Nursing Care Scenarios, Exams of Advanced Education

Download Nursing Care Scenarios and more Exams Advanced Education in PDF only on Docsity! NCLEX-RN Practice Set A client is admitted to the ED. The family reports the client had a sudden onset of left-sided facial droop and slurred speech at home. The nurse observes left-sided muscle weakness. Which is the most important question for the nurse to ask? - "When did you notice the onset of your parent's symptoms?" The nurse meets with the parent of an adolescent male who presents for an annual health maintenance visit. The parent voices concern that the child has recently become clumsy and uncoordinated. Which response by the nurse is correct? a. your son might have ADHD b. I'll talk with the HCP about assessing for motor dysfunction c. your son's clumsiness is expected at this age d. this may be an early sign of depression - "Your son's clumsiness is expected at this age." *The client diagnosed with chronic lymphocytic leukemia (CLL) is scheduled for a bone marrow aspiration and biopsy. The client says, "I am frightened. I have never had this test before, and I don't know what to expect." Which statements will the nurse include when responding to the client's concerns? (SATA) a. We will move you to the operating room where the test is always performed b. the bone in front of your chest will be used for the biopsy specimen c. A tight pressure dressing will be placed over the test site after the procedure. d. You will not feel any discomfort as the local anesthetic is injected e. There is a risk of bleeding, so we will monitor the site frequently - "A tight pressure dressing will be placed over the test site after the procedure." "You will not feel any discomfort as the local anesthetic is injected." *The LPN/LVN reporting to the nurse says, "You may want to see the client recently diagnosed with pancreatic cancer. I am not sure how well things are going." The nurse enters the room and finds the client sitting quietly, looking out the window. As the nurse approaches client, the client does not look at the nurse. Which is the most appropriate response by the nurse? - "Tell me what you know about your diagnosis and the treatment you will receive." *The nurse provides care for the client immediately after arrival in the ED. Emergency personnel report that the client was involved in a head-on collision with immediate loss of consciousness. Which is the first action taken by the nurse? a. determine glasglow coma scale (GCS) score b. assess bilateral blood pressure c. check bilateral pupillary responses to light d. determine oxygen saturation levels - Determine oxygen saturation levels. At a rehabilitation center for clients with spinal cord injuries (SCIs), the nurse conducts an orientation session for a group of unlicensed assistive personnel (UAP). Which statement is most important for the nurse to include? - "Obtain client's permission before touching client." *The home care nurse instructs a client diagnosed with multiple sclerosis. The client states, "I have poor concentration and difficulty pronouncing words." The nurse notes that the client's speech is slow and slurred. Which client statement indicates to the nurse that further teaching is necessary? - "During a conversation, I will carefully build up to my most important points." A client diagnosed with malnutrition is prescribed continuous enteral feedings through a newly placed gastrostomy tube. Which actions will the nurse include in the client's plan of care? (SATA) a. cover the insertion site with an adhesive bandage b. add 7 hours of feeing to the bag at a time c. rotate the gastrostomy tube 360 degrees once daily d. Auscultate for a whoosh of air through the gastrostomy tube e. check for slight in-and-out movement of the gastrostomy tube - Rotate the gastrostomy tube 360 degrees once daily Check for slight in-and-out movement of the gastrostomy tube. The nurse provides care to a client who is diagnosed with a stroke and is admitted to a rehab center. The client has left-sided pronator drift and decreased dorsiflexion strength of the left extremity. The nurse notes the client bumps into the left wall when ambulating with a walker. The client leans to the left when sitting in a chair or wheelchair. Which is the most appropriate action for the nurse to take? - Position the client so the right side faces the door of the room. d. fever e. urticaria f. severe shortness of breath - Hypotension, Low back pain, Fever *The HCP prescribes an increase in the parenteral nutrition (PN) infusion rate from 50 mL/hour to 100 mL/hour. The PN is infusing through a PICC device. Which is the priority action for the nurse? a. assess hourly urine b. evaluate total serum protein level c. assess vital signs (VS) every 4 hours d. Evaluate aspartate aminotransferase (AST) test - Assess hourly urine. The nurse provides care for a client who underwent a vagotomy with antrectomy to treat a duodenal ulcer. Postoperatively, the client develops dumping syndrome. Which client statement indicates to the nurse that further teaching is necessary? a. I am able to eat a roll or bread at dinner b. I usually eat smaller meals, about 6 per day c. I need to recline after meals to help with digestion d. I should avoid drinking fluids with my meals - I am able to eat a roll or bread at dinner During a urinary bladder catheter insertion, with a size 16 French catheter on an older adult male, the nurse feels increased resistance. Which is