Nursing Scenarios and Best Practices, Exams of Advanced Education

Download Nursing Scenarios and Best Practices and more Exams Advanced Education in PDF only on Docsity! UWORLD NCLEX - PN TEST 1 WITH 100% CORRECT ANSWERS 2024 The nurse on an inpatient mental health unit is caring for a client with paranoid delusions who is refusing to eat. The client states that all the food and drinks have been poisoned. Which intervention by the nurse is appropriate? - Correct Answer-provide the client food in unopened, individually packaged food After listening to the parents' reports and seeing the following pediatric clients, the nurse knows that which client demonstrates signs of abuse that may necessitate mandatory reporting? - Correct Answer-5- year -old whose x-ray reveals 1 new and 2 healed humerus fractures after falling from a tree. The nurse is discussing the care needs of a client in the last stage of Huntington disease with the family. When the nurse mentions arranging for delivery of a prescribed hospital bed, the client's spouse becomes visibly upset and says, "No hospital bed. I'm just not ready for it yet." What is the best response by the nurse? - Correct Answer-what upsets you about having a hospital bed? The nurse administers ondansetron to a hospitalized client. Which statement would indicate to the nurse that the ondansetron was effective? - Correct Answer-The nausea is a lot better The nurse has just received report on 4 clients. Which client should the nurse see first? - Correct Answer-client receiving Iv normal saline at 250 ml / hr who is reporting puffy legs and a new cough An unaccompanied 16-year-old girl comes to the emergency department with severe abdominal pain and vomiting. The client has a temperature of 102.2 F (39 C) and a pulse of 120/min and is lethargic. The client's parents are out of town, and no guardians can be reached. How should this client's care be handled? - Correct Answer-Administer care until the parents or guardians can be reached. The nurse reinforces teaching to the parents of a 12-month-old who has begun weaning from breastfeeding. Which statement by the parents indicates that teaching has been effective? - Correct Answer-I can start substituting breastfeeding sessions with whole cow's milk. The nurse cares for a client with a terminal disease who has an advance directive supporting a do not resuscitate (DNR) code status. The client stops breathing and loses a pulse. The client's adult child states, "I changed my mind. Do whatever you can to save him!" Which intervention is most appropriate at this time? - Correct Answer-Explain the client's wishes to the client child. The nurse speaks with a client diagnosed with schizophrenia who begins to look away toward the door and grimace. Which statement by the nurse is most therapeutic at this time? - Correct Answer-what do you see at the door? The nurse reinforces teaching to a 15-year-old primigravid client at 16 weeks gestation during an initial prenatal visit. Which information would be a priority for the nurse to include? - Correct Answer-stress the importance of consistent prenatal care A female client is visiting the clinic for an annual well-woman examination. The client reports having had sex with women. Which question will help the nurse determine the client's risk for sexually transmitted infections? - Correct Answer-what barrier methods do you and your partner(s) use? While the nurse is transporting a client to a new unit, the client's chest tube drainage system falls off the bed and the tube becomes dislodged from the chest wall. What is the nurse's priority action? - Correct Answer-Firmly cover the insertion site with the palm of a clean, gloved hand The nurse cares for a client with a burn on the arm and finds that the area is red, moist, and covered in shiny, fluid-filled vesicles. Which burn stage does the nurse document? - Correct Answer-Second degree A nurse in the emergency department is caring for 4 clients. Which client should the nurse see first? - Correct Answer-Client with myasthenia gravis who has a fever and increasing difficulty swallowing The nurse is caring for a client who is being treated for depression and suicidal ideation. Which client statement best indicates that the client is not currently at risk for suicide? - Correct Answer-I plan to attend my granddaughter's graduation next month. The nurse is caring for a client taking escitalopram who reports no improvement of depressive feelings since starting the medication 2 months ago. What is the best response by the nurse? - Correct Answer-Let's talk more about how you have taking this medication The nurse removes personal protective equipment (PPE) after completing a wound dressing change for a client in airborne