NCLEX EXAM1 QUESTION WITH ANSWERS TESTED AND VERIFIED SOLUTIONS RATED A+, Exams of Nursing

Download NCLEX EXAM1 QUESTION WITH ANSWERS TESTED AND VERIFIED SOLUTIONS RATED A+ and more Exams Nursing in PDF only on Docsity! NCLEX EXAM1 QUESTION WITH ANSWERS TESTED AND VERIFIED SOLUTIONS RATED A+ 1. The nurse is caring for a client diagnosed with a magnesium imbalance whose magnesium level is 4 mEq/L (2 mmol/L). The nurse interprets that the electrolyte imbalance is resolving if the client has relief from which sign/symptom? Loss of deep tendon reflexes 2. The nurse is caring for a client diagnosed with depression. Which therapeutic intervention should the nurse employ to promote sleep for the client? Suggest restful, quiet music and sleep-inducing relaxation techniques. 3. The nurse is monitoring the laboratory values of a child diagnosed with leukemia who is receiving chemotherapy. The nurse prepares to implement bleeding precautions if the child becomes severely thrombocytopenic, indicated by a platelet count at or below which level? 20,000 mm3 (20 × 109/L) 4. A client presents to the emergency department with lethargy and a fruity odor to the breath, and has deep, regular respirations. The client's arterial blood gas (ABG) results are pH of 7.25; Pco2, 34 mm Hg; Po2, 86 mm Hg; and HCO3, 14 mEq/L. The nurse should interpret that the client has which acid-base disturbance? Metabolic acidosis 5. The nurse manager of a hemodialysis unit observes a new nurse preparing hemodialysis on a client with a diagnosis of chronic kidney disease. The nurse manager should note that the new nurse needs further teaching and intervene if which action is carried out by the new nurse? Covers the connection site with a bath blanket to enhance extremity warmth 6. The mother of an infant newly diagnosed with cystic fibrosis is being taught proper nutritional needs for the infant. Which comment by the mother most indicates that the mother understands the infant's nutritional needs? "I know I need to monitor my infant's stools, and if there are more than four stools a day, I will increase the pancreatic enzyme." 7. The nurse is monitoring a client diagnosed with cardiac disease for the presence of cyanosis. The nurse monitors the client, knowing that which body area will be the best site for checking for the presence of cyanosis? Nail beds 8. The nurse is preparing to collect a sterile urine specimen from a client who has an indwelling Foley catheter. The nurse clamps the catheter and returns to the client to collect the specimen 30 minutes later. Arrange the actions in the order that they should be performed. All options must be used. Explain the procedure to the client. Perform hand hygiene and put on gloves. Cleanse the needle entry port with disinfectant, and insert the needle into the sampling port. Draw urine into the syringe and place into the urine specimen container Unclamp the catheter. Label the specimen according to agency protocol and send to laboratory. 9. The nurse is taking care of a client who earlier today had surgery under spinal anesthesia. Which nursing interventions will best prevent headache in this client? Select all that apply. Keeping the client lying flat Maintaining a quiet environment 10. A male client being treated for a diagnosis of urethritis from chlamydial infection asks the nurse how long it will be necessary to refrain from sexual relations. The nurse bases the response on which information regarding chlamydial infection transmission? Should refrain from sexual activity until fully cured 11. The nurse is participating in end-of-life care for a client who has recently immigrated from Vietnam. Which interventions should the nurse consider in the plan of care for this client? Select all that apply. Respect family wishes for use of herbal medicines Acknowledge that lack of eye contact does not mean disinterest 12. A home care nurse is instructing a mother of a child diagnosed with cystic fibrosis (CF) about the appropriate dietary measures. Which diet should the nurse tell the mother that the child needs to consume? High-calorie, high-protein diet 13. The client with a diagnosis of bladder cancer is to undergo weekly intravesical chemotherapy for the next 8 weeks. Which statement by the client should indicate to the nurse that the client understands how to manage urine as a biohazard? Disinfect the toilet with household bleach after voiding for 6 hours after a treatment 14. A client has been taught to use a walker to aid in mobility after internal fixation of a hip fracture. After which observation should the nurse determine that the client needs further teaching on how to use the walker correctly? Advances the walker with reciprocal motion Avoid the use of relatives to interpret to prevent misinterpretation Use dialect-specific interpreters who are the same gender if possible. Become familiar with common health care words used in the client's language 31. The nurse working in the long-term care