NURSING EXAM NCLEX QUESTIONS WITH ANSWERS GRADED A+ 2022/2023 UPDATE, Exams of Nursing

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GRADED A+ 2022/2023 UPDATE

A 7 year old girl with type 1 insulin-dependent diabetes mellitus (IDDM) has been home sick for several days and is brought to the ED by her parents. If the child is experiencing ketoacidosis, the nurse would expect to see which of the following lab results?

1. Serum glucose 140 mg/dL
2. Serum creatinine 5.2 mg/dL
3. Blood pH 7.
4. Hematocr it 38% 3. Blood pH 7. The nurse delivers external cardiac compressions to a client while performing cardiopulmonary resuscitation (CPR). Which of the following actions by the nurse is BEST?
5. Maintain a position close the client's side with the nurse's knees apart
6. Maintain vertical pressure on the client's chest through the heel of the nurse's hand
7. Re-check the nurse's hand position after every 10 chest compressions
8. Check for a return of the client's pulse after every 8 breaths by the nurse
9. Maintain vertical pressure on the client's chest through the heel of the nurse's hand The nurse obtains a health history form a client admitted with acute glomerulonephritis that is associated with beta- hemolytic Streptococcus., The nurse expects which of the following to be significant in the health history?
10. The client had a sore throat 3 weeks earlier
11. There is a family history of glomerulonephritis
12. The client had a renal calculus 2 year earlier
13. The client had an accident involving renal trauma several years ago 1. The client had a sore throat 3 weeks earlier 00:0201: The nurse plans care for a client diagnosed with an acute myocardial infarction (MI). An appropriate nursing diagnosis is decreased cardiac output secondary to which of the following?
14. Ventricular dysrhythmias
15. Congestive heart failure
16. Recurrent myocardial infarction

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4. Hypertensive crisis

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1. Ventricular dysrhythmias A client comes to the ER reporting nausea, vomiting, and severe right upper quadrant pain. His temperature is 101.3, and an abdominal x-ray reveals an enlarged gallbladder. He is scheduled for surgery. Which of the following actions should the nurse take FIRST?
2. Assess the client's need for dietary teaching
3. Evaluate the client's fluid and electrolyte status
4. Examine the client's health history for allergies to antibiotics
5. Determine whether the client has signed consent for surgery
6. Evaluate the client's fluid and electrolyte status A client is being treated in the burn unit for second- and third-degree burns over 45% of his body. The physician's orders include the application of silver sulfadiazine cream. The BEST way for the nurse to apply this medication is to use which of the following?
7. Sterile 4x4 dressings soaked in saline
8. Sterile tongue depressor
9. Sterile gloved hand
10. Sterile cotton-tipped applicator
11. Sterile gloved hand When caring for a client with anorexia nervosa, which of the following observations indicates to the nurse that the client's condition is improving?
12. The client eats all the food on her meal tray
13. The client asks friends to bring her special foods
14. The client weighs herself daily
15. The client's weight has increased
16. The client's weight has increased Which of the following symptoms observed by the nurse during the first 24 hrs after a percutaneous liver biopsy would indicate a complication from the procedure?
17. Anorexia, nausea, and vomiting
18. Abdominal distention and discomfort
19. Pulse 112, blood pressure 100/60, respirations 20
20. Pain at the biopsy site
21. Pulse 112, blood pressure 100/60, respirations 20 The nurse is caring for a 56-year-old man receiving haloperidol (Haldol) 2 mg PO bid. The nurse assists the client to choose which of the following menus?

