Nursing Interventions and Client Care Scenarios, Quizzes of Nursing

Download Nursing Interventions and Client Care Scenarios and more Quizzes Nursing in PDF only on Docsity! NGN NCLEX PN ACTUAL EXAM 2024- 2025 WITH NGN /PN NCLEX ACTUAL EXAM (NEXT GENERATION) 2024-2025 COMPLETE 180 QUESTIONS AND CORRECT DETAILED ANSWERS 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? - ANS 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? - ANS 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? - ANS 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? - ANS 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? - ANS "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? - ANS 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) - ANS 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? - ANS "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? - ANS 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? - ANS 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? - ANS 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? - ANS 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? - ANS "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? - ANS Irrigate the bladder with 20 to 30 mL of 0.9% sodium chloride 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? - ANS "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? - ANS 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? - ANS 1100 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? - ANS "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? - ANS 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? - ANS "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? - ANS 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? - ANS "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? - ANS 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? - ANS 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? - ANS 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? - ANS 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? - ANS 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.) - ANS 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? - ANS 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? - ANS 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? - ANS 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? - ANS 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? - ANS 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? - ANS 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? - ANS 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? - ANS 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? - ANS 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? - ANS I have this flat, scaly area with red edge on neck A nurse is caring for a client who has been placed in restraints. Which of the following is appropriate? - ANS 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? - ANS 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? - ANS 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? - ANS 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? - ANS 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? - ANS 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 - ANS Install gates at the top and bottom of the stairs A nurse is preparing a sterile field to peform a dressing change. Which of the following actions should the nurse take? - ANS Place sterile objects at least 2.5 cm (1 inch) from the edge of the sterile field A nurse is collecting data from an adolescent client who is a victim of sexual abuse. The nurse recognizes the use of the defense mechanism of suppression when the client states, - ANS "I guess I have to take some of the blame because of the way my friends and I dress" A client is prescribed 2g of ampicillin. The pharmacy dispenses this medication in 500 mg tablets. Which of the following should the nurse give the client? - ANS 4 tablets A nurse is providing home care to a client and is reinforcing teaching regarding home safety. Which of the following by the client indicates a need for further teaching? - ANS "I will walk barefoot to prevent slipping" "I will check my smoke alarms once a month" A Client with emphysema asks the nurse why he has difficulty exhaling. Which of the following statements by the nurse is appropriate? - ANS "Your windpipe is inflamed and constricted" A nurse is caring for a client who was admitted 12 hours ago and is experiencing acute alcohol withdrawal. Which of the following is an expected finding for the client? - ANS Irritability A nurse is caring for a client who is in active labor and is accompanied by her partner. The client and her partner tell the nurse they were unable to attend childbirth preparartion classes. Which of the following responses by the nurse supports the partner's involvement during labor? - ANS "Breathing with your partner will help her to relax during contractions" A nurse is planning tracheostomy care for a client in a long-term care facility. Which of the following actions should the nurse plan to take first? - ANS Remove the tracheostomy inner cannula A nurse in a provider's office is reinforcing teaching with the parents of a school-age child who has an active case of pediculosis capitis. Which of the following should be included in the teaching? - ANS Wash the bed linens in hot water. Clean the child's toys with 1:10 bleach solution. A nurse caring for the mother of a newborn finds the client crying in her room. The client tells th nurse, "I don't think I can handle caring for a baby." Which of the following nursing interventions is appropriate? - ANS Encourage the client to share her feelings A nurse is assisting with the care of a 36-year-old client who is at 16 weeks of gestation and is scheduled for an amniocentesis. The nurse recognizes that the client understands the amniocentesis is performed to identity - ANS Chromosomal abnormalities A nurse is caring for client who is requesting assistance with smoking cessation. For which of the following medications should the nurse anticipate having to reinforce teaching? - ANS Nicotinic acid (niacin) A nurse is caring for a client who is 12hr postpartum. The nurse observes an increase in vaginal bleeding. Which of the following actions should the