transmission-based precautions. Which PPE should the nurse remove first? - Correct Answer-Gloves The client admitted to the psychiatric unit with severe anxiety is pacing rapidly in the room, crying, and hyperventilating. The client yells, "I can't believe you took my belongings! Where are you keeping them? This is so frustrating!" What is the appropriate response by the nurse? - Correct Answer-Your belongings are locked in a safe place to ensure that they are protected while you are here. For which client is it most important for the nurse to reinforce teaching regarding ways to prevent the spread of the condition? - Correct Answer-client with tinea corporis The nurses on a medical-surgical unit maintain a shared social media page. Which social media posts written by nurses breach client confidentiality? Select all that apply. - Correct Answer-I'm going to private message everyone a cute story about our sweet client with dementia it breaks my heart that are paraplegic client was so neglected by her husband The client in room five is positive for influenza so please remember your flu vaccines Wash your hands well if you had room for this week! cultures are now positive for clostridium difficile The nurse assists with medication reconciliation for a client visiting the clinic for a follow- up appointment. Which medication reported by the client requires further investigation? Click the exhibit button for additional information. - Correct Answer-200 mg of celecoxib PO once daily A client is in cardiac arrest, and resuscitation efforts are in progress when the client's spouse arrives. The client's spouse insists on coming into the room. How should the nurse respond? - Correct Answer-Allow the spouse into the room and provide a chair The clinic nurse instructs a female client on how to collect a clean-catch urine specimen for culture and sensitivity. Which of the following client statements indicate that teaching has been effective? Select all that apply. - Correct Answer-I will be very careful not to touch the inside or rim of the container I will begin to urinate before passing the container into the stream for collection I will cleanse the area with single use antiseptic wipes prior to urinating The nurse in a psychiatric unit is approached by an aggressive client who grabs the nurse's stethoscope and attempts to strangle the nurse with it. The nurse is able to escape the client's grasp unharmed. Which action should the nurse take first? - Correct Answer-Beginning scoring other clients out of the room A client comes to the emergency department after being bitten by a bat. The nurse observes 2 small, nondraining puncture wounds resembling pinpricks on the fingertip. Which action should the nurse implement first? - Correct Answer-scrub the wound with povidone iodine solution or soap and water The nurse on a medical-surgical unit prepares scheduled daily medications for a client and places them in a pill cup. After receiving the pill cup, the client states, "I take a whole tablet of metoprolol at home. Why did you cut this one in half?" What is the best response by the nurse? - Correct Answer-show me which pill you're talking about so I can verify the prescriptions again A 10-year-old client with autism spectrum disorder is hospitalized for a diagnostic workup. Which is the most appropriate nursing action? - Correct Answer-Give the client a schedule of daily activities The charge nurse is educating a new nurse on intramuscular injection technique for a 6- year-old with autism spectrum disorder. Which statement by the new nurse indicates that further teaching is required? - Correct Answer-I will hold the child's hand as a soothing measure The nurse is reinforcing client teaching about newly prescribed cyclosporine. Which client statement indicates a need for further teaching? - Correct Answer-I am going to a concert with my friends this weekend The nurse is caring for a client who reports severe abdominal pain and vaginal spotting. The client had a positive urine pregnancy test at home, and her last menstrual period was 8 weeks ago. Which client report to the nurse is most concerning? - Correct Answer-Right shoulder pain and dizziness A nurse is reinforcing teaching to a client newly prescribed verapamil for chronic migraine headaches. Which statement by the client indicates the need for further teaching? - Correct Answer-I will take this medication at the first sign of a migraine The nurse is reviewing the medical history of a client who has sustained a right tibia/fibula fracture from a fall. The nurse identifies which finding as most likely to hinder healing? - Correct Answer-peripheral arterial disease The student nurse assists in caring for a client who is scheduled for