the most appropriate action for the nurse to take? a. withdraw the catheter and apply more lubricant b. instruct the client to take a deep breath and bear down c. Stop the insertion and instruct the client to take deep breaths. d. withdraw the catheter and notify the health care provider - Stop insertion & instruct client to take deep breaths. The nurse preceptor observes the novice nurse obtain blood through a peripherally inserted central catheter. Which observation requires an intervention by the nurse preceptor? a. the nurse discards 1 ml of blood prior to obtaining the blood sample b. the nurse uses a 10ml syringe to flush through the port of the catheter c. the nurse applies clean gloves prior to beginning the procedure d. the nurse uses the push-pause technique to flush the catheter - The nurse discards 1 mL of blood prior to obtaining the blood sample. The nurse observes the unlicensed assistive personnel (UAP) obtain a capillary glucose sample. Which is the best location for obtaining a blood glucose sample? - Lateral aspect of finger; end of finger is not recommended d/t less blood flow & more nerve fibers. The nurse provides care to a client who has a chest tube and pleural drainage system placed for the treatment of a right-sided pneumothorax. The suction control chamber is set at 20 cm and tubing is attached to the wall suction. Which finding will the nurse expect to observe after the insertion of the chest tube? a. bubbling in the water-seal chamber b. serosanguinous drainage in the collection chamber c. Fluctuations in the suction control catheter during coughing d. one cm sterile water in the water-seal chamber - Bubbling in the water-seal chamber. The nurse determines that a client's tracheostomy requires suctioning. Which action does nurse take first? - Preoxygenate the client. Upon assessment of a client admitted for dehydration, the nurse observes that the client appears restless and reports difficulty breathing. Upon auscultation of the client's lungs, the nurse notes bilateral basilar crackles. Which actions will the nurse take first? a. place the client on 2 L of oxygen by nasal cannula and auscultate the lungs b. Elevate the head of the bed and stop the IV infusion c. Decrease the IV flow rate and administer furosemide as prescribed d. Stop the IV infusion and notify the HCP - Elevate the HOB & stop the IV infusion. The nurse provides care for a client diagnosed with diastolic HF. The nurse observes the recent onset of the A-fib. Which is the most appropriate action for the nurse to take? a. administer digoxin 0.25 mg IV b. instruct the client to take a deep breath and hold it c. assess level of consciousness and orientation d. auscultate posterior chest - Assess level of consciousness & orientation. The family member of a client diagnosed with a pneumothorax states, "I think something is wrong with that drainage device. It just got very noisy." The nurse observes that bubbling in the underwater seal is continuous compared to several hours ago. Which action does the nurse take first? a. clamp the chest tube at the insertion site b. add sterile water to the underwater seal chamber c. notify the health care provider d. observe the connections of the drainage system - Observe the connections of the drainage system. When assessing the incision of a client 2 days postoperatively, the nurse notes a shiny pink area with underlying bowel visible. Which action does the nurse implement? - Cover area w/ sterile gauze soaked in normal saline. The nurse assesses a client diagnosed with Ménière disease. The client states, "I take my prescribed meds regularly, but I continue to have episodes of vertigo." Which response by the nurse is most important? - "Tell me about your diet." *A client who is diagnosed with end-stage kidney disease is prescribed hemodialysis treatments 3 times a week. After two weeks of treatment, the client states, "I have a HA when the dialysis finishes. Is this normal?" Which is the most appropriate response by the nurse? a. "I have seen this in a lot of clients. don't worry too much about it." b. "headaches may occur at the beginning of treatment and should improve over time." c. "have you experienced any headache similar to these in the past?" d. "Why are you so worried about this?" - "Headaches may occur at the beginning of treatment & should improve over time." *The nurse receives a phone call from a client's adult child who states, "I just got here to see my elderly parent, and I think heat stroke has occurred. I think the air conditioning is not working and the house is very hot." The adult child reports that the parent is confused, very thirsty, nauseated, and in pain. Which is the most appropriate statement for the nurse to make? a. if perspiration is present, heat stroke has not occured c. Client at 22 weeks gestation, reporting feeling fetal movement four times in the last hour d. client at 2 days postpartum, reporting urinary incontinence - Client at 5 days postpartum, reporting bright red, bloody discharge. *The nurse provides care for a young adult client requiring an emergent appendectomy. The HCP explains to the client the risks and benefits of the procedure. However, the client refuses to sign the informed consent. The client states, "No one is removing any organs from my body because it is against my religious beliefs. I'm leaving!" The client's mother insists the client receive the operation. Which response does the nurse make to the client? - "It is your