facility is caring for a client who suffered a stroke with resulting paralysis. Which interventions should the nurse institute for this client to prevent pressure injury? Select all that apply. Frequent skin monitoring Ensuring adequate nutrition Frequent repositioning in bed Use of pressure relief devices 32. A client who is to be discharged to home with a temporary colostomy states to the nurse, "I know I've changed this thing once, but I just don't know how I'll do it by myself when I'm home alone. Can't I stay here until the surgeon puts it back?" Which therapeutic response should the nurse make to best deal with the client's concerns? “Going home to care for yourself still feels pretty overwhelming? I will schedule you for home visits until you're feeling more comfortable." 33. A registered nurse (RN) is orienting an unlicensed assistive personnel (UAP) to the clinical nursing unit. The RN determines that the UAP needs further teaching if which action is performed by the UAP during a routine hand-washing procedure? Dries from forearm down to fingers 34. The nurse is reviewing the preoperative teaching plan for a client scheduled for a radical neck dissection for laryngeal cancer. Which part of the nursing care plan should the nurse initially focus on? Information given to the client by the surgeon 35. Which statement by the client would alert the nurse to suspect that the thyroid laboratory blood test results from a blood specimen drawn today may be inaccurate? "I had a radionuclide test done 3 days ago." 36. A client arrives at the emergency department reporting frequent excessive urination, excessive thirst, and an increased appetite. Which laboratory test would be significant, based on the client's signs/symptoms? Blood glucose 37. An assessment of a client's vocal cords requires indirect visualization of the larynx. Which instruction should the nurse give the client to facilitate this procedure? Breathe normally 38. The nurse is collecting data from a Hispanic client regarding a medication history. Which cultural practice should the nurse be aware of when performing care to this population? This culture uses home medicines in addition to prescription medications. 39. A client in a long-term care facility is preparing for discharge to home in 2 days. The client has been eating a regular diet for a week; however, he is still receiving intermittent enteral tube feedings. The client states concern that he will not be able to continue the tube feedings at home. Which response by the nurse would be most therapeutic? “Tell me more about your concerns with your diet after going home." 40. The client's phosphorus level is 2.1 mg/dL (0.679 mmol/L). Which food selections made by the client should indicate to the nurse that the client understands the dietary teaching? Select all that apply. Almonds Baked flounder Roast beef on whole-grain bread 41. The nurse is assessing a client for a pericardial friction rub. Which action by the nurse indicates the best method in assessing for this abnormality? Placing the diaphragm of the stethoscope over the left sternal border 42. The rehabilitation nurse witnessed a postoperative client who had a coronary artery bypass graft and his spouse arguing after a rehabilitation session. Which would be the most appropriate therapeutic statement for the nurse to make to identify the feelings of the client? "You seem upset." 43. The registered nurse is observing a new nurse auscultate the breath sounds of a client. Which action by the new nurse should lead the registered nurse to determine that further teaching is needed? Uses the bell of the stethoscope 44. A clinic nurse is performing an assessment on a client diagnosed with primary hypertension. Which should the nurse do to best assess the client's blood pressure accurately? Seat the client with the arm bared, supported, and at heart level. 45. The nurse cares for a client who is pale and frequently reports fatigue, weakness, and dizziness. Which serum laboratory test result is the nurse's priority for planning care? Hemoglobin of 7 g/dL (70 mmol/L) 46. The nurse has counseled a client with myocardial infarction about limiting cholesterol and saturated fat in the diet. The nurse determines that the client understands the dietary modifications if the client selected which sample meals? Baked haddock, steamed broccoli, herbed rice, sliced strawberries 47. The nurse is caring for a client who is of Asian descent and is assessing for client perceptions regarding nutrition. Which, in addition to the impact of food on disease and illness, should the nurse consider in order to provide culturally competent care? Client perception of body weight and size relative to culture 48. The nurse is teaching the parents of a child diagnosed with celiac disease about dietary measures. The nurse should instruct the parents to take which measure? Avoid foods that are hidden sources of gluten. 