electroconvulsive therapy for the treatment of depression. Which statement by the student indicates a need for further teaching? - Correct Answer-Because this client has a mental illness, the agent with medical power of attorney should sign the informed consent document The nurse is reinforcing discharge teaching for a client who is hearing impaired. Which of the following actions should the nurse implement? Select all that apply. - Correct Answer-Encourage the client to repeat back teaching Ensure adequate lighting in the client's room Said directly in front of the client while speaking Use printed materials with pictures and illustrations A student nurse is accompanying the charge nurse when conducting daily rounds. Which personal protective measure by the charge nurse does the student nurse question? - Correct Answer-Wears two pairs of gloves when emptying the urinary catheter collection bag of a client with HIV The nurse helps a client with end-stage renal disease and a serum potassium level of 5.2 mEq/L to plan menu choices. Which items would be best to include in the meal plan? - Correct Answer-Grilled chicken sandwich on white bread, applesauce The nurse receives handoff of care report on four clients. Which client should the nurse see first? - Correct Answer-client who has a urinary tract infection, temperature of 102° F, and respiratory rate of 25 beats a minute The nurse is reinforcing education about lifestyle choices to help reduce symptoms for a client with gastroesophageal reflux disease. Which of the following statements by the client indicate a correct understanding? Select all that apply. - Correct Answer-I have switched from coffee to decaffeinated herbal tea in the morning I plan to join a smoking cessation program I brought myself up on a couple of pillows when I go to sleep I will switch to low-fat dairy product and avoid high-fat foods The nurse cares for a client with depression who states, "If I tell you something, will you keep it a secret?" What statement by the nurse is correct? - Correct Answer-I cannot make that promise; I may need to share it with your therapist The nurse is caring for an older adult client with advanced dementia, confusion, and a history of falls. Which of the following interventions are appropriate to promote client safety? Select all that apply. - Correct Answer-Activate the bed alarm before leaving the room Place a bedside commode next to the bed Place a client in a room close to the nursing station The nurse is caring for an adult client who is in soft wrist restraints. Which nursing actions should be included in the plan of care? Select all that apply. - Correct Answer- Offer fluids, nutrition, and toileting every two hours and as needed Perform neural vascular checks of the extremities every hour Release restraints to perform range of motion exercises every two hours The nurse is caring for 5 clients and is assisted by experienced unlicensed assistive personnel (UAP). Which tasks can the nurse safely delegate to the UAP? Select all that apply. - Correct Answer-Emptying a urinary drainage bag and recording output Which tasks can the charge nurse appropriately delegate to the unlicensed assistive personnel? Select all that apply. - Correct Answer-Apply protective skin ointment after perineal cleansing Document daily wait for the client with congestive heart failure Perform passive range of motion exercises for a client on a ventilator During a follow-up visit to the primary care clinic, the nurse evaluates a client's understanding about prevention of complications from varicose veins. Which client statements indicate a correct understanding? Select all that apply. - Correct Answer-I avoid crossing my legs when sitting I have started wearing elastic compression holes I tried to elevate my legs as often as possible I tried to walk at least a mile everyday A client is diagnosed with septic arthritis of the knee. What manifestations does the nurse expect to find? Select all that apply. - Correct Answer-fever Joint swelling with effusion limited range of motion moderate to severe pain The nurse is reinforcing education with a client with Marfan syndrome who is recovering from an aortic root repair and mechanical aortic valve replacement via sternotomy and is prescribed warfarin. Which of the following statements by the client indicate appropriate understanding of teaching? Select all that apply. - Correct Answer-I will have my spouse list and carry heavy objects for me for several months I will need to take the prescribed warfarin for the rest of my life If I gain 3 lb or more in a week, I will need to tell my healthcare provider My usual razor blades will need to be replaced with an electric shaver The nurse responds to the bed alarm of a