NURSE NUR4650 NCLEX INFORMATION Questions with answers 100% correctly verified Answers lat, Exams of Nursing

Download NURSE NUR4650 NCLEX INFORMATION Questions with answers 100% correctly verified Answers lat and more Exams Nursing in PDF only on Docsity! DO NOT COPY NURSE NUR4650 NCLEX INFORMATION Questions with answers 100% correctly verified Answers latest update 2023- 2024 GRADED A+ The charge nurse is reviewing the protocol of care for clients with cervical radioactive inplants with the new nurse. Which statement tells the charge nurse that the nurse requires more teaching? a. Visitors can’t stay more than 30 minutes in the client’s room b. A long tong should be kept in the room, in case of implant dislogement c. The client has to wear a dosimeter at all times d. Visitors have to keep a distance of 6 feet from the client’s bed Which absent milestone should concern the nurse in a 3yearold child? a. Can’t draw a square b. Can’t hop in one foot c. Can’t eat with a spoon d. Can’t catch a ball Nurse receives four phone calls from pregnant women in their last trimester of pregnancy. Which call should be answered first? a. Client can’t sleep supine because shortness of breath b. Client with frequent heartburn c. Client who can’t remove wedding ring d. Client with frequent non painful uterine contractions A diabetic client has been diagnose with gastroparesis. Which medication the nurse expects to be prescribed? a. Omeprazole b. Metocloprami de c. Metronidazole d. Ranitidine P a g e 1 | 226 Which of the following clients have a formal indication for screening of hepatitis C carrier status. SATA a. A client who ate contaminated shellfish b. A client who received a blood transfusion before 1992 c. A client in long term hemodialysis d. A client who injected IV drugs only once many years ago e. A child born to a woman hepatitis C positive f. A extensively tattoed client How the nurse explores the V cranial nerve? SATA a. Make the client close the eyes and smile b. Make the client close the eyes and touch each side of face with a cotton c. Ask the client to clench the jaw d. Obtainin the blinking reflex blowing on each eye e. Asking client to move the eyeballs in all directions A client with severe dehydration is receiving fluids through a peripheral IV. The client is confused and pulls out the IV catheter. What is the nurse priority at this moment? a. Obtain a MD order for arms restrains b. Insert another IV catheter and reestablish fluids c. Explan the client the importance of not pulling the IV d. Medicate the client with prn ordered anxiolytic The nurse recognizes which of the following medication as a tocolytic? a. Bethametasone b. Terbutaline c. Carboprost d. Methergin A client is recovering from a endoscopy and the nurse notes the client is drooling and coughing. What should the nurse assess first? P a g e 2 | 226 b. Initiate an IV catheter c. Prepare client for lumbar tap d. Initiate seizure precautions The nurse is teaching a client with hyperuricemia and gout about the dietary requirements. Which food selection the nurse that more teaching is required? a. The client adds spinach to a tossed salad b. The client eats grilled chicken with tortillas c. The client eats grilled scallops with rice d. The client selects steamed broccoli and carrots The nurse is assessing a client and while tapping on the VII cranial nerve observes the following reaction . Which client’s statement requires more follow up? a. I will drink a glass of milk every morning and night. b. I will choose mango and orange for a snack c. I do not have problem adding whole grains and broccoli to my diet d. I will increase my intake of kale and spinach A client has been newly prescribed olanzapine. What should the nurse include in the teaching plan? SATA a. Change position slowly when getting up b. Advise this medication could result in hypertension c. You could experience dry mouth d. Communicate with your doctor before taking OTC medications e. Do not discontinue the medication abruptly P a g e 5 | 226 A woman at 25 weeks gestation is going to have an amniocentesis. Which client’s statements indicate correct understanding about the procedure? SATA a. The procedure can last for about 30 min long b. I will have to lay in bed in lateral position c. I will have to sign