroke 1 day ago. Which of the following actions should the nurse take to reduce the risk for aspiration? - ANSWER >>>Allow for 30 min of rest before meals. A nurse is reinforcing teaching with the client. Which of the following instructions should the nurse include? Select all that apply. - ANSWER >>>Avoid drinking fluids with meals. Eat several small meals per day. Consume high-protein snacks. A nurse is contributing to the plan of care for a client who has Ménière's disease. Which of the following interventions should the nurse include in the plan of care? - ANSWER >>>Administer an antiemetic to the client. A nurse is examining a client's IV site and notes a red line up their arm. The client reports a throbbing, burning pain at the IV site. The nurse should identify that the client's manifestations indicate which of the following complications of IV therapy? - ANSWER

Thrombophlebitis A nurse is reinforcing teaching about glycosylated hemoglobin Instruct the client to swish the medication in their mouth. A nurse is reviewing the laboratory results of a client who has type 2 diabetes mellitus. The nurse should identify that which of the following laboratory values indicates the client is at risk for delayed wound healing? - ANSWER >>>Prealbumin 12 mg/dL A nurse is caring for a client who had an acute ischemic stroke 1 day ago. Which of the following actions should the nurse take to reduce the risk for aspiration? - ANSWER >>>Allow for 30 min of rest before meals. A nurse is reinforcing teaching with the client. Which of the following instructions should the nurse include? Select all that apply. - ANSWER >>>Avoid drinking fluids with meals. Eat several small meals per day. Consume high-protein snacks. A nurse is contributing to the plan of care for a client who has Ménière's disease. Which of the following interventions should the nurse include in the plan of care? - ANSWER >>>Administer an antiemetic to the client. A nurse is examining a client's IV site and notes a red line up their arm. The client reports a throbbing, burning pain at the IV site. The nurse should identify that the client's manifestations indicate which of the following complications of IV therapy? - ANSWER >>>Thrombophlebitis A nurse is reinforcing teaching about glycosylated hemoglobin (HbA1c) testing with a client who has diabetes mellitus. Which of the following statements indicates that the client understands the

teaching? - ANSWER >>>"I will have my HbA1c checked twice per year." A nurse enters the room of a client whose transfusion of packed RBCs was initiated 15 min ago by the RN. The client reports dyspnea and urticaria. After stopping the infusion, which of the following actions should the nurse take next? - ANSWER >>>Take the client's vital signs. A nurse is contributing to the plan of care for a client who has multiple sclerosis and is taking dantrolene to manage muscle spasms. Which of the following interventions should the nurse include? - ANSWER

Encourage the client to complete ADLs. A nurse is caring for a client who is postoperative and has an epidural infusion. Which of the following findings should the nurse recognize as the priority? - ANSWER >>>Dyspnea A nurse is contributing to the plan of care for a client who has partial hearing loss. Which of the following interventions should the nurse include in the plan of care? - ANSWER >>>Face the client while speaking. A nurse is reinforcing teaching with the caregiver of a client who has a cervical injury and has a halo vest in place. Which of the following safety precautions should the nurse include in the teaching? - ANSWER >>>Change the sheepskin liner weekly. A nurse is reinforcing teaching about home care with a client who had a knee arthroplasty. Which of the following factors should the nurse identify as an indication that a barrier to learning might be present? - ANSWER >>>The client stops the nurse and asks for pain medication. A nurse is caring for a client who has a prescription for phenazopyridine. Which of the following findings should the nurse identify as a therapeutic effect of the medication? - ANSWER Decreases pain during urination.

A nurse is assisting a client who reports difficulty falling asleep. Which of the following activities should the nurse recommend to promote sleep? - ANSWER >>>Listen to soft music before sleeping. A nurse is reinforcing teaching with a client who has asthma. Which of the following client statements indicates an understanding of the use of budesonide and albuterol inhalers? (Select all that apply.) - ANSWER >>>"I never forget to rinse my mouth after using my budesonide inhaler" "Between office visits, I keep a record of how many times I use my albuterol inhaler" "I use my albuterol inhaler before I go swimming" The nurse is reviewing the client's diagnostic results. Which of the following findings require follow up? Select all that apply. - ANSWER >>>PaCO WBC count Chest x-ray Oxygen saturation BUN The nurse is reviewing the client's medical record. Click to highlight the findings below that indicate that the client has a potential problem. To deselect a finding, click on the finding again. - ANSWER >>>Client is short of breath and has a productive cough with yellow mucus States, "I could barely breathe when I got up this morning and I had a throbbing headache" Client is diaphoretic Crackles heard in posterior lung A nurse is prioritizing care for the client. Complete the following sentence by using the lists of options. At 1000, the nurse should first address the client's________, followed by the client's________. - ANSWER >>>Oxygen saturation Heart rate