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1. 3 oz. roast beef, baked potatoes, salad with dressing, dill pickle, baked apple pie, and milk
2. 3 oz. baked chicken, green beans, steamed rice, 1 slice of bread, banana, and milk
3. Cheeseburger on a bun, french fries with catsup, chocolate chip cookie, apple, and milk
4. 3 oz. baked fish, slice of bread, broccoli, ice cream, and pineapple drink taken 30-60 min after the meal
5. 3 oz. baked chicken, green beans, steamed rice, 1 slice of bread, banana, and milk An adolescent is seen in the ER for a fracture of the left femur sustained in a sledding accident. The fracture is reduced and a cast is applied. The client is taught how to use crutches for ambulating without bearing weight on the left leg. The nurse would expect the client to learn which of the following crutch-walking gaits?
6. Two-point gait
7. Three-point gait
8. Four-point gait
9. Swing-through gait
10. Three-point gait The nurse cares for a client diagnosed with a right-sided CVA with dysphagia. Which of the following actions by the nurse reflects appropriate care for the client? Select all that apply.
11. The nurse assesses the client's ability to swallow
12. the nurse positions the client at a 45-degree angle
13. The nurse offers the client scrambled eggs
14. The nurse instructs the client to place food on the left side of the mouth
15. The nurse turns off the television 1, 3, 5 The nurse plans care for a 4 year old girl who has been sexually abused by her father. Play therapy is scheduled. The nurse knows that the PRIMARY goal of play therapy for a 4 year old is which of the following?
16. Provide her with the opportunity to express anger and hostility by playing with dolls
17. Promote communication because she may lack the emotional and intellectual capacity to express her perceptions verbally
18. Assess whether she is functioning at an age-appropriate developmental level
19. Reveal through direct observation of her at play what type of abuse has been experienced
20. Promote communication because she may lack the emotional and intellectual capacity to express her perceptions verbally A client is being treated for heart failure with diuretic therapy. Which of the following assessments BEST indicates to the nurse that the client's condition is improving?
21. The client's weight has remained stable since admission

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2. The client's systolic blood pressure has decreased

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3. There are fewer crackles heard when auscultating the client's lungs
4. The client's urinary output is 1,500 mL per day
5. There are fewer crackles heard when auscultating the client's lungs A preschooler with a fractured femur is brought to the ER by her parents. When asked how the injury occurred, the nurse finds old and new lesions on the child's buttocks. Which of the following statements MOST appropriately reflects how the nurse should document these findings?
6. "Six lesions noted on buttocks at various stages of healing"
7. "Multiple lesions on buttocks due to child abuse"
8. "Lesions on buttocks due to unknown causes"
9. "Several lesions on buttocks caused by cigarettes"
10. "Six lesions noted on buttocks at various stages of healing" A construction worker is admitted to the hospital for treatment of active TB. The nurse teaches the client about TB. Which of the following statements by the client indicates to the nurse that further teaching is necessary?
11. "I will have to take my medication for 6 months"
12. "I should cover my nose and mouth when coughing or sneezing"
13. "I will remain in isolation for at least 6 weeks"
14. "I will always have a positive skin test for TB"
15. "I will remain in isolation for at least 6 weeks" A woman admitted to the hospital in premature labor has been treated successfully. The client is to be sent home on an oral terbutaline. Which of the following statements by the client indicates to the nurse that the client understands the discharge teaching about the medication?
16. "As long as I take my medication, I can be sure I will not deliver prematurely"
17. "It is important that I count the fetal movements for one hour, twice a day"
18. "I may feel a rapid heartbeat and some muscle tremors while on this medication"
19. "Bed rest is necessary in order for the medication to work properly"
20. "I may feel a rapid heartbeat and some muscle tremors while on this medication" The nurse describes the procedure to a male client for collecting a clean-catch urine specimen for culture and sensitivity testing. Which of the following explanations by the nurse would be MOST accurate?
21. "The urinary meatus is cleansed with an iodine solution and then a urinary drainage catheter is inserted to obtain urine"
22. "You will be asked to empty your bladder one-half hour before the test; you will then be asked to void into a container"
23. "Before voiding, the urinary meatus is cleansed with an iodine solution and urine is voided into a sterile container; the container must not touch the penis"