decision to refuse medical treatment." The nurse completes documentation for a client & realizes the entry has been placed in the wrong client's medical record. Which action by nurse is most appropriate? a. complete an incident report and place a copy in the client's medical record b. Draw a single line through each line of the incorrect entry and write a new note explaining what occurred c. Use correction fluid d. copy the note into the correct client's record and indicate that it was erroneously put in the wrong client's record - Draw a single line through each line of the incorrect entry and write a new note explaining what occurred. The nurse provides care for an adolescent client reporting arm pain after a fall. The nurse notes bruising in multiple stages of healing. The nurse accesses client's medical record and notes the client was treated twice last month for reported back pain after two separate falls. The client was treated two months ago for a perforated eardrum. Which action by nurse is priority? - Contact social services. The nurse provides care for a hospitalized older adult client who has a BMI of 16.1. Which is the priority action by the nurse? - Confer with a dietitian. The nurse speaks with a client and the spouse who have been undergoing family counseling. The client's spouse states, "You never take any responsibility for the messes you always cause!" Which response by the nurse is best? a. why do you say that? b. blaming is not effective c. lets focus only on the positives d. when is the last time you two had a vacation - "Blaming is not effective." *The nurse provides care for a client who is diagnosed with depression and anxiety. The client states, "I feel overwhelmed because I'm the only caregiver for my two children." Which response by the nurse is best? - "Do you participate in any religious or spiritual activities?" The nurse discusses the client's plan of care with the student nurse. The student nurse states, "I know the client is from another country, but the client could at least look at me when I'm talking. That is so rude." Which response by the nurse is best? - "Eye contact may be a sign of arrogance in the client's country." *The community health nurse conducts a program for suicide prevention at a high school. The nurse discusses high-risk groups for suicide. The nurse determines that further teaching is necessary if students from the group make which statement? a. adolescents are at risk to commit suicide b. depressed people are at risk to commit suicide c. history of previous suicide attempts put people at risk d. people grieving a loss for 9 months are at risk - "People grieving a loss for 9 months are at risk." The nurse assesses clients for potential spousal abuse. The nurse is most concerned if a client makes which statement? - "It's my fault because I push my spouse's buttons." The nurse makes client assignments on the medical surgical unit. The nurse assigns an LPN/LVN to a client diagnosed with localized herpes zoster. The LPN/LVN tells the nurse, "I have never had chickenpox." Which response by the nurse is most appropriate? a. use standard precautions when providing care for the client b. you will be fine because the client is on airborne precautions c. your client assignment will be changed d. why are you concerned about providing care for the client - "Your client assignment will be changed." The nurse instructs a student nurse about the correct way to set up a sterile field. The nurse determines that teaching is effective if which action is observed? - The student nurse sets up the sterile field above waist level. The nurse in the ED prepares to administer morphine sulfate to a client. Which action does nurse take first? - Verify the client's name and date of birth. *The nurse provides care for an older adult client who is diagnosed with a fractured ulna. The client reports falling frequently. Which client statements require that the nurse collect more information? (SATA) - "I keep my bedroom pitch black at night." "My sister gave me her cane before she died." "I have my vision checked every 3 years." "I prefer for my pants to fit loosely around my waist." The client approaches the triage desk in ED & reports exposure to chemicals after a truck overturned. The client has powder and unknown liquid substances on the clothing. The client is diaphoretic & reports difficulty breathing. Which action does nurse take first? - Put on appropriate protective gear. *The nurse reviews the medical record of a client who is confused. The client has soft wrist and ankle restraints in place. The nurse determines care is effective if which actions are documented? (Select all that apply.) a. restraints secured tightly to the kin b. client placed in room next to nursing station c. restraints attached to side rails on client's bed d. informed conset for the restraints has been obtained from client's spouse e. client alert and oriented x3 f. client placed in prone position - Client placed in room next to the nursing station, Informed consent for the restraints obtained from the client's spouse. The nurse provides care for a client diagnosed with acquired immune deficiency syndrome (AIDS). The nurse performs discharge teaching with the client. The nurse determines teaching is effective if the client makes which statements? (Select all that apply.) - "I will contact the health care provider if my bed sheets become drenched with perspiration." "I will not go to the fall festival."