The nurse is assisting with the plan of care for the client. For each potential provider prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client. - ANSWER >>>Cough and deep breathe every 2 hr is anticipated Obtain a sputum culture and sensitivity is anticipated Titrate oxygen to keep oxygen saturation greater than 90% is anticipated. Place client on a 1,500 mL fluid restriction is contraindicated Administer acetaminophen 500 mg PO every 6 hr PRN is anticipated. Administer famotidine 40 mg PO daily is nonessential. The nurse is reviewing the client's medical record. Select the 3 findings that require nursing intervention - ANSWER

Temperature WBC count Potassium level The nurse is reviewing the client's medical record from Day 5. Click to highlight the findings that indicate the client is improving. To deselect a finding, click on the finding again. - ANSWER >>>Heart rate 72/min, regular; Respiratory rate 20/min; Blood pressure 128/ mm Hg Oxygen saturation is 95% on room air A nurse is contributing to the plan of care for a client who is having difficulty eating following a stroke. Which of the following actions should the nurse take first? - ANSWER >>>Implement recommendations from the speech language pathologist. A nurse is preparing to administer furosemide to a client who has heart failure. Which of the following findings should the nurse report before administering the medication? - ANSWER >>>Decreased potassium

A nurse is reinforcing teaching with an adolescent client regarding testicular self-examination. Which of the following statements by the client demonstrates an understanding of the teaching? - ANSWER

"I understand that testicular cancer is typically painless." A nurse observes a client who is lying in bed and experiencing a tonic- clonic seizure. Which of the following actions should the nurse take? - ANSWER >>>Loosen clothing around the client's neck. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress. - ANSWER Hypovolemia Insert a large gauge IV Heart rate 72/min, regular; Respiratory rate 20/min; Blood pressure 128/ mm Hg Oxygen saturation is 95% on room air A nurse is contributing to the plan of care for a client who is having difficulty eating following a stroke. Which of the following actions should the nurse take first? - ANSWER >>>Implement recommendations from the speech language pathologist. A nurse is preparing to administer furosemide to a client who has heart failure. Which of the following findings should the nurse report before administering the medication? - ANSWER >>>Decreased potassium A nurse is reinforcing teaching with an adolescent client regarding testicular self-examination. Which of the following statements by the client demonstrates an understanding of the teaching? - ANSWER >>>"I understand that testicular cancer is typically painless." A nurse observes a client who is lying in bed and experiencing a tonic- clonic seizure. Which of the following actions should the nurse take? - ANSWER >>>Loosen clothing around the client's neck. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress. - ANSWER >>>Hypovolemia Insert a large gauge IV Initiate a fluid challenge Urine output blood pressure A nurse is preparing to administer scheduled medications to a client. Which of the following prescriptions should the nurse verify with the provider? (Click on the exhibit tabs for additional information about the client. There are three tabs that contain separate categories of data.) - ANSWER >>>Ceftriaxone A nurse is contributing to the plan of care for a client who is at risk for osteoporosis. Which of the following interventions should the nurse include to prevent bone loss? - ANSWER >>>Encourage weight- bearing exercises. A home health nurse is reinforcing teaching with a client about preventing complications of peripheral vascular disease. Which of the following statements indicates that the client is adhering to the nurse's instructions? - ANSWER >>>"I don't cross my legs anymore." A nurse is reviewing the laboratory results of a client who has chronic kidney failure and is receiving epoetin alfa. The nurse should identify

that which of the following laboratory values indicates the treatment is effective? - ANSWER >>>Hgb 11 g/dL A nurse is caring for a client who has meningococcal pneumonia. Which of the following personal protective equipment should the nurse use? - ANSWER >>>Mask Drag 1 condition and 1 client finding to fill in each blank in the following sentence. The client is experiencing manifestations of ________. as evidenced by _______. - ANSWER >>>Pancreatitis amylase and lipase A nurse is participating in a health fair for older adult clients. Which of the following vaccines should the nurse recommend for this age group? - ANSWER >>>Herpes Zoster A nurse is assisting in the care of a client who has manifestations of sepsis. Which of the following provider prescriptions should the nurse implement first? - ANSWER >>>Initiate oxygen at 4 L/min via nasal cannula. A nurse is caring for a client who is receiving chemotherapy. The client mentions that they have a loss of appetite because of sores in their mouth and that food no longer tastes good. Which of the following suggestions to the client should the nurse make? - ANSWER >>>Eat several, small-portioned meals daily. A nurse is caring for a client who has terminal pancreatic cancer. The client states, "I don't think I can go on any longer." Which of the following responses should the nurse make? - ANSWER >>>"you feel like you want to discontinue treatment?" A nurse is assisting the charge nurse with developing an in-service about caring for clients who have internal sealed radiation implants. Which of the following information should the nurse include? - ANSWER >>>Dispose of radiation implants in a lead container.