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4. "You must void a few drops of urine, then stop; then void the remaining urine into a clean container, which should be immediately covered"
5. "Before voiding, the urinary meatus is cleansed with an iodine solution and urine is voided into a sterile container; the container must not touch the penis" The physician orders an arterial blood gas for a client receiving oxygen at 6 L/min. Results show pH 7.37, HCO3 26 mmHg, pCO2 42 mmHg, pO2 90 mmHg. Which of the following should the nurse do FIRST?
6. Increase the rate of oxygen flow the client is receiving
7. Elevate the head of the bed
8. Document the results in the chart
9. Instruct the client to cough and deep breathe
10. Document the results in the chart A client's brought to the emergency room reporting pressure in her chest. Her blood pressure is 150/90, pulse 88, respirations 20. The nurse administers nitroglycerin 0.4 mg SL as ordered. After five minutes her blood pressure is 100/60, pulse 96, respirations 20. Which of the following should the nurse do next?
11. Notify the physician that the client has become hypotensive, and obtain an order to administer IV fluids.
12. Place the client in semi-Fowler's position, and administer O2 at 4 L.
13. Administer a second dose of nitroglycerin
14. Document the results, and continue to monitor the client.
15. Document the results, and continue to monitor the client. A client contacts his home care nurse and reports nausea and abdominal pain. He has type 1 diabetes. The nurse should advise the client to do which of the following?
16. "Hold your regular dose of insulin"
17. "Check your blood glucose level every 3-4 hrs"
18. "Increase your consumption of foods containing simple sugars"
19. "Increase your activity level"
20. "Check your blood glucose level every 3-4 hrs" A client is being treated for Addison's disease. The physician orders cortisone 25 mg PO daily. The nurse should explain to the client that adjustment of the dosage may be required in which of the following situations?
21. Dosage is increased when the blood glucose level increases
22. Dosage is increased when dietary intake is increased
23. Dosage is decreased when infection stimulates endogenous steroid secretion
24. Dosage is increased relative to an increase in the level of stress
25. Dosage is increased relative to an increase in the level of stress

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A client with a history of heart failure visits the clinic. He states, "I have not been feeling like my old self for about 2 weeks." It would be MOST important for the nurse to ask which of the following questions?

1. "Do your ankles swell at the end of the day"
2. "Where do you sleep at night?"
3. "How do you feel after you eat dinner?"
4. "Do you have chest pain when you inhale?"
5. "Where do you sleep at night?" The nurse is caring for a client immediately after a paracentesis. It it MOST important for the nurse to ask which of the following questions?
6. "Do your clothes still feel tight?"
7. "Do you need to void?"
8. "Are you feeling dizzy?"
9. "Do you have any pain?"
10. "Are you feeling dizzy?" On admission to the hospital, an elderly client appears disheveled and is restless and confused. During the client's second day on the unit, a nurse approaches the client to administer medications. The nurse is unable to identify the client because his armband is missing. Which of the following actions by the nurse is the BEST?
11. Have the client's roommate identify him
12. Ask the client to state his full name
13. Ask another nurse to identify the client
14. Look in the chart at the picture of the client
15. Look in the chart at the picture of the client A client is treated in the ER for acute alcohol intoxication. He has a 4 year history of alcohol abuse. He is agitated and verbally abusive. His admission orders include chlordiazepoxide 50 mg IM or PO every 4-6 hrs for agitation. The nurse should take which of the following precautions after chlordiazepoxide is administered?
16. Place the client in restraints.
17. Leave the client in a room by himself until the tranquilizer takes effect.
18. Assign a practical nurse to stay with the client and document his condition
19. Ask the security guard to stay with the client
20. Assign a practical nurse to stay with the client and document his condition A woman is admitted to the hospital and delivers a healthy 7 lb, 2 oz girl. The mother decides to bottle-feed her infant. Which of the following statements by the mother after a teaching session

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indicates to the nurse that the client needs further instruction?

1. "I'll pump my breasts and use warm packs to relieve breast pain"