a consent prior to the procedure d. The doctor will ask me to empty my bladder before starting e. I will lay supine for the procedure f. I do not have to empty my bladder, it must be full for the procedure A client with hypothyroidism is taking levothyroxine. Which of the following statements is correct in relation with this medication. SATA a. Take the medication everyday with breakfast b. Take everyday with empty stomach c. Don’t change brands without consulting your doctor d. Don’t take at night because it will give you insomnia e. I will need blood work to evaluate if the dose is therapeutic Which of the following client’s statements suggest the diagnose of anorexia nervosa? SATA a. I have a vigorous work out plan to perform at least twice daily b. I’m extremely terrified of becoming fat c. I have lots of thin hair in my back and arms d. I finally have decided a career I would like to persue e. I have set myself goals that I will work on achieving soon A med surg nurse is floating to the Pediatric ICU unit. Which client should be assinged to the floating nurse? a. An 18monthold baby just diagnosed of type 1 diabetes mellitus b. An unconscious 4 month old baby after parent stroke his head against the wall c. A baby with mecanical ventilation after abdominal surgery d. A baby with irregular respirations after choking at home with food P a g e 6 | 226 The nurse has an order for enema for a client with moderate Alzheimer’s disease. When the nurse enters the room the client screams: “Get out of here. I don’t want you touching me”. What should the nurse do next? a. Ask for a physician order to restrain before administering the enema b. Force the client to stay still and insert the enema c. Leave the room and return in half an hour with the enema d. Explain the procedure to the client and the importanc of compliance How the nurse assess pain in a 3yearold child after surgery? a. Ask the mother for pain clues b. Use the FLACCR scale c. Use the WongBaker face scale d. Assess heart and signs of sympathetic activation Most common side effect of azithromycin? a. Nephrotoxicity b. Jaundice c. Abdominal cramps and diarrhea d. Cross allergic reaction with penicillin The client is prescribed oxybutynin for hyperactive bladder. Which recommendation is the most important to give when providing education to the client? a. Suck ice chips for dry mouth b. Avoid hot weathers c. Increase intake of roughage d. Drive very carfully after taking it Client is admited with severe abdominal flank pain and history of kidney stones. Hours after admision the client presents chest pain and is transferred to CCU to rule out myocardial infarction. What order should the nurse question? a. Morphine IV q 3 hours PRN P a g e 7 | 226 A client complains of palpitations and chest pain. Assesment shows a client awake and oriented, with heart rate 140 bpm, respirations 20 x’, BP 98/60 mmHg. The monitor showed the following rhythm: What intervention by the nurse should be initiated immediately: a. Call for help (code) b. Make a 12 lead EKG c. Defibrillate immediately d. Start chest compressions A client in nasogastric suction. What electrolyte alteration the nurse expects to find? a. Hyperkalemia b. Hypocalcemi a c. Hypokalemia d. Hypercalcemia A pregnant woman who initiated pregnancy with a BMI of 21 is asking the nurse about dietary recommendations. Which of the following recommendations should the nurse advise? a. At the end of pregnancy, the client should have increased her weight between 15 to 25 pounds b. The diet should show an increment in the proportion of proteins and fats c. The client should increase in 500 kcalories the total caloric intake during the third trimester. d. The diet should duplicate the content of calcium to prevent osteoporosis and tooth decay A client with 35 weeks gestation came to labor room with membrane rupture of 18 hours. The test for group B streptococcus in vagina is not known yet. Which of the following interventions P a g e 10 | 226 has the highest priority? a. Assess for uterus contraction b. Initiate prophylactic antibiotics c. Avoid vaginal examination d. Practice a deep stick urine analysis A 59 yearold male alcoholic client with type 2 diabetes mellitus well controlled wigh glymepiride for the last 5 years presents to the ER