client with a severe urinary tract infection and finds the client lying on the floor and soiled with urine. Which of the following entries by the nurse are appropriate to include when documenting the event in the client's electronic medical record? Select all that apply. - Correct Answer-Blood pressure 102/60, pulse 97 beats a minute, oxygen 98% on room air Client found at 2310 soiled with urine, lying on the floor near foot of bed Client states, my bottom hurts and I feel a little bit dizzy Jones, MD, notified at 2322. Will continue to monitor for indications of injury The nurse is reinforcing education about injury prevention with the parent of a 6-month- old infant. Which statements by the parent indicate that teaching has been effective? Select all that apply. - Correct Answer-I should place safety locks on the cabinets under the bathroom and kitchen sinks I will need to move sharp and breakable objects onto high shelves, out of reach The nurse is reviewing home instructions with a client who just underwent cataract surgery with intraocular lens implantation. Which of the following client statements indicate appropriate understanding of the teaching? Select all that apply. - Correct Answer-I need to wear an eye patch at night I should avoid sexual intercourse until I'm healed I will increase my fluid intake and take docusate daily The nurse accidentally administers orally dissolving mirtazapine through a client's percutaneous endoscopic gastrostomy tube instead of the prescribed sublingual route. After assessing the client for adverse reactions, what is the nurse's priority action? - Correct Answer-Notify the prescribing healthcare provider The nurse is preparing to dance sterile gloves before suctioning a client's tracheostomy. place the steps of doning sterile gloves in the correct order - Correct Answer-Hand hygiene and remove outer glove package Open the inner glove package by folding back the edges Use non-dominant hand to grab scuff on inside of dominant hand glove Pull on dominant hand glove Place dominant hand fingers under cuff on outside of non-dominant glove pull on non-dominant hand glove The emergency department nurse is assigned 4 clients. Which client needs to be seen first? - Correct Answer-9-year-old with recent pacemaker insertion with dizziness and purulant drainage at the incision site The nurse working in a gastrointestinal clinic is reviewing the list of walk-in clients. Which client should the nurse see first? - Correct Answer-client reporting constipation since having a barium enema 3 days ago The nurse is performing a home visit for a child with cystic fibrosis who had a percutaneous endoscopic gastrostomy (PEG) tube placed 6 weeks ago. During inspection of the PEG tube, the nurse should correctly recognize which finding as expected? - Correct Answer-gastrostomy tube movement of 0.2 in is noted when the client coughs A pregnant client in the third trimester completes an intake form for a clinic visit. The nurse understands that which signs and symptoms warrant further investigation? Select all that apply. - Correct Answer-Copious amounts of watery, clear vaginal discharge Dysuria and right flank pain Headache and blurred vision The nurse understands that which factor increases a client's risk of experiencing atypical symptoms of myocardial infarction? - Correct Answer-Female gender The staff nurse caring for a client with a history of drug abuse approaches the charge nurse and says, "My client constantly requests more oxycodone elixir. I gave a cup of cherry-flavored syrup and told the client it was oxycodone, because it wasn't time for another dose." Which action by the charge nurse is the priority at this time? - Correct Answer-Instruct the nurse to notify the health care provider about the lack of pain The nurse is providing postmortem care for a client who has died after a long hospitalization. The client had a do-not-resuscitate prescription in place at the time of death. Which of the following interventions should the nurse include during postmortem care in preparation for transfer to the funeral home? Select all that apply. - Correct Answer-Allow family member to assist with care Gently close the client's eyes Place a pad under the perinium The nurse is reviewing new arterial blood gas results for a client with an exacerbation of chronic obstructive pulmonary disease. The client's serum pH is 7.45. Which result noted by the nurse is a priority to report to the health care provider? - Correct Answer- PaO2 of 52mm Hg (6.92Kpa) Four clients enter the emergency department at the same time. Which client should the nurse alert the health care provider to see first? - Correct Answer-40-year-old with a first-degree burn and singed beard from a campfire