A nurse is reinforcing discharge instructions with a client who is postoperative following a right hip arthroplasty. Which of the following statements should the nurse make? - ANSWER >>>"Avoid bending your hips more than 90 degrees." An assistive personnel tells the charge nurse that her assignment is too demanding. She angrily tells the nurse to reassign one of her tasks to another AP. Which of the following actions should the nurse take to resolve the conflict? - ANSWER >>>>>Ask the AP to discuss the issue in a private area A nurse is supervising an assistive personnel (AP) obtain supplies for a client who is on seizure precautions. Which of the following materials should the AP place in the client's room? - ANSWER

Oral Suction Equipment A charge nurse on a mental health unit is supervising a newly licensed nurse. For which of the following actions by the newly licensed nurse should the supervising nurse intervene? - ANSWER >>>>>Tells a client he will lose his phone privileges if he does not take his medication A nurse is caring for a client who follows a kosher diet. Which of the following menu items should the nurse include in the meal tray? - ANSWER >>>>>Roasted Salmon A nurse is reviewing information about advance directives with a newly admitted client. Which of the following statements by the client indicates an understanding of the information? - ANSWER "Advance directives include a living will" A nurse is collecting data from the caregiver of a client who has Alzheimer's disease. The caregiver reports the client has difficulty sleeping at night and wanders throughout the house. Which of the

following interventions should the nurse recommend? - ANSWER

Encourage the client to take frequent walks during the day A nurse is assisting in the care of a client who is 8hr postpartum and has uterine atony with increased bleeding. Which of the following actions should the nurse take? (Select all that apply) - ANSWER Assist the client to empty her bladder A nurse is reinforcing teaching with the support person of a client who is in the first stage of labor. Which of the following instructions should the nurse include regarding effleurage? - ANSWER >>>>>"Gently stroke her abdomen during contractions" A nurse is caring for an older adult client who is postoperative following a total hip arthroplasty. The client is incontinent of stool and urine. Which of the following actions should the nurse take to prevent skin breakdown? - ANSWER >>>>>Use a moisture barrier on the client's skin A nurse is caring for a client who has terminal cancer. Which of the following actions should the nurse take to promote the client's autonomy? - ANSWER >>>>>Allow the client to choose treatment times A nurse in a clinic is caring for a client who is at 40 weeks of gestation and experiences a sudden gush of vaginal fluids. Which of the following findings is evidence of an obstetric complication? - ANSWER Appears greenish-brown in color A nurse is assisting with the care of an adolescent client immediately following a lumbar puncture. Which of the following actions should the nurse take? - ANSWER >>>>>Inform the adolescent that he might experience a headache A nurse is reinforcing teaching about advance directives with a client who has end-stage heart failure. Which of the following statements by

the client indicates an understanding of the teaching? - ANSWER

"I should discuss this document with my family after I sign it" A nurse is caring for a client who has continuous bladder irrigation following a transurethral resection of the prostate. The nurse notices clots and dark red blood in the catheter collection bag. Which of the following actions should the nurse take? - ANSWER >>>>>Irrigate the bladder with 20 to 30 mL of 0.9% sodium chloride A nurse is planning to obtain a 12-lead ECG for a client who has a history of cardiac dysrhythmias. Which of the following actions should the nurse plan to take? - ANSWER >>>>>Instruct the client to remain

as still as possible during the recording A nurse is reinforcing teaching with a client who has genital herpes. Which of the following information should the nurse include in the teaching? - ANSWER >>>>>"You should increase fluid intake to relieve dysuria" A nurse is preparing to empty a postoperative client's closed-wound drainage system. Which of the following actions should the nurse plan to take? - ANSWER >>>>>Compress the container before replacing the drainage plug A nurse is reinforcing teaching with the parents of a toddler who has a new diagnosis of asthma and a prescription for montelukast. Which of the following instructions should the nurse include in the teaching? - ANSWER >>>>>Administer the medication to the toddler each evening A nurse in an acute mental health facility is caring for a newly admitted client. Which of the following should occur during the orientation phase of the nurse-client relationship? - ANSWER >>>>>Defining responsibilities A nurse is caring for a client who reports having a decrease in fetal movement following an external cephalic version 6 hr ago. The nurse