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2. "I'll use a tight bra and ice packs to relieve engorgements discomfort"
3. "I'll take the medication prescribed by the doctor for pain"
4. "I'll take the pills ordered by my doctor to help stop the production of milk"
5. "I'll pump my breasts and use warm packs to relieve breast pain" A client sustains a fractured left femur in a car accident. She is placed in balanced suspension skeletal traction using a Thomas splint and a Pearson attachment. The client tells the nurse that she has "terrible" pain in her left thigh. Which of the following should the nurse do FIRST?
6. Determine that all the weights and ropes from the traction apparatus are in line and hanging free
7. Ask the client for more information about the location and characteristics of her pain
8. Check the Thomas splint and Pearson attachment to make sure they are appropriately positioned
9. Explain to the client that the pain she is experiencing in the affected leg is a common occurrence
10. Ask the client for more information about the location and characteristics of her pain A client is admitted to the hospital with flu-like symptoms. When taking the history, the nurse learns that the client has been taking digoxin 0.125 mg PO daily and furosemide 40 mg PO daily for 3 years. Last month her physician changed the prescription for digoxin to 0.25 mg qd. The nurse would expect the physician to order which of the following laboratory tests?
11. Serum electrolytes and digoxin level
12. White blood cell count, hemoglobin, and hematocrit
13. Cardiac enzymes and an arterial blood gas
14. Blood cultures and urinalysis
15. Serum electrolytes and digoxin level The nurse plans care for a teenager admitted with fever, vomiting, and diarrhea. The nurse writes the following nursing diagnosis on the client's care plan: "fluid volume deficit." Which of the following changes in laboratory values would demonstrate an improvement in the client's condition?
16. Urine specific gravity, 1.015; hematocrit, 37%
17. Urine specific gravity, 1.020: hematocrit, 45%
18. Urine specific gravity, 1.032: hematocrit. 52%
19. Urine specific gravity, 1.025: hematocrit, 35%
20. Urine specific gravity, 1.020: hematocrit, 45% A client is hospitalized with a diagnosis of atrial fibrillation. Heparin 5,000 units is ordered every 12 hrs to be given SQ. The health care provider orders daily partial thromboplastin time (PTT). The result of the client's most recent PTT is 55. Which of the following actions should be taken by the nurse?
21. Document the results and administer the heparin
22. Withhold the heparin

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3. Notify the health care provider
4. Have the test repeated
5. Document the results and administer the heparin The physician orders furosemide and spironolactone for a client. Prior to administering the medication, the nurse determines that the client's potassium, is 3.2 mEq/L. In addition to notifying the physician, the nurse should anticipate taking which of the following actions?
6. Do not administer the furosemide or spironolactone
7. Administer the spironolactone only
8. Administer the furosemide only
9. Administer the furosemide and spironolactone
10. Administer the spironolactone only A client returns to the clinic 2 weeks after being started on allopurinol 200 mg PO daily. The nurse reviews information about this medication with the client. Which of the following statements by the client indicates that the teaching was effective?
11. "I should take my medication on an empty stomach"
12. "I should take my medication with orange juice"
13. "I should increase my intake of protein"
14. "I should drink at least 8 glasses of water every day"
15. "I should drink at least 8 glasses of water every day" A client is receiving packed red blood cells. Several minutes after the infusion is started, the client reports itching and develops hives on his chest and abdomen. Which of the following actions should the nurse take FIRST?
16. Slow the rate of the transfusion
17. Call the physician for an order for an antihistamine
18. Mix IV fluid with the blood to dilute it
19. Stop the transfusion
20. Stop the transfusion Upon returning form lunch, the nurse is approached in the elevator by a hospital employee from another unit. The employee states that her close friend is a client on the nurse's unit. The employee asks how her friend is doing and if all of her tests were normal. The nurse should do which of the following?
21. Answer the employee's questions softly so other people on the elevator will not hear
22. Refuse to discuss her friend's medical condition. Suggest that she visit her friend.
23. Give the employee the name of the client's physician to call for this information
24. Tell the employee about the results of the client's tests because they were within normal limits

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2. Refuse to discuss her friend's medical condition. Suggest that she visit her friend.

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An hour after admission to the nursery, the nurse observes a newborn baby having spontaneous jerky movements of the limbs. The infant's mother had gestational diabetes mellitus during pregnancy. Which of the following actions should the nurse take FIRST?

1. Give dextrose water
2. Call the physician immediately
3. Determine the blood glucose level
4. Observe closely for other symptoms
5. Determine the blood glucose level A woman is admitted to the hospital with a ruptured ectopic pregnancy. A laparotomy is scheduled. Preoperatively, which of the following goals is MOST important for the nurse to include on the client's plan of care?
6. Fluid replacement
7. Pain relief
8. Emotional support
9. Respiratory therapy
10. Fluid replacement The nurse obtains a diet history from a pregnancy 16 year old girl. The girls tells the nurse that her typical daily diet includes cereal and milk for breakfast, pizza and soda for lunch, and a cheeseburger, milk shake, fries, and salad for dinner. Which of the following is the MOST accurate nursing diagnosis based on this data?
11. Altered nutrition: more than body requirements related to high-fat intake
12. Knowledge deficit: nutrition in pregnancy
13. Altered nutrition: less than body requirements related to increased nutritional demands of pregnancy
14. Risk for injury: fetal malnutrition related to poor maternal diet
15. Altered nutrition: less than body requirements related to increased nutritional demands of pregnancy The nurse plans acre for a 14 year old girl admitted with an eating disorder. On admission, the girl weighs 82 lb. and is 5'4" tall. Lab tests indicate severe hypokalemia, anemia, and dehydration. The nurse should give which of the following nursing diagnosis the HIGHEST priority?
16. Body image disturbance related to weight loss
17. Self-esteem disturbance related to feelings of inadequacy
18. Altered nutrition: less than body requirements related to decreased intake
19. Decreased cardiac output related to the potential for dysrhythmias
20. Decreased cardiac output related to the potential for dysrhythmias The mother of a boy with type 1 diabetes calls the physician's office to discuss the child's self- monitoring blood glucose home reading. He is being tightly regulated with a combination of NPH and