49. The nurse has a prescription to test a client's stools using Hemoccult slides. The nurse should question the prescription if the client has been taking which medication? Ascorbic acid 50. The nurse is reviewing the laboratory results of a client hospitalized with a diagnosis of Crohn's disease. The client has a magnesium level of 1.0 mEq/L (0.5 mmol/L). Which is the most appropriate intervention for the nurse to implement? Monitor the client for cardiac dysrhythmias. 51. A client arrives at the nursing unit after internal maxillary fixation (IMF) surgery. Which is the immediate intervention for the nurse to implement? Positioning the client on the side with the head slightly elevated 52. Which interventions are most appropriate as safety considerations to minimize the risk of injury for a client in the emergency department? Select all that apply Reorient the confused client frequently. Keep the stretcher in the lowest position. Remind the client to use the call light if anything is needed. Implement measures to prevent skin breakdown for the client at risk. 53. The nurse is assessing an older client's risk for falls. Which factors place the client at the most risk of falling? Select all that apply. Use of a walker Bilateral cataracts Use of nitroglycerin Episodes of dizziness 54. The registered nurse is orienting a new nurse on how to care for a client diagnosed with type Avoiding any frequent engagement with the client in conversation of a personal nature 70. The nurse collects a urine specimen for a urinalysis from a client recently diagnosed with polycystic kidney disease. The results of the urinalysis indicate a urine specific gravity of 1.000. Which determination should the nurse most likely make when analyzing this result? This finding is lower than normal, indicating dilute urine. 71. The nurse reviews the client's most recent blood gas results that include a pH of 7.43, Pco2 of 31 mm Hg, and HCO3 of 21 mEq/L. Based on these results, the nurse determines that which acid- base imbalance is present? Compensated respiratory alkalosis 72. A client expresses concern after receiving a positive tuberculin skin test and asks the nurse to explain what that means. Which interpretation of this result by the nurse is accurate? There has been an exposure to tuberculosis. 73. The nurse creates a plan of care to facilitate effective communication for a client who requests assistance in order to live independently. Which intervention has highest priority? Focusing directly on the client's message regarding needs 74. The nurse should assign a client who is scheduled for the implantation of a sealed internal radiation source to which hospital room? A single room at the distant end of the hall 75. The nurse is teaching a client with a kidney mass who has been scheduled for a renal biopsy about the reason for this test. Which comment by the client indicates that teaching was effective? "A renal biopsy can tell if my mass is either cancerous or noncancerous." 76. The nurse is preparing to auscultate bowel sounds. Which actions suggest appropriate assessment techniques and interventions? Select all that apply. Divide the abdomen into four quadrants at the umbilicus. Do not feed the client if no sounds are audible in 5 minutes Listen in each quadrant for gurgling sounds indicating movement. 77. The nurse is preparing to care for a client who has undergone esophagogastroduodenoscopy (EGD). After checking the vital signs, what should be the nurse's next priority? Check for a return of the gag reflex 78. The nurse evaluates the patency of a peripheral intravenous (IV) site and suspects an infiltration. Which action should the nurse take to determine if the IV has infiltrated? Gently palpate regional tissue for edema and coolness. 79. Which procedure should the nurse implement when preforming a voice test to assess hearing on clients attending a community health screening? Quietly whisper a statement from 1 to 2 feet away, and ask the client, who has blocked 1 ear, to repeat it. 80. A client diagnosed with left pleural effusion has just been admitted for treatment. The nurse should plan to have which procedure tray available for use at the bedside? Thoracentesis 81. The nurse is preparing to administer a tuberculin skin test to a client. The nurse determines that which area is to be used for injection of the medication? Inner aspect of the forearm that is not heavily pigmented 82. A client is being discharged from the hospital after a bronchoscopy that was performed a day earlier. After the discharge teaching, the client makes the following statements to the nurse. Which statement should the nurse identify as indicating a need for further teaching? “I can expect to cough up bright red blood." 83. The nurse provides home care instructions to the mother of a child with a diagnosis of chickenpox about preventing the transmission of the virus. Which is the best statement for the nurse to include in the instructions? Isolate the child until the skin vesicles have dried and crusted. 