identifies the fetus is in the right occiput anterior position. The nurse should place the fetal heart monitor on which of the following sites to auscultate the fetal heart rate? - ANSWER >>>>>Lower left A charge nurse is observing a newly licensed nurse perform suctioning for a client who has a tracheostomy. For which of the following actions by the newly licensed nurse should the charge nurse intervene? - ANSWER >>>>>Suction for 30 seconds A nurse is reviewing the medication administration record of a client who takes atenolol PO and supplies a nitroglycerin transdermal patch daily. Which of the following interactions should the nurse monitor with this client? - ANSWER >>>>>Hypotension A nurse in an acute care setting is preparing to administer medications to a client. Which of the following actions should the nurse verify the client's identity? - ANSWER >>>>>Verify the client's identity using a photograph A nurse in a provider's office is collecting data from a client who has psoriasis. Which of the following statements made by the client should she report to the provider? - ANSWER >>>>>"I try not to look at the scales on my body" A nurse is completing chart reviews in a long-term care facility in response to an increase in falls. Which of the following responses in the chart should the nurse use to determine the potential causes of falls? - ANSWER >>>>>Medication record A nurse is making client care assignments for an assistive personnel (AP). Which of the following tasks should the nurse assign to the AP?

• ANSWER >>>>>Complete post mortem care for a client who has died A nurse is reinforcing teaching with a client who is taking allopurinol about the risk for developing Stevens-Johnsons syndrome. For which

of the following manifestations should the nurse instruct the client to monitor and report? - ANSWER >>>>>Skin rash with fever A charge nurse in a long-term care facility is reinforcing teaching with a group of nurses about fall precautions. Which of the following statements made by the nurse indicates an understanding of the teaching? - ANSWER >>>>>"I will instruct the client to sit when putting on a pair of pants" A nurse is recommending clients for discharge to allow for admission of clients following a tornado disaster. Which of the following clients should the nurse recommend for discharge? - ANSWER >>>>>A client who has a sodium level of 140 mEq/L after one episode of diarrhea A nurse is assisting with the plan of care for a newly admitted client who has anorexia nervosa. Which of the following interventions should the nurse include in the plan? - ANSWER >>>>>Administer liquid supplements A charge nurse is reinforcing teaching with a newly licensed nurse about floating to a different unit. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? - ANSWER >>>>>"I will document in the medical record the support nurse who assists with planning care for my clients" A nurse is caring for a client who has dehydration due to diarrhea. Which of the following findings should the nurse report to the provider? - ANSWER >>>>>Urine output 12 mL/hr A nurse is preparing the administer NPH (Novolin N) insulin to a client who has diabetes mellitus before breakfast at 0700. At which of the ff. times should the nurse plan to check the client for hypoglycemia? - ANSWER >>>>> A nurse in a clinic is obtaining a health history from a client scheduled to un- dergo a cardiac catheterization in 2 days. Which of the ff.

questions is the most im- portant for the nurse to ask? - ANSWER

"Do you know if you're allergic to iodine?" A nurse in an urgent-care facility is collecting data from a client who is scheduled for a procedure. Which of the ff. clinical manifestations indicates a possi- ble latex allergy? - ANSWER >>>>>Rhinorrhea A nurse in a provider's office is reinforcing teaching with a client who has a new prescription for ferrous sulfate elixir. Which of the ff. statements by the client demonstrates understanding of the teaching?

• ANSWER >>>>>"I will rinse my mouth after taking this medication" A nurse is observing an assistive personnel (AP) apply antiembolic stockings for a client who is at risk for a deep thrombosis. Which of the following actions the AP is applying the stockings correctly? - ANSWER >>>>>The AP applies the stockings before getting the client out of bed A nurse working in a provider's office receives a phone call from the parent of a school-age child who has varicella (chickenpox). The parent asks the nurse when the child can return to school. Which of the ff. responses by the nurse is cor- rect? - ANSWER >>>>>"When all the blisters are scabbed over" A nurse is caring for a client who just had blood drawn for an arterial blood gas analysis. Which of the ff. values should the nurse expect if the client is in respi- ratory acidosis? - ANSWER >>>>>PaCO2 51 mm Hg A nurse is reinforcing teaching with a client who has a new prosthesis for an above the knee amputation of the right leg. Which of the ff. instructions should the nurse reinforce to the client? - ANSWER