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regular insulin before breakfast and supper. The past 2 morning his blood sugar readings were 220 mg/dL and 210 mg/dL. Which of the following should the nurse tell the boy's mother?

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1. "Continue with his medication regimen"
2. "Check his blood sugar during the night"
3. "Give his NPH insulin later in the evening"
4. "Serve his bedtime snack earlier in the evening"
5. "Check his blood sugar during the night" A boy was riding his bike to school when he hit the curb. He fell and hurt his leg. The school nurse was called and found him alert and conscious, but in severe pain with a possible fracture of the right femur. Which of the following is the FIRST action that the nurse should take?
6. Immobilize the affected limb with a spinal split and ask him not to move
7. Make a thorough assessment of the circumstances surrounding the accident
8. Put him in semi-Fowler's position for comfort
9. Check the pedal pulse and blanching sign in both legs
10. Immobilize the affected limb with a spinal split and ask him not to move A child undergoes a tonsillectomy for treatment of chronic tonsillitis unresponsive to antibiotic therapy. After surgery, the child is brought to the recovery room. Which of the following actions should the nurse include in the child's plan of care?
11. Institute measures to minimize crying
12. Perform postural drainage every 2 hours
13. Cough and deep breathe every hour
14. Give ice cream as tolerated
15. Institute measures to minimize crying A client is receiving intravenous cimetidine. After 20 minutes of the infusion, the client reports a headache and dizziness. Which of the following actions should the nurse take FIRST?
16. Stop the infusion
17. Take the client's vital signs
18. Reposition the client
19. Call the pharmacist
20. Stop the infusion A client is admitted with a diagnosis of dementia. He attempts several times to pull out his nasogastric tubes. An order for cloth wrist restraints is received by the nurse. Which of the following actions by the nurse is MOST appropriate?
21. Attach the ties of the restraints to the bed frame
22. Perform range of motion to the restrained extremities once a shift

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3. Remove the restraints when the client is up in a wheelchair
4. Explain the need for restraints only to the family because the client is confused
5. Attach the ties of the restraints to the bed frame The nurse cares for a client with a diagnosis of CVA. The nurse is feeding the client in a chair when he suddenly begins to choke. Which of the following actions should the nurse take FIRST?
6. Check for breathlessness by placing an ear over the client's mouth and observing the chest
7. Leave the client in the chair and apply vigorous abdominal or chest thrusts fro behind the client
8. Ask the client, "Are you choking?'
9. Return the client to the bed and apply vigorous abdominal chest thrusts while straddling the client's thighs
10. Ask the client, "Are you choking?' A client with a history of bipolar disorder is admitted to the psychiatric hospital. She was found by the police attempting to climb onto the wing of a plane at the airport. Her husband reports that she has not eaten or slept in 2 days, and he suspects she has stopped taking lithium. On admission, the nurse should place the HIGHEST priority on which of the following client care needs?
11. Teaching the client about the importance of taking lithium as prescribed
12. Providing the client with safe environment with few distractions
13. Arranging for food and rest for the client
14. Setting limits on the client's behavior
15. Arranging for food and rest for the client The physician orders a NG tube inserted and connected to low intermittent suction for a client with an intestinal obstruction. Two hours after insertion of the NG tube, the client vomits 200 mL. While irrigating the NG tube, the nurse notes resistance. Which of the following actions should the nurse take FIRST
16. Replace the NG tube with a larger one
17. Turn the client on his left side
18. Change the suction from intermittent to continuous
19. Continue the irrigation
20. Turn the client on his left side A child with a compound fracture of the left femur is being admitted to a pediatric unit. Which of the following actions is BEST for the nurse to take?
21. Ask the NAP to obtain the child's vital signs while the nurse obtains a history from the parents.
22. ASK the LPN/LVN to assess the peripheral pulses of the child's left leg while the nurse completes the admission forms
23. Ask the LPN/LVN to stay with the child and his parents while the nurse obtains phone orders from the physician