with confusion, restlessness and tachycardia. Which nursing intervention is the most important at this moment? a. Assess for signs of alcohol withdrawal b. Administer thiamine as ordered c.Determine capillary blood sugar d. Initiate seizure precautions A female client is brought to ED uncounscious and requiring mechanical ventilation. Which of the following actions by the nurse is the priority next? a. Remove all the jewelry b. Remove a vaginal tampoon c. Localize any medical alert tag d. Remove any medication patches P a g e 11 | 226 A client with recent stroke can understand the language but answers with incorrect words. Which communication problem is presenting? a. Aphasia b. Apraxia c. Dysartria d. Dysphagia The nurse is measuring the blood pressure and the client develops the following contraction in hand and wrist. How should the nurse document the finding? a- Trousseau’s sign b- Pedal spasm c- Colles’ fracture d- Chvostek’s sign Patient with alcohol withdrawal is experiencing confusion, muscle weakness and tremors, which of the following can the nurse expect is a deficiency the patient probably has: a) Calcium b) Iron c) Thiamin d) B12 Which symptom or sign should the nurse know is observed in a client on cocaine overdose? P a g e 12 | 226 Client’s potassium is 7.0 mEq/dL. Which prescription should the nurse administer first? a. Calcium gluconate IV b. Sodium polystyrene enema c. Spironolactone oral d. Dextrose 10% IV 13. Client needs blood transfusion and is O positive. Which blood can they receive? SATA a. O negative b. AB negative c. B positive d. A negative e. O positive Nurse is going to administer nitroglycerin ointment. Which of the following is correct? P a g e 15 | 226 a. apply to a nonshaved area and tape down the ends b. wash area with soap and water before applying c. place ointment in the same place where it was in previous dose d. wearing gloves spread out ointment to 4 inches on area of application A positive direct Fluorescent Treponema Antibody Absorption (FTAABS) test confirms which condition? a. Renal infection b. Syphilis c. Lupus d. Urethritis Which nurse intervention is correct routine when providing post mortem care? a. send the corpse for autopsy b. allow family to join in post mortem care c. dispose of client’s belongings in biohazards bins d. contact the hospital chaplain for religious services The nurse is providing care for a client1 hour post electroconvulsive therapy. What client statement requires the nurse intervention? a. “I can’t remember anything from this morning” P a g e 16 | 226 b. “Second round of electroshock is in about 12 hours” c. “I won’t be attending group activities because I’m tired” d. “I can expect having a headache after the procedure” A diabetic client presents to ED with acute alcohol intoxication, confusion, agitation, systolic hypertension, and tachycardia. Which nursing intervention is the most important at this moment? a. Assess for other signs of alcohol withdraw b. Administer IV thiamine as per protocol c. Assess capillary blood glucose d. Administer benzodiazepine as per protocol A client with syndrome of inappropriate antidiuretic hormone (SIADH), the nurse expects to find: SATA P a g e 17 | 226 a. ask for history of allergies b. perform a respiratory assessment c. notify the physician d. take vital signs, including temperature The nurse is hanging the bag of blood for a transfusion. What is the correct way of administering the transfusion after the tubing is primed? a. Bags of NS and blood with independent tubing, NS clamped and blood opened b. Bags of NS and blood connected with Y tubing with blood and NS opened c. Bags of NS and blood with independent tubing, both left opened d. Bags of NS and blood connected with Y tubing, with NS clamped. A nurse is caring for a client who had a vaginal delivery 4 hours ago. The client has saturated a perineal pad in 20 minutes. During assessment, the nurse notices that the client has a boggy uterus that is deviated to the right. Which intervention should the nurse perform first? a. Assist client to the empty bladder b. Begin oxytocin infusion at 125 milliunits/min IV c. Obtain a complete blood count (CBC) d. Start oxygen at 10 L/min via facemask Male client with type 2 diabetes mellitus well controlled with metformin. Six hours