Apply the prosthesis immediately upon waking each day A nurse is preparing a client for the insertion of an NG tube. Which of the ff. actions should the nurse take? - ANSWER >>>>>Determine if the client has a deviated septum

A nurse is caring for a client who has a fractured radius and has a short arm cast applied yesterday. Which of the ff. findings should the nurse report to the provider? - ANSWER >>>>>Client report of decreased sensation in the finger A nurse is contributing to the plan of care for a client who is on suicide pre- cautions. Which of the ff. interventions is appropriate for the nurse to recommend? - ANSWER >>>>>Encourage the client to sign a no- harm contract A nurse is preparing to administer haloperidol (Haldol) 4 mg IM start to a client. Available is haloperidol for injection mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if applicable. Do not use a trailing zero.) - ANSWER >>>>>0.8 mL A nurse is caring for a client who reports an excruciating headache, nuchal rigidity, nausea and vomiting, and fever with chills. Which of the following diagnostics tests should the nurse expect to be prescribed? - ANSWER >>>>>Cerebrospinal fluid analysis A nurse is discussing alopecia with a client who is scheduled to begin chemotherapy. Which of the following statements is appropriate for the nurse to make? - ANSWER >>>>>If you'd like to wear a wig, you should select it before hair loss occurs A charge nurse in a long-term care facility observes an assistive personnel (AP) who appears to be under the influence of alcohol. Which of the following actions should the nurse take first? - ANSWER

Confront the AP about suspected impairment A nurse is caring a client who has asthma and has a prescription for theophylline (theochron) 200mg PO BID. Which of the following should the nurse include in the teaching? - ANSWER Discontinue drinking caffeinated beverages

While a nurse is assisting a client to ambulate, the client reports lightheadedness and begins to fall. Which of the following nursing actions demonstrates a correct understanding by the nurse about ergonomic principles? - ANSWER >>>>>Spread feet apart and extend one leg for the client to slide down while lowering the client to the floor A nurse is caring for an older adult client who appears lethargic and somnolent. The nurse reviews the client's medications prior to contacting the provider. Which of the following medication is the likely cause of the increased sedation? - ANSWER >>>>>Lorazepam (Ativan) A nurse is caring for a client who had a bronchoscopy and just arrived to the medical surgical unit. Which of the following actions should the nurse perform first? - ANSWER >>>>>Check for a gag reflex A client is requesting information from a nurse regarding the appointment of a health care proxy. Which of the following responses by the nurse is appropriate? - ANSWER >>>>>The person you appoint will make health care decision for you if you cannot do so yourself A nurse enters client's room and sees smoke coming from a wastebasket next to the bed. Which of the following actions should the nurse first? - ANSWER >>>>>Assist the client to a nearby waiting room A nurse is interviewing clients as part of a skin cancer screening program. Which of the following statement made by a client indicates that he may have a premalignant lesion? - ANSWER >>>>>I have this flat, scaly area with red edge on neck A nurse is caring for a client who reports 12 liquid stools in the past 8hr. Which of the following findings indicates that the client is experience dehydration? - ANSWER >>>>>Potassium level 2.5 mg/L

A nurse is reinforcing teaching for a client undergoing radiation therapy to the neck. Which of the following should the nurse include? - ANSWER >>>>>Avoid exposing the neck to the cold A nurse is providing anticipatory guidance to the parent of a 6-year old child. Which of the following statements by the parent indicated an understanding of appropriate safety precautions for the child? - ANSWER >>>>>"I will encourage my child to wear a bicycle helmet whenever bike riding" A nurse is collecting data from a client who presents to the clinic reporting vomiting. Which of the following findings indicate that the client is experiencing a fluid volume deficit? - ANSWER