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4. Ask the NAP to obtain equipment for the child's care while the nurse talks with the child and his parents

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4. Ask the NAP to obtain equipment for the child's care while the nurse talks with the child and his parents Which of the following tasks is appropriate for the nurse to delegate to an experienced NAP?
5. Obtain a 24 hr diet recall from a client recently admitted with anorexia nervosa
6. Obtain a clean-catch urine specimen form a client suspected of having a urinary tract infection
7. Observe the amount and characteristics of the returns from a continuous bladder irrigation for a client after a transurethral resection
8. Observe a client newly diagnosed with diabetes mellitus practice injection techniques using an orange
9. Obtain a clean-catch urine specimen form a client suspected of having a urinary tract infection Which of the following clients should the nurse on a pediatric unit assign to an LPN/LVN?
10. a 3 year old admitted yesterday with laryngotracheobronchitis who has a tracheostomy
11. A 6 year old girl admitted after a gastric lavage for acetaminophen ingestion
12. A 6 year old boy admitted for a fracture of the femur, in balanced suspension traction
13. A 10 year old boy admitted for observation after an acute asthmatic attack
14. A 6 year old boy admitted for a fracture of the femur, in balanced suspension traction Immediately after a percutaneous liver biopsy, the nurse should place the client in which of the following positions?
15. Supine
16. Right side-lying
17. Left side-lying
18. Semi-Fowler's
19. Right side-lying An angiogram is scheduled for a client with decreased circulation in her right leg. After the angiogram, the nurse should place the client in which of the following positions?
20. Semi-Fowler's with right leg bent at the knee
21. Side-lying with a pillow between the knees
22. Supine with right leg extended
23. High Fowler's with right leg elevated
24. Supine with right leg extended The nurse cares for a client after a lumbar laminectomy. Which of the following statements BEST describes the method of turning a client following a lumbar laminectomy?

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1. The head of the bed is elevated 30 degrees; the client locks her knees when turning
2. A pillow is placed between the client's legs; her body is turned as a unit
3. The client straightens her back and grasps the side rail on the opposite side of the bed
4. The head of the bed is flat; the client bends her knees and rolls to the side

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2. A pillow is placed between the client's legs; her body is turned as a unit The nurse cares for a client after an appendectomy. The client continues to report discomfort to the nurse shortly after receiving an analgesic. Which of the following measures by the nurse would be MOST appropriate?
3. Notify the physician
4. Place the client in Fowler's position
5. Massage his abdomen
6. Provide him with reading material
7. Place the client in Fowler's position A client is admitted to the ER with a diagnosis of acute myocardial infarction. The client tells the nurse, "I'm sacred. I think I'm going to die." Which of the following responses by the nurse would be MOST appropriate?
8. "Everything is going to be fine. We'll take good care of you."
9. "I know what you mean. I thought I was having a heart attack once."
10. "I'll call your doctor so you can discuss it with him."
11. "It's normal to feel frightened. We're doing everything we can for you."
12. "It's normal to feel frightened. We're doing everything we can for you." A mother is to undergo a breast biopsy. She tells the nurse, "If I lose my breast, I know my husband will no longer find me attractive." Which of the following responses by the nurse would be MOST appropriate?
13. "You don't know if you are going to lose your breast. They are just doing the biopsy now."
14. "You should focus on your children. They are young and they need you."
15. "You seem to be concerned that your relationship with your husband might change."
16. "Why don't you wait and see what your husband's reaction is before you get upset."
17. "You seem to be concerned that your relationship with your husband might change." A client in the psychiatric unit asks the nurse, "Am I in a special radioactive shelter? When was it last checked for radioactivity?" Which of the following responses by the nurse would be MOST appropriate?
18. "This is a hospital, and we do not have a Nuclear Medicine Department here."
19. "Don't worry, you're safe. There's no radioactivity here."
20. "I'm sure your safety is of concern to you, but this is a hospital."
21. "Please share with me what makes you think there is radioactivity here."
22. "I'm sure your safety is of concern to you, but this is a hospital." A 58 year old man with head and neck cancer is admitted to the hospital and tells the nurse he does not want parenteral nutritional therapy as his cancer progresses. The nurse explains he can specify his wishes by creating an advance directive. The nurse knows that the requirement to provide clients with

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this type of information can be found in which of the following?