ago the client went to cardiac catheterism with iodine contrast. Now the client is telling the nurse his metformin dose is due. Which of the following interventions is the appropriate to be carried out by the nurse? A. Reinitiate metformin with a snack B. Determine capillary blood sugar before giving metformin C. Withhold the dose and continue administering fluids D. Administer metformin with water Client is going to a cardiac catheterism to determine extension of coronary compromise. Which P a g e 20 | 226 laboratory finding requires follow up before the procedure? A. A1c 9 % B. Creatinine 1.8 mg/dL C. Positive Hepatitis B antibodies D. Hemoglobin 10g/dL Which step should the nurse take first when administering a liquid medication to an infant? a. Hold the infant securely and raise the infant’s head to about a 45 degree angle or higher b. Place the dropper at the corner of the infant’s mouth and let the drug run into the pocket between the cheek and gum c. Identify the infant by checking the armband and asking the name to parent d. Verify the physician’s order and the available medication The nurse is receiving the morning shift. What patient should the nurse see first? A. Client with MI 72 hours ago B. Client to be discharged in two hours P a g e 21 | 226 C. Client with UTI and a dose of levofloxacin IV due D. Client admitted with asthmatic status and absent wheezing Order: levofloxacin 250 mg in 100 mL bag of D5W to pass in 15 minutes. At what rate should be set the pump? Vol x (60/minutes) Order: Mg sulfate: 4 g IV to pass in 20 minutes. Available solution 40 g/L. Calculate pump rate in ml/h, round to whole number. (DO/available) x ml. (4g/40g) x 1000 mL = 100 mL Vol x (60/min) 100 mL x (60/20) = 300 mL/h Select client position immediately after surgery for ventricularperitoneal shunt placement in client with hydrocephalus and increased intracranial pressure: a. Flat b. 30o c. 45o d. 90o P a g e 22 | 226 c. The nurse tells the infant the vaccine is going to hurt a little d. The nurse asks for the client’s reasons to refuse medication What laboratory finding in a client receiving IV heparin requires the nurse immediate intervention? a. aPTT 70” b. Platelets 130,000/mm3 c. INR 1.1 d. positive Ddimer Which intervention provides the most accurate information about and infant’s hydration status? a. Measuring the infant’s urinary output b. Accurately measuring intake and output P a g e 25 | 226 c. Monitoring serum electrolyte levels and osmolarity d. Weighing the infant daily A client diagnosed with hypothyroidism is treated with levothyroxine. Which finding could tell the nurse that the treatment is effective? a. The client is able to wear a wool sweater in summer b. The client is resting on bed more frequent when feels tired c. The client has a daily bowel movement d. The client has gained eight pounds of weight The nurse received a telephone call from a diabetic client who has one insulin syringe left for the morning dose, but no insulin syringe for the afternoon dose. The client is unable of obtaining more syringes until the next day, but stated he has tuberculin and 3 ml syringes. What is the best nurse response? a. You can use a tuberculin syringe the same way as the insulin syringe b. You have to withhold the afternoon insulin until obtaining more insulin syringes c. You can use the insulin syringe left, recap and use it again for the pm dose d. You can use a 3 ml syringe as far as you are very careful measuring the insulin Which intervention is correct when applying wrist restrains to an agitated client? a. The restrains are tied to the side rails b. The client is restrained in flat supine position c. A soft pad is placed between the restrain and the client’s skin d. The restrains are applied tightly allowing one finger space between skin and the restrain Client with history of coronary artery disease arrives to ER with chest pain. The nurse is going to administer nitroglycerin sublingual as per protocol. Which medication previously taken by the patient contraindicates the use of nitroglycerin? a. Acetyl salicylic acid b. Warfarin P a g e 26 | 226 c. Tadalafil d. Bupropion Term gestation client, in active phase of labor, is already receiving epidural. When nurse needs to intervene? a. Client resting flat on lateral position