nurse plan to take first? - ANS Massage the fundus. Obtain the client's vital signs. A nurse is preparing to administer ibuprofen solution 60 mg orally to a 7 month old infant who is febrile. Available is ibuprofen 50 mg/ 1.25 mL. How many mL should the nurse administer? - ANS 1.5 mL A nurse is caring for a child who has terminated cancer. Which of the following responses by the child's school-age brother should the nurse expect? - ANS Believes his bad behavior is causing his brother's death A nurse is caring for a client who is experiencing alcohol withdrawal. Which of the following medications should anticipate administering to prevent complications of withdrawal? - ANS Lorazepam A nurse is reinforcing dietary teaching with a client whose pre-pregnancy BMI was 30.5. The nurse should recognize that the client understands the teaching when she states that she should expect to gain how many pounds during her pregnancy? - ANS 16 lb A nurse is assisting with the care of a client following electroconvulsive therapy for the treatment of a depressive disorder. Which of the following findings should the nurse expect 15 min following this procedure? - ANS Disorientation A nurse is caring for a client who has right-sided heart failure. The client's partner expresses concern that the client will die. Which of the following is an appropriate re- sponse by the nurse? - ANS "It is difficult to see someone so sick. What have you been told about your partner's prognosis?" A nurse in a long-term care facility is auscultating the lung sounds of a client who reports shortness of breath and increase fatigue. Listen to the audio clip. Which of the following lung sounds should the nurse report to the provider? - ANS Fine crackles A nurse is reinforcing teaching with a client who is to self-administer epoetin alfa (Epogen). Which of the following instructions should the nurse include? - ANS Administer the medication subcutaneously A nurse is caring for a client who has a Salem Sump tube connected to intermittent wall suction. Which of the following nursing interventions should the nurse perform? - ANS Reposition the client every 2 hours A nurse is provider's office is reviewing pediculosis capitis management and pre- vention strategies with the parent of a school-age child. Which of the following strategies should the nurse include? (select all that apply) - ANS Store the child's clothing in a separate cubicle when at school. Boil brushes and combs in water for 10 min. Dry bed linens and clothing for at least 20 mins. A nurse is contributing to the plan of care for an adolescent who has cystic fibrosis. Which of the following diets should the nurse recommend? - ANS High-calorie A nurse is assisting with the transfer of a client to a long-term care facility. The nurse should review which of the following sections of the medical record to the locate information about the clients personal health insurance? - ANS Admission sheet A nurse is reinforcing teaching with a client who has a new prescription for pred- nisone for the treatment of Addison's disease. Which of the ff. instructions should the nurse include? - ANS "You will need to schedule a bone density test" A nurse is assisting in the admission of a client who has diabetic ketoacidosis to a medical unit. Which of the ff. IV solutions the nurse anticipates administering first upon admission? - ANS 0.9% sodium chloride A nurse is caring for a client who is postoperative following a thyroidectomy. Which of the following findings is the priority? - ANS Tingling around the mouth A client who has asthma and is started on montelukast (Singular) returns to the clinic 1 month later. Which of the ff. indicates that the client is complying with this medication regimen? - ANS The client takes the medication once daily at bedtime A nurse is collecting data from an older adult client who is receiving a unit of packed RBCs. Which of the ff. findings should the nurse report to the provider as an indication of circulatory overload? - ANS Crackles heard on auscultation A nurse is preparing a client for surgery. The client states, "I'm sure this surgery will not help me get better." Which of the ff. responses by the nurse is appropriate? - ANS "You're saying that you are doubtful that this procedure will benefit you" A nurse is preparing to provide suctioning for a toddler who has a tracheostomy. Which of ff. actions should be included in the plan of care? - ANS Allow the child to rest for 45 seconds between aspirations A nurse in a long-term care facility is assisting with the admission of a client who requires oropharyngeal suction. Which of the ff. supplies does the nurse need to perform this task? - ANS Yankauer catheter A nurse is maintaining droplet precautions for a client who has meningitis. Which of the following actions by the nurse is appropriate? - ANS Wear a surgical mask within 3 feet of the client A nurse is collecting data from a client who has cholecystitis. In which of the ff. lo- cations should the nurse expect the client to report pain? - ANS Right upper quadrant The parents of a 12-month-old voice their concern that their child is crawling but not pulling herself up to stand like the other children at the day care center. The nurse should recommend to the parents that they - ANS Have the child evaluated by a pediatrician A nurse recognizes that nurse-client communication is effective when the client. - ANS Asks the nurses to listen to potential solutions A nurse is caring for a client who is receiving IV fluids. As the nurse enters the room, the IV pump's alarm begins beeping. The client tells the nurse, "That happens all the time. Just turn off the alarm." Which of the ff. actions should the nurse take first? - ANS Observe the IV site A nurse is caring for a client who is scheduled for colonoscopy with polyp removal. Which of the following client statements should alert the nurse that the client may be at risk for complications from the procedure? - ANS "I needed three ibuprofens for my arthritis pain last night" A nurse is reinforcing teaching with the parents of a newborn about physical assessments. Which of the ff. statements by the parent demonstrates understanding of the newborn hearing screening test? - ANS "If my baby fails the hearing test, he