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1. The Patient Self-Determination Act
2. Nursing Scope and Standards of Practice
3. The Patient Protection and Affordable Care Act
4. The Patients' Bill of Rights
5. The Patient Self-Determination Act A 14 year old girl newly diagnosed with diabetes is preparing for discharge. Which of the following activities BEST describes the nurse's role as a client advocate?
6. Arranging for a visit with a home health nurse
7. Providing written medication instructions to the client's parents
8. Instructing the client to follow up with her provider in 4 weeks
9. Teaching the client how to administer insulin rejections
10. Teaching the client how to administer insulin rejections A client is seen for an outpatient appointment and asks the nurse if he can obtain a copy of his medical record. The nurse knows the client has the right to read and copy his medical records, and that this guaranteed by virtue of which of the following?
11. The Code of Ethics for Nurses
12. The Health Insurance Portability and Accountability Act
13. The Patient Self-Determination Act
14. The Americans with Disabilities Act
15. The Health Insurance Portability and Accountability Act After receiving report at the start of the evening shift, which of the following clients should the nurse attend to FIRST?
16. A 34 year old man undergoing treatment for non-Hodgkin's lymphoma with a potassium level of 7.5 mEq/L
17. A 21 year old woman with sickle-cell anemia with pain of 6 on a scale of 1-10
18. A 55 year old woman with ovarian cancer waiting to be discharged
19. A 72 year old man with chronic obstructive pulmonary disease and a pulse oximetry of 96% on room air
20. A 34 year old man undergoing treatment for non-Hodgkin's lymphoma with a potassium level of 7.5 mEq/L A 34 year old woman who developed Stevens-Johnson syndrome while undergoing treatment with carbamazepine is being transferred in stable condition from the intensive care unit to the medical unit. There are 4 beds available. The nurse knows the BEST choice of roommates for this client is which of the following?
21. A 40 year old man with MRSA
22. A 28 year old woman diagnosed with diarrhea

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3. A 72 year old man with fever of unknown origin
4. A 68 year old woman with atrial fibrillation
5. A 68 year old woman with atrial fibrillation

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A 72 year old man who had a stroke is being transferred from a medical unit to a rehabilitation center. The nurse case manager is assisting in the process. The nurse knows that the goals of case management include which of the following? Select all that apply.

1. Improving the coordination of care
2. Increasing referrals to local organizations
3. Reducing the fragmentation of care
4. Discharging clients quickly 1, 3 An 18 year old client with acute lymphocytic leukemia is admitted to the bone marrow transplantation unit. His family is having trouble dealing with the emotional and financial pressures of his disease. The nurse, case manager, physician, and social worker meet to discuss the plan of care. The nurse knows this type of interdisciplinary interactions is BEST referred to as which of the following?
5. Case management
6. Collaboration
7. Cooperation
8. Collegiality
9. Collaboration A pregnant woman at 15 weeks' gestation is scheduled for an amniocentesis. As the client is being prepped for the procedure, it becomes clear to the nurse that the client doesn't fully understand the risks and benefits associated with the procedure. Which of the following describe the nurse's role in obtaining informed consent? Select all that apply.
10. Explain the risks and benefits associated with the procedure
11. Describe the alternatives to the procedure
12. Witness the client's signature on the consent form
13. Advocate for the client by ensuring she is making an informed decision 3, 4 The nurse noticed and increase in the prevalence of pressure ulcers among clients in an intensive care unit. Sh documented her findings and worked with her manager to develop and implement a new policy using a pressure ulcer risk assessment scale. Which of the following BEST describes the nurse's actions?
14. Quality improvement
15. Collaboration
16. Advocacy
17. Case management
18. Quality improvement The nurse is working on a surgical unit. Which of the following tasks would be appropriate for the nurse

GRADED A+ 2022/2023 UPDATE

to delegate to the nursing assistive personnel?