84. A new graduate nurse has been hired by the health care clinic to assist in conducting hearing tests in a local neighborhood. The clinic nurse is observing the graduate perform a voice test to assess hearing in a client. Which observation indicates that the graduate nurse is performing the procedure correctly? Asks the client to block one ear, quietly whispers a statement, and asks the client to repeat it 85. A client is receiving intravenous (IV) antibiotic therapy at home via an intermittent IV catheter. In order to facilitate the early detection of IV therapy complications, which intervention should be included in the client's education? Report local pain, drainage, or edema. 86. The nurse while monitoring the client for brachial plexus compromise assesses the status of the ulnar nerve. Which technique should the nurse implement to assess the status of this nerve? Have the client spread all the fingers wide and try to resist pressure. 87. A bone marrow aspiration is scheduled for a client suspected of having leukemia. When preparing supplies for the procedure, which skin-cleansing agents are most appropriate for the nurse to bring to the bedside before this procedure? Povidone-iodine 88. client was brought to the emergency department for a possible medication overdose. The client is now responsive and thrashing around. Which action by the nurse is a priority to keep the client safe? Assign a staff member to stay with the client at all times. 89. The nurse has responded to a diabetic client's question about dietary preparation before blood is drawn for a glycosylated hemoglobin analysis. The nurse determines that the client understands the nurse's response if the client makes which statement? “Fasting is not necessary." 90. A client is diagnosed with organic erectile dysfunction and the nurse is collecting subjective data from the client. After the assessment, the nurse explains to the client that which are causes of this disorder? Select all that apply. Hypertension Vascular disease Diabetes mellitus Alcohol consumption 91. A client with the diagnosis of chronic kidney disease (CKD) has received dietary counseling about potassium restriction in the diet. The nurse determines that the client has learned the information correctly when the client states that he or she will do what when preparing vegetables? Boil them and discard the water. 92. The nurse educator is describing mind-body medicine to a group of orienting nurses. Which statement, made by one of the nurses, indicates an understanding of this therapy? "This therapy enhances the mind's ability to affect the body." 93. client has been receiving total parenteral nutrition (TPN) at home for several weeks, and the health care provider is considering discontinuing the TPN. The nurse is aware that the client should have an adequate dietary intake before TPN is discontinued. Which statement to the client would be helpful in determining the client's readiness to have the TPN discontinued? "It will be helpful if you would keep a journal of what you eat every day." 94. The registered nurse is observing a new nurse pour a sterile solution. Which action by the new nurse indicates the need for further teaching? Click on the Question Video button. Places the cap of the sterile bottle downward on the nonsterile surface so that it is not contaminated 95. During a follow-up visit 2 weeks after pneumonectomy, the client reports numbness and tenderness at the surgical site. Which statement should the nurse make to accurately address the client's concerns? Dry toast and strawberry jelly 109. Which nursing question would elicit the most thorough assessment data regarding the client's recent sleeping patterns? "May we talk about how you've been sleeping?" 110. The nurse is creating a plan of care for a client receiving enteral feedings. The nurse identifies which concern as the highest priority for this client? Risk of aspiration 111. The nurse is caring for a new immigrant from the Philippines. The client is 4 cm dilated and 30% effaced. This is her first child. The mother is grimacing; her pulse, respiratory rate, and blood pressure are elevated. The nurse offers to call the health care provider for an epidural prescription. The mother declines. The nurse should hypothesize that the client declined the epidural for which reason? Select all that apply. Filipino mothers fear drug addiction. Filipino mothers believe that pain is a form of spiritual atonement for one's past deeds. 112. The client states to the nurse, "I'm scheduled for outpatient surgery, but I live alone and my only child lives 300 miles away. I'm afraid. What happens if something goes wrong after I go home?" Which statement by the nurse is the most therapeutic? "You seem very concerned about going home without help. Have you discussed your concerns with both your surgeon and your family?" 