b. UAP helping patient to seat on bed border for a while c. UAP offering ice chips to patient d. Client requesting bed pan to void every hour Client with pressure ulcer stage III. Which of the following vitamins has to be increased in the diet to enhance healing: a. Zinc P a g e 27 | 226 b. Muffled heart sounds c. Pleuritic chest pain d. Tachycardia e. Anxiety f. Hypertension Organize steps for administration of eye drops: 1. Position upright 2. Clean eye secretions from inner to outer cantus 3. Ask patient to look upward 4. Make a pocket with lower lid 5. Instill eye drop and ask to gently close eye lids HIV/AIDS patient with p. jiroveci pneumonia. Wife concerned about risk of acquiring the pneumonia. Best nurse response: a. Use a regular surgical mask and gloves b. Use a particulate respirator c. The risk is for the patient acquiring germs from you d. The pneumonia can be acquired through sexual contact only T3 spinal cord injury client complains of headache. What nurse does first? a. Check for fecal impaction b. Check for bladder distension c. Elevate HOB to high Fowler d. Loose client clothes Child who had head injury, what instruction RN gives the parents before going home? a. Provide only liquid food like soups b. Keep awake, don’t allow to sleep c. Elevate head with two P a g e 30 | 226 pillows d. Give acetaminophen every 8 hours Match drug and its indication ASA, diltiazem, glipizide, lisinopril, diphenhydramine, fenofibrate Hyperlipidemia, diabetes mellitus, heart failure, hypertension, urticaria, TIA Post adrenalectomy care, what is the most important parameter to monitor? a. Glucose b. Blood pressure c. Creatinine d. Calcium Priority drug in myxedema coma: a. IV normal saline b. IV dextrose c. IV sodium levothyroxine P a g e 31 | 226 d. IV cortisol Finding to follow up in newborn 16 hours: a. Sacral melanosis b. Epstein pearls c. Yellow discoloration skin d. Acrocyanosis Patient with Grave’s disease and exophthalmos. Position to sleep and reduce ocular pressure: a. Prone with elevation b. Supine with elevation c. Supine flat d. Lateral with elevation Food to administer after tonsillectomy: a. Frozen lemonade b. Orange juice c. Cranberry juice d. Pudding What is true in aging process? a. Old people develop coronary artery disease b. Old people have increased risk of cancer c. Old people have less risk of UTI d. Old people need to sleep less hours than young people Nurse recommends for a Wilson disease client which item from the menu list? a. Liver b. Shrimps c. Turkey d. Mushrooms P a g e 32 | 226 e) Urinary excretion of sodium increases Which of the following are symptoms of developing anorexia nervosa (SATA) a) Anorexia nervosa usually develops after age 10 b) Early dieting c) Tooth erosion and electrolytes imbalances d) Food rituals and obsessive behaviors e) Guilt or fear when eating d) Obsession with body weight and shape Which of the following should the nurse implement in a patient with Somogyi effect? a) increase the morning insulin b) decrease the morning insulin c) decrease the evening insulin P a g e 35 | 226 d) eliminate the bedtime insulin Which of the following patients can be delegated to the UAP? (SATA) a) Assist the patient changing the stoma of an ileostomy bag b) Maintain abduction while changing the linens of a patient with skeletal traction c) feed the client recovering from aspiration pneumonia d) apply permethrin after bathing a client with pediculosis e) give chest compressions while the nurse ventilates de client A depressed patient demonstrates a sudden improvement of mood soon after beginning of antidepressive therapy. Which of the following is an appropriate response by the nurse? a) I’m glad you feel that way b) did you have visitors last night? c) that sounds like if you want to hurt yourself d) why do you think that things are going to get better Which of the following should the nurse assess in a patient with Gillian Barre? (SATA) a) check for forced vital capacity (FVC) b) check for use of accessory muscles for breathing c) encourage the patient to walk frequently d) assess for difficulty breathing e) blood pressure and cardiac rhythm The new graduate nurse is assisting a client with a wound evisceration. Which of the following interventions by the nurse requires intervention? a) cover the wound with sterile gauze socked in normal saline b) applies gentle pressure on the wound c) places the patient supine with the legs flexed d) check vital signs Which of the following indicates understanding of the teaching of a patient with a gastric bypass P a g e 36 | 226 surgery? a) I will not lay down when I eat b) I will drink a full glass of water immediately after eating c) I will increase my intake of carbohydrates in my food d) I will eat six small meals daily Which of the following promotes weight gain? (SATA) a) eating large portions of foods b) slow metabolism c) poor exercise d) soft drinks P a g e 37 | 226 Monitor shows supraventricular tachycardia. Vagal maneuvers fail to slow the heart rate. Which medication the nurse anticipates will be used? a. amiodarone b. atropine c. lidocaine d. adenosine Expected finding in a client with important hyponatremia a. Constipation b. Bradycardia c. Headache d. Muscle spasms Interventions in a wound infected with VRS. SATA a. Keep stetoscope and thermometer in room b. Nurse removes gloves before leaving room c. Client is allowed to go to visit other room d. Keep door closed e. Tell UAP to limit time in room to less tan 30 minutes A client with Mycoplasma pneumoniae pneumonia is arriving from ED. What expects the nurse to be associated with this condition? a. Severe elevation of temperatura b. Severe hipoxemia c. Client requires isolation room d. Particulate respirator required Client is hospitalized with mumps. What is correct in the management of this condition? a. Room’s door should be kept closed b. Negative pressure room is required P a g e 40 | 226 c. Client wears surgical mask when leaving the room for procedure d. Nurse immune to mumps must wear surgical mask when entering room Which pregnant woman see first: a. 8 weeks with nausea and vomitss b. 20 weeks preeclampsia BP 130/80 c. 30 weeks tender and rigid uterus d. 39 weeks contractions every 10 minutes The nurse is caring of a male client just diagnosed with lung cáncer; but his wife requests to withold this information from the client. When the client asks the nurse: “Is it true that I could die from this disease? Based in which ethical principle the nurse should answer? a. autonomy b. benefíciense c. justice P a g e 41 | 226 d. veracity The client is treated with prednisone for idiopathic thrombocytopenic purpura ITP. Which finding the nurse should follow up? a. platelets 50,000 b. petechia in trunk and neck c. glucose 120 d. wbc 15,000 Which sign found only in rubeola? a. Koplik spot b. Slapped cheek rash c. Strawberry tongue d. Murphy’s sign MD ordered Vancomycin for a client with infected wound. When the nurse reviews the case, which finding requires withholding the drug and clarifying with MD: a. Allergy to penicillin b. Allergy to sulfas c. Creatinine 1.9 mg/dL d. Elevation of AST and ALT The nurse receives a client with hypertension, left heart failure, cough, fever and purulent sputums. The question has exhibits: glycemia 150, K 3.5, history of anaphylaxis with penicillin, alcohol use, among other info. Which of the following ordered drug must be questioned by the nurse? a. losartan 25 mg daily b. low sodium diet c. Cephacidal 1 g IV P a g e 42 | 226 b. Terminal client who wants to donate a kidney to a sibling but it is not compatible c. Pregnant woman who 8 weeks after in vitro fertilization bears 6 viable embryos but only one to have two babies. d. Eighteen year old male who refuses chemotherapy for Hodgkin lymphoma Interventions to prevent falls in a confused elder client: SATA a. Connect to a bed alarm b. Place near nurse station c. Raise side rails to prevent getting out of bed d. Restrain hands P a g e 45 | 226 e. Leave a night light on The nurse enters an unoccupied room and finds a fire in the garbage can. What should the nurse do first? a. Close the doors b. Turn off the oxygen valve c. Rescue the clients d. Activate the alarm A client going for a mastectomy has already signed the informed consent. When the nurse is proceeding with the pre operatory checklist, the client confesses she is not sure this is the kind of surgery convenient to her. What should the nurse do? a. Reassure everything will be OK b. Call the surgeon c. Cancel the surgery d. Notify the case manager of what is going on Which of the following are correct asepsis measures at a hospital? SATA a. Using a biohazard bag to dispose an old gauze with dry blood b. Using double bagging when cleaning the room of a client in contact isolation c. Placing all the hospital garbage in biohazard bags d. Cleaning body fluid spills with a diluted bleach solution e. Wearing gloves to take blood pressure in clients with HIV Which of the following could be the cause of an acute pancreatitis? a. Use of statins b. Cholelithiasis (gallstones) c. Diabetes mellitus d. Smoking P a g e 46 | 226 Which nutrient could help healing a burned client? a. Calcium b. Vitamin C c. Phytonadione d. Vitamin D Risks factors for osteoporosis: SATA a. Menopause b. Aging c. Family history d. Smoking e. History of bone cancer P a g e 47 | 226 Client in labor has 5 cm of cervical dilation. In which stage and phase is the client? a. First stage, active phase b. Second stage, transition phase c. First Stage, transition phase d. Second stage, latent phase The nurse is caring a client with lung cancer and superior vena cava syndrome. The nurse expects to find the following signs: SATA a. Pink frothy sputum b. Fever c. Edema of face and hands d. Neck vein distension e. Crackles in both lungs f. Headache and lethargy The nurse is caring of a client with fever, sore throat, erythematous rash, and strawberry tongue. The nurse is aware that the symptoms correspond to scarlet fever and a possible complication of this condition can be: a. Bacterial endocarditis b. Meningoencephalitis c. Acute glomerulonephritis d. Hepatic abscess The nurse observes an LPN taking care of a child with RSV. The nurse intervenes if the LPN: a. Doesn’t allow the child leaving the room b. Leaves the stethoscope in the room after taking BP c. Wear a surgical mask before entering the room d. Remove gloves before leaving the room P a g e 50 | 226 What are risk factors for breast cancer? SATA a. Family history b. History of breast trauma c. Use of oral contraceptive d. Pregnancy at early age e. Replacement hormonal therapy f. Early menarche The new graduate nurse is asking help to the charge nurse to introduce a urinary catheter because has not enough practice. The charge tells her to find a solution without asking for help. The charge nurse is demonstrating which style of leadership? a. Autocratic, b. Democratic, c. Laissez- faire, d. Situational The nurse is evaluating the parent’s understanding about the prescription of methylphenidate to their 10 years old male child. Which statement tells the nurse that more teaching is needed? a. We will offer him finger foods instead of complete meals b. We will leave the bigger dose before going to bed c. We expect the doctor will discontinue the medication while on school vacations d. We will call the doctor if our child complains of rapid heart beats P a g e 51 | 226 The nurse is teaching about the diuretic spironolactone to a male client with hepatic cirrhosis and ascites. Which statement is correct? a. This drug can make my breast enlarge b. I should increase the consume of dried fruits and bananas c. I can reduce my salt intake substituting for salt substitutes d. While on this drug I will need to have paracentesis more frequently Which of the following complaints the nurse expects from a client with prostatitis? a. rectal pain. b. macroscopic hematuria c. decreased urinary output d. urethral discharge Findings in superior vena cava compression. SATA a. facial edema b. crackles c. headache d. confusion e. neck vein distension f. history of lung cancer g. presence of a central venous catheter Patient to see first: a. boy with asthma attack, peak flow in 48% b. post-surgical client with unilateral leg edema with tenderness c. open fracture right arm covered by dressing stained with dark blood d. new onset atrial fibrillation complaining of fluttering in chest P a g e 52 | 226 d. Client has lithium blood level 1.2 mEq/L Which initial intervention should thake the nurse in conscious client showing the following ECG: a. Place client in Trendelemburg position b. Administer IV lidocaine as per protocol c. Ask client to bear down or cough d. Massage both carotid arteries Client to see first from four burned clients: a. Partial thickness burn on 50% BSA b. Client walking into in ED for electrical burn on chest 30 minutes ago c. 5 % burned BSA including singed beard hair d. Full thickness burn on both legs and genitals P a g e 55 | 226 ABG to expect in panic attack a. pH 7.50 pCO2 25 HCO3 24 b. pH 7.15 60 26 c. pH 7.50 49 38 d. pH 7.15 28 18 Calculation: Ordered: 40 mg/kg/day to be divided every 8 hours Available: suspension 250 mg/5 ml Weight 18.18 Kg Round to nearest whole number 4.848 = 5 ml Calculation - Nurse measures infant client’s I & O during 8 hours shift: - Dry diaper weighs 7 g. Two diaper changes: one 36 g, other 32 g. Nasogastric suction 54 mL, JP drainage 24 mL. Calculate output in 8 hours. Bipolar client screams to other client: “stop looking at me”, “I hate everybody looking at me”. What it the nurse’s best intervention? a. Escort client to a quiet place b. Place the client in seclusion room c. Take the client to play soccer with other clients d. Explain the client that the hospital policies prohibit screaming this way Correct nursing intervention in stage one pressure ulcer on sacral area: a. Carefully massage the erythematous skin over sacrum to promote circulation P a g e 56 | 226 b. Order the UAP to change position and apply collagenase cream with each diaper change c. Cover the sacral area with a transparent dressing d. Decrease pressure using a doughnut cushion while sitting on chair Which findings are expected in hyperparathyroidism? (SATA) a. Hyperphosphatemia b. Hypercalcemia c. Trousseau sign d. nephrolithiasis e. diarrhea With which other diagnose can the nurse cohort a client with osteomyelitis? a. Hepatitis A b. Bacterial pneumonia c. Norovirus diarrhea d. Suppurative cellulitis P a g e 57 | 226 The woman is in labor with 6 cm dilation, and station 1-. After three hours the cervix has dilated to 9 cm but the baby did not move to a lower station. What would the nurse do first? a. Call MD b. Assess for umbilical cord prolapse c. Assess for bladder distention d. Encourage client to walk MD has ordered an internal uterine monitor placed in a client who started labor. What the nurse has to assess first before carrying out the order? a. Fetal heart rate and looking for decelerations b. Mother blood pressure and blood type c. Cervical dilation and for broken membranes d. White blood cell count and for intact membranes Client is prescribed thiazide diuretic for hypertension. Which medical history requires immediate report to the prescriber? a. History of penicillin allergy b. History of hypocalcemia c. History of sulfonamide allergy d. History of asthma SATA about teaching after a hip replacement: a. Use prophylactic warfarin for 3 to 4 weeks when discharged home b. Checking for high INR c. Use prophylactic intramuscular heparin intramuscular while hospitalized d. Avoid activities implying adduction and less than 90 degree flexion e. Monitor for local signs of infections P a g e 60 | 226 SATA about female condom: a. Use water based lubricant b. Needs a prescription from a doctor c. Condom is slightly loose fitting on the cervix d. Men wear a condom while intercourse e. Decreases the risk of transmitting a STD SATA about treatment for hemodynamically unstable patient with atrial flutter a. Diltiazem b. Metoprolol c. Amiodarone d. Cardioversion P a g e 61 | 226 e. Atropine What is the best way of providing education to a 5-year-old, newly diagnosed with DM1 requiring lifelong insulin treatment? a. Let the child play with needless insulin syringes b. Explain the child in simple words the reasons to receive insulin in shots c. Show a video about self-administration of insulin d. Demonstrate insulin injections to parents, but in presence of the child What of the following precautions is correct in a client with rubeola? a. Nurse wears a surgical mask b. Client is placed in a negative pressure room c. Fit client with a particulate respirator when leaving the room d. Use gloves previous to administer oral medication The mother develops rubella at the end of pregnancy and gives birth. What should the nurse do with the child after birth? a. Leave newborn with mother in same room b. Isolate the mother and keep the newborn in nursery b. Isolate mother and newborn in different areas c. Vaccinate the newborn as soon is born Recommendations for a client starting lisinopril: SATA a. Keep recumbent for a couple of hours after