will need to be tested in 3 months" A nurse is reviewing instructions with a male client who is uncircumcised about obtaining a clean-catch midstream urine specimen. Identify the sequence of actions the client should take after washing his hands. (Move the steps into the box on the right, placing them in the selected order of performance. All steps must used.) - ANS A. Expose the glans of the penis B. Cleanse the penis using aseptic swab C. Begin urination D. Pass the cup into the urine stream E. Move the cup out of the urine stream F. Move the cup out of the urine stream A nurse is caring for a client in a mental health inpatient facility who reports auditory and visual hallucinations. Which of the following should the nurse recognize as indicating the client is most in need of intervention? - ANS States he is being told to hit his roommate A nurse is reinforcing teaching for a client who has just started taking amitriptyline (Elavil). Which of the following should the nurse include as an adverse effect of this medication? - ANS Orthostatic hypotension A nurse in a long-term care facility is caring for a client who uses a continuous positive airway pressure (CPAP) machine at night for sleep apnea. The client reports daytime sleepiness. Which of the following actions should the nurse take first? - ANS Check for proper fit of the mask on the CPAP machine. Provide activities during the day to stimulate the client. A nurse is caring for a client in the provider's office who has is experiencing an episode of acute asthma. The nurse should aminister which of the following medications? - ANS Traimcinolone (Azmacort) A nurse is assisting with the care of a client who is recieving IV therapy of 0.9% sodium chloride. The client recieved 200mL more than prescribed in 1 hr because the infusion pump was set incorrectly. Data collection reveals that the client is stable. This incident does not meet the criteria of malpractice because - ANS The client was not harmed as a result of the incident A nurse is reinforcing teaching with a client who is undergoing chemotherapy to treat laryngeal cancer and has developed mucositis. Which of the following client statements indicates an understanding of the teaching? - ANS "I will rinse my mouth with room-temperature saline solution" A nurse is caring for a toddler who is admitted to the pediatric unit and is 2 hr postoperative following a tonsillectomy. Which of the following findings is a sign of hemorrhage? - ANS Frequent swallowing A nurse is caring for an adolescent client who has anorexia nervosa. Which of the following findings should the nurse expect? - ANS Absence of menses. Elevated blood pressure. A nurse has administered cephalexin (Keflex) to a client. Which of the following is the earliest indicator of an anaphylatic reaction? - ANS Wheezes. Hypotension. A nurse is admitting a client with active tuberculosis. Which of the following is an appropriate nursing intervention? - ANS Place the client in a room that is ventilated to the outside A nurse is providing change-of-shift report on four clients. Which of the following is most important for the nurse to include in the report? - ANS A client had a blood glucose of 140 mg/dL A nurse is caring for a client who has an order for NPH insulin (Humulin N) 10 units and regulat insulin (humulin R) 15 units SQ. Which of the following actions should the nurse perform first? - ANS Inject 10 unites of air into the NPH insulin vial A nurse discovers a fire in the trash can of a client's room. Which of the following actions should the nurse take first? - ANS Escort the client to a secure area A client has a large, deep ulcer on her right hip. The primary care provider has prescribed a woman vacuum to be applied. Which of the following is an appropriate nursing action? - ANS Maintain hydrophillic material deep into the ulcer A nurse is reinforcing teaching to a client who has been taking dig 0.25 mg PO daily for 6 months, which of the following indicates a need for further teaching? - ANS I will call my provider if I experience a yellow tinge to my vision A nurse receives a verbal order for a client to receive a stat dose of meperidine (demerol) 100 mg PO. She administers the medication, charts the administration, and then realizes she has administered Phenytoin (dilantin) 100 mg PO. After obtaining the client's vital signs, which of the following actions should the nurse take? - ANS Notify the provider A nurse is administering medication to a client. Which of the following actions is appropriate for the nurse to take? - ANS Verify with another nurse when calculating a new dose of medication A nurse is reinforcing discharge teaching to a client who is prescribed propylthiuracil. For which of the following should the nurse instruct the client to monitor and report to the provider immediately? - ANS Sore throat A nurse is reinforcing foot care to a client with diabetes mellitus. Which of the following clients' statements indicate to the nurse a need for further teaching? - ANS "I will soak my feet in warm water every night" A nurse is caring for a client who has heart failure and is taking furosemide (lasix). Which of the following statements made by the client indicates a need for the nurse to intervene? - ANS "I have to sleep sitting up" A nurse is reinforcing teaching to a client who has a new prescription for transdermal nitroglycerin (Nitro-Dur). Which of the following statements indicates the client understands the teaching? - ANS "I will leave the patch on for 12 to 14 hours each day" A nurse is caring for a client who is 2 days postoperative. The client has a prescription for acetaminophen 300mg with codeine 30 mg (Tylenol #3), 1 tablet every 3 to 4 hr PRN for pain. The nurse inadvertently gave the client 2 tablets. Which of the following is the proper place to document this error? - ANS Incident report A nurse is caring for a client in a mental health unit who is pacing back and forth and wringing his hands. Which of the following interventions should the nurse implement? - ANS Take the client for a walk to the recreation room A nurse is caring for a client who is in bed and experiencing a toni-clonic seizure. Which of the following actions should the nurse take? - ANS Place the bed in the lowest position