113. A client diagnosed with diabetes mellitus has expressed frustration with learning the diabetic regimen and insulin administration. Which should be the initial action by the home care nurse? Attempt to identify the cause of the frustration. 114. The nurse is caring for a client with a suspected urinary tract infection and the primary health care provider orders a midstream (clean-voided) urine specimen. Which tasks can be safely implemented by the unlicensed assistive personnel (UAP)? Select all that apply. Collect the midstream urine specimen from client Obtain the needed supplies for the specimen collection. Report if client experienced pain/burning upon urination 115. The client has been diagnosed with iron deficiency anemia. The nurse instructs the client to increase the intake of which foods? Lean beef and chicken liver 116. The nurse is conducting a cultural assessment on a newly admitted client. Which factors specifically related to culture are most appropriate for the nurse to include? Select all that apply. Nutrition Communication High-risk behaviors Health care practices Family roles and organization 117. The nurse is assigned to care for a group of clients on the clinical nursing unit. The nurse determines that the clients who are most likely to develop third spacing of fluids are those with which diagnosis? Select all that apply. Major burn Laënnec's cirrhosis Kidney failure 118. The nurse is ambulating a postoperative client for the first time since surgery. The nurse raises the head of the bed and the client reports dizziness. Which action should the nurse implement first? Lower the head of the bed back down slowly. 119. A client experiencing vomiting and diarrhea is admitted to the hospital with a diagnosis of dehydration. The nurse should assess for which primary clinical manifestation that correlates with this fluid imbalance? Increased respiratory rate 120. A client diagnosed with iron deficiency anemia asks the nurse about food items that are high in iron. The nurse instructs the client that a serving of which food has the greatest amount of iron? Broccoli 121. The nurse is providing client teaching for the client who is undergoing nuclear imaging scans (scintigraphy). Which statement, if made by the client, indicates a need for further instruction regarding this procedure? "This procedure can be dangerous because of the radioactive substance I need to ingest." 122. An adult client diagnosed with diabetes mellitus reports to the health care clinic for a glycosylated hemoglobin (HbA1c) level. Which laboratory result indicates client compliance with the prescribed diabetic regimen? 5% 123. The nurse has given a postoperative thoracotomy client instructions about how to perform arm and shoulder exercises after discharge. The nurse determines that the client needs further teaching about the exercises when the client is observed doing which movement on the affected side? Making circles with the wrist 124. A client admitted to the hospital with a diagnosis of acute exacerbation of chronic obstructive pulmonary disease (COPD) has had an arterial blood gas (ABG) test done. Which result should the nurse expect to note? Po2 of 60 mm Hg and Pco2 of 50 mm Hg 138. The nurse is providing teaching to a client who is scheduled to undergo an abdominal ultrasonography. Which statement, if made by the client, indicates an understanding of this procedure? "A gel will be applied to my abdomen during this procedure." 139. A client is to undergo pleural biopsy at the bedside. Knowing the potential complications of the procedure, what equipment should the nurse plan to have available at the bedside? Chest tube and drainage system 140. In providing a list of medications to the clinic nurse, the client shares that they are taking a nonprescription medication, melatonin. Which assessment data should the nurse collect from this client, based on this medication? Sleep patterns 141. What factors should the nurse consider for teaching a child about his or her disease and related health care measures? Select all that apply. A child's imagination may create greater fear than the truth. A child may regress developmentally in a situation of illness. A child may better manage uncomfortable information through role-playing. 142. A client has been seen in the clinic, and anemia has been diagnosed. The client appears pale and complains of feeling exhausted. On further assessment, the nurse notes that the client is complaining of heart palpitations. The client also complains of weakness, dizziness, headache, and loss of appetite. Based on the client's symptoms, the nurse should determine that the hemoglobin results would indicate which finding? Hemoglobin of 7 g/dL (70 mmol/L) 143. A client who underwent bronchoscopy was returned to the nursing unit 1 hour ago. The nurse determines that the client is experiencing complications of the procedure when making which observation during assessment? Breath sounds greater on the right than the left 144. The nurse is preparing a client for electroconvulsive therapy (ECT). After the client signs the informed consent form for the procedure, a family member states, "I don't think that this ECT will be helpful, especially since it makes people's memory worse." What form of communication should the nurse implement to address the family member's concern? Involve the family member in a dialog to ascertain how the family member arrived at this conclusion. 145. The nurse evaluates the arterial blood gas (ABG) results of a client who is receiving supplemental oxygen. Which Po2 finding would indicate that the oxygen level was adequate? 80 mm Hg 146. Which clients should the nurse determine are at greatest risk for developing hypokalemia? Select all that apply. Client receiving prednisone 20 mg daily for 2 years Client with a nasogastric tube to continuous suction for 5 days 147. A preoperative client complains of anxiety accompanied by tingling in the fingers and toes. The client has a pulse rate of 100 beats per minute, a respiratory rate of 30 breaths per minute, and a blood pressure of 138/86 mm Hg. Which initial action should the nurse implement? Encourage the client to breath slowly. 148. The community health nurse has been called in to assist with problem-solving for a group of homeless people in a certain area of a city. In planning for the needs of this group, which immediate concern would the nurse attend to? Ensuring that the clients' basic needs can be met 149. The new nurse examines an Asian American infant's eyes and notes that the infant's eyes are crossed. The registered nurse asks the new nurse to interpret the finding. Which statement by the new nurse best indicates an understanding of this assessment finding? "It probably isn't strabismus but appears that way because of the child's ethnic background." 150. The registered nurse is teaching a new nurse about body mechanics. Which, if stated by the new nurse, indicates the need for further teaching? "I should bend at the hips to maintain my center of gravity when picking something up." 151. The client has had blood drawn from the radial artery for an arterial blood gas (ABG) analysis, and the nurse is asked to hold pressure on the site. Which is the minimum amount of time for which the nurse should apply pressure? 5 minutes 152. A client's arterial blood gas report is as follows: pH, 7.35; Po2, 85 mm Hg; Pco2, 55 mm Hg; Hco3, 25 mEq/L. How should the nurse interpret these values? Compensated respiratory acidosis 153. The nurse is preparing to provide preoperative teaching with a client scheduled for radical neck dissection. Which topic should the nurse initially focus on? The information already supplied by the surgeon 154. A client has a diagnosis of chronic respiratory acidosis. Which method for administering oxygen to the client is most appropriate? Low-flow oxygen via nasal prongs at 2 L/min 155. A client with the diagnosis of hyperparathyroidism states to the nurse, "I can't stay on this diet. It is too difficult for me." Which therapeutic response by the nurse is best when intervening in this situation? "You are having a difficult time staying on this plan. Let's discuss this." 156. A client's potassium level is 2.5 mEq/L (2.5 mmol/L). The nurse determines that which client assessment data best correlate with the potassium level? Select all that apply. Shallow respirations U waves on the cardiac monitor ST segment depression on the cardiac monitor 157. Family members of a client who attempted suicide are tearful. Which statement by the nurse would be most helpful in the management of their concerns? "I certainly can see that you are terribly worried about your loved one." 158. The nurse determines that the client with atherosclerosis understands dietary modifications to lower the risk of heart disease if which food selection is made? Fresh cantaloupe 159. The clinic nurse is providing instructions to a mother whose child was diagnosed with rubeola (measles). The mother asks the nurse how the measles are transmitted to prevent the infection from spreading to her other children. Which method of transfer is most appropriate for the nurse to discuss with the mother? Airborne particles 160. A client who has undergone radical neck dissection is experiencing a problem communicating verbally because of postoperative hoarseness. What is an appropriate goal for this client problem? Incorporates nonverbal forms of communication as needed 161. A client who is being evaluated for tuberculosis has never had a chest radiograph. What should the nurse instruct the client about before the procedure? A metal neck chain must be removed while the film is taken. 162. The nurse is monitoring the fluid balance for a client diagnosed with arterial bypass surgery. The nurse should assess which parameter daily as the best indicator of fluid balance? Weight 163. The nurse reviewing the results of an eye examination on a client notes that results from the tonometry test indicate an intraocular pressure of 20 mm Hg. How should the nurse interpret these findings?