NCLEX Q&A: Nursing Instructions for Diet, Heart Murmurs, Post-op Complications & More, Exams of Nursing

Download NCLEX Q&A: Nursing Instructions for Diet, Heart Murmurs, Post-op Complications & More and more Exams Nursing in PDF only on Docsity! NCLEX QUESTIONS AND ANSWERS . Download to score 1. When reinforcing dietary instructions to a client with irritable bowel syndrome whose primary symptom is alternating constipation and diarrhea, the nurse would tell the client that which foods are best to include in the diet for this disorder? Answer: Apples and Whole-grain bread 2. A low-sodium diet has been prescribed for a client with hypertension. Which food selected from the menu by the client indicates an understanding of this diet? Answer: Baked turkey 3. A client with a burn injury is transferred to the nursing unit, and a regular diet has been prescribed. The nurse encourages the client to eat which dietary items to promote wound healing? Answer: Chicken breast, broccoli, strawberries, and milk 4. The nurse is providing dietary instructions to a client with gout. The nurse should tell the client to avoid which food item? Answer: Scallops 5. A clear liquid diet has been prescribed for a client with gastroenteritis. Which item is appropriate to offer to the client? NCLEX QUESTIONS AND ANSWERS . Download to score Answer: Fat-free beef broth 6. A Spanish-speaking client arrives at the triage desk in the emergency department and states to the nurse, “No speak English, need interpreter.” Which action should the nurse take? Answer: Seek an interpreter from the hospital’s interpreter services. 7. While collecting data related to the cardiac system on a client, the nurse hears a murmur. Which best describes the sound of a heart murmur? Answer: Gentle, blowing or swooshing noise 8. The nurse is monitoring an adult client for postoperative complications. Which is most indicative of a potential postoperative complication that requires further observation? Answer: A blood pressure of 100/70 mm Hg NCLEX QUESTIONS AND ANSWERS . Download to score 19. The nurse cares for a client with myxedema coma. Which sign or symptom is the nurse likely to observe in this client? Answer: The client's blood pressure is 78/52 mmHg. 20. The nurse cares for an adolescent client with a broken foot from skiing. What developmental factor most contributes to the adolescent client sustaining this injury? Answer: Feelings of invulnerability leading to risk taking. 21. The client with scheduled heart valve surgery in 8 hours takes warfarin at home. The client’s international normalized ration (INR) is 2.3. Knowing that the health care provider (HCP) wants the INR < 2.0 prior to surgery, the nurse prepares to administer which treatment to the client? Answer: 10 mg IV vitamin K 22. A client with multiple pulmonary emboli (PE) is scheduled for placement of an inferior vena cava (IVC) filter. What statement by the nurse explains the purpose of this intervention? Answer: “The device trap blood clots traveling to the lungs.” 23. A nurse cares for a client with a newly applied cast who reports increasing pain in the extremity that does not respond to the currently prescribed analgesia. What is the nurse's priority action? Answer: Perform a neurovascular assessment. 24. A nurse administers a dose of escitalopram to a client. Which client statement most concerns the nurse? Answer: “I feel agitated and confused at times.” 25. A nurse cares for a postpartum client diagnosed with human immunodeficiency virus (HIV) who has a newborn. The client expresses relief when learning the infant's HIV test taken two weeks ago is negative for HIV. How does the nurse respond? NCLEX QUESTIONS AND ANSWERS . Download to score Answer: "That is great news. Have you arranged for the second test yet?" 26. The nurse performs a neurological assessment on a client admitted with traumatic brain injury. Which new finding does the nurse report the HCP immediately? Answer: The client demonstrates decerebrate posturing. 27. The nurse cares for a client following a head injury. Based on the Glasgow Coma Scale, which assessment would place the client in the classification of moderate traumatic brain injury? Answer: The client opens eyes to command, uses inappropriate words, and demonstrates purposeful movement to painful stimuli. 28. A client with a burn three days ago has diuresed 3,000 mL over the past 24 hours and has decreasing edema. The nurse notifies the healthcare provider (HCP) of which lab result during the fluid mobilization phase? Answer: Potassium 3.2 mEq/L NCLEX QUESTIONS AND ANSWERS . Download to score 29. An infant client with hydrocephalus is admitted due to an enlarged head circumference, bulging fontanelles, and sunset eyes. What is the priority nursing responsibility? Answer: Keep the head of the bed elevated. 