Orthostatic hypotension A nurse is caring for a client who is recieving warfarin (coumadin) for deep vein thrombosis. The nurse observed that the client's INR is 3.8.Which of the following actions should the nurse take? - ANSWER Withhold the ordered dose of the medication A nurse is reinforcing teaching with the parents of a 4-month-old infant during a home visit. Which of the following findings in the infant's room indicates a need for further teaching? - ANSWER >>>>>The infant is lying in the crib with a stuffed animal A nurse is caring for a client who has hepatitis B. When caring for the client, which of the following actions places the nurse at highest risk for acquiring hepatitis B? - ANSWER >>>>>Performing oral hygiene A nurse is reinforcing dietary teaching with a client whose pre- Avoid exposing the neck to the cold A nurse is providing anticipatory guidance to the parent of a 6-year old child. Which of the following statements by the parent indicated an understanding of appropriate safety precautions for the child? - ANSWER >>>>>"I will encourage my child to wear a bicycle helmet whenever bike riding" A nurse is collecting data from a client who presents to the clinic reporting vomiting. Which of the following findings indicate that the client is experiencing a fluid volume deficit? - ANSWER >>>>>Orthostatic hypotension A nurse is caring for a client who is recieving warfarin (coumadin) for deep vein thrombosis. The nurse observed that the client's INR is 3.8.Which of the following actions should the nurse take? - ANSWER >>>>>Withhold the ordered dose of the medication A nurse is reinforcing teaching with the parents of a 4-month-old infant during a home visit. Which of the following findings in the infant's room indicates a need for further teaching? - ANSWER >>>>>The infant is lying in the crib with a stuffed animal A nurse is caring for a client who has hepatitis B. When caring for the client, which of the following actions places the nurse at highest risk for acquiring hepatitis B? - ANSWER >>>>>Performing oral hygiene A nurse is reinforcing dietary teaching with a client whose pre- pregnancy BMI was 30.5. The nurse evaluates that the client understands the teaching when she states she will gain - ANSWER A..? A nurse is reinforcing teaching with school staff about streptococcal infection of the pharynx. The nurse should instruct the staff that the period of contagion for children who have this infection is which of the

following? - ANSWER >>>>>From onset of symptoms until 24 hours of antibiotic therapy A nurse is caring for a client who is 2 days postoperative following a partial bowel resection. The client reports that the "felt something pop" when he sneezed. The nurse observes an evisceration. After calling for assistance, which of the following actions should the nurse take first? - ANSWER >>>>>Cover the wound with sterile saline-soaked gauze A nurse is caring for a client who is in balanced skeletal traction for a leg fracture. Which of the following should the nurse expect to be included in the care plan? - ANSWER >>>>>Increase counter traction every 24 hours. Inspect the ropes, knots, and pulleys every 8 hours. A nurse is using contact precautions while caring for a toddler. Which of the following actions should the nurse take? - ANSWER >>>>>Use a designated stethoscope for the toddler A client's daughter calls the nurse requesting information about her mother's condition. The client's chart does not specify that information can be released to the daughter. Which of the following is an appropriate response by the nurse? - ANSWER >>>>>"You will need to contact your mother directly about her condition" A nurse is reviewing the immunization records of a 9 year old child during a routine physical exam. Which of the following should indicate to the nurse the child is not current with the minimum required immunization? - ANSWER >>>>>One MMR vaccine A nurse is reinforcing teaching with a new mother on facility security measure. Which of the following statements by the mother indicates that the teaching was effective? - ANSWER >>>>>"I will have an identification band that matches the one my baby wears"

A nurse is reinforcing teaching with a client who is at 10 weeks gestation and has a medical history of mild hypertension. The nurse should remind the client to call the clinic if she - ANSWER

Develops edema of the ankles A nurse is caring for a client who has been placed in restraints. Which of the following is appropriate? - ANSWER >>>>>Monitor the client's skin integrity on a regular schedule A nurse is working on a mental health unit is reviewing policies for client seclusion. For which of the following is seclusion appropriate? - ANSWER Aggressive behavior A nurse in a long-term care facility has received a change-of-shift report on four clients. Which of the following clients should the nurse attend to first? - ANSWER >>>>>A client who has COPD and dementia and was agitated during the night shift A nurse is applying a condom catheter to a male client who is incontinent. Which of the following is an appropriate technique to use?

• ANSWER >>>>>Leave space between the tip of the penis and the end of the condom catheter A nurse is assisting a client to move up in bed. Which of the following actions should the nurse take? - ANSWER >>>>>Ask the client to flex the hips and knees A nurse is supervising an assitive personnel (AP). During the morning meal, the nurse observes the AP accidentally spill a cup of coffee on a client. Which of the following actions should the nurse take? - ANSWER >>>>>Reinforce safe meal setup techniques A nurse is reinforcing teaching to a first-time mother about toddler safety. The nurse should recognize the client's understanding of the teaching when the client states, "I will - ANSWER >>>>>Install gates at the top and bottom of the stairs