30. A client who accidentally ingested two doses of prescribed digoxin four hours ago has a heart rate of 84 beats/min, a blood pressure of 130/70 mmHg, an ECG reading atrial fibrillation with controlled rate, and is alert and oriented x3. The nurse takes what action next for the client? Answer: Monitor electrocardiogram. 31. The nurse prepares a client for a pericardiocentesis for the treatment of cardiac tamponade. The nurse places the client in which position? Answer: Supine with the head of bed at 45 degrees 32. Two days following a repair for an abdominal aortic aneurysm, a client requires 1 unit of packed red blood cells (PRBCs) for hemoglobin of 7.6 g/dL and hematocrit of 23.1%. After receiving the PRBCs from the blood bank, which action does the nurse perform first at the client’s bedside? Answer: Verify the blood with a second nurse 33. A nurse educates a group of high school students about sexually transmitted diseases and the long-term consequences. One student asks the nurse about the sexually transmitted virus that can cause cancer. Which statement by the nurse is the best response? Answer: “Human papillomavirus has been linked to some cervical cancer.” 34. The client with primary peritonitis asks the nurse, "What caused my infection?" The nurse answers the client with what response? Answer: "It is an infection of peritoneal fluid associated with cirrhosis and ascites." 35. A nurse from the pulmonary unit is assigned to the intensive care unit (ICU) to fill a NCLEX QUESTIONS AND ANSWERS . Download to score child aspirin. The nurse responds with which statement? Answer: No, aspirin can be harmful. There are other options." 46. The nurse cares for a client admitted with subarachnoid hemorrhage following a ruptured aneurysm. The nurse intervenes after becoming aware of which action? Answer: The UAP reports the client has been on the bedpan for 20 minutes. 47. A toddler-age client has had a cleft palate repair. Which is the best way for the nurse to assist the client in taking in fluids 24 hours post-surgery? Answer: A syringe with a rubber tip 48. A client is prescribed atenolol. The nurse assesses what parameter as most relevant to the mechanism of action of atenolol? NCLEX QUESTIONS AND ANSWERS . Download to score Answer: Heart rate 49. The nurse cares for a client with a Clostridium difficile (C. diff) infection. Which action does the nurse take when leaving the room? Answer: Inside the room, remove the gloves first and the gown second. Wash the hands thoroughly with warm water and antibacterial soap. 50. A nurse cares for a client with type I diabetes and a serum blood glucose of 400 mg/dL. Which set of arterial blood gases does the nurse expect to find? Answer: pH: 7.29, PaCO2: 22 mmHg, HCO3: 14 mEq/L 51. An elderly client diagnosed with respiratory failure insists to the nurse to not be placed on a ventilator. Which action does the nurse take? Answer: Contact the client’s health care provider. 52. An adult female client reports that she leaks urine while exercising. All other assessment data are normal. For which condition does the nurse assess further? Answer: Stress incontinence 53. A client with stage IV non-Hodgkin's lymphoma has a WBC count of 1,500/mm³, a hemoglobin of 7.6 g/dL, a hematocrit of 22.3%, and a platelet count of 20,000/mm³ ten days after receiving chemotherapy through a vascular access device. The nurse performs what intervention for the client? Answer: Provide the client a soft toothbrush for oral care. 54. A nurse works on a psychiatric unit with several clients. When working with which client does the nurse take the greatest precautions due to there being the highest risk for physical aggression? Answer: A 45-year-old female client with psychosis and paranoid delusions. 55. The nurse cares for a client with insulin-dependent diabetes mellitus. Which insulin NCLEX QUESTIONS AND ANSWERS . Download to score prescription does the nurse clarify with the health care provider? Answer: Administer six units of insulin glargine 20 minutes before each meal. 56. A client at risk for colorectal cancer receives education about lifestyle choices. The nurse emphasizes which modifiable risk factor for colorectal cancer? Answer: Consuming a high-fat diet 57. A client is diagnosed with infiltrating ductal carcinoma of the breast. The nurse expects what finding during the physical assessment? Answer: An irregularly shaped, fixed mass 58. A client taking lithium has a serum lithium level of 1.1 mEq/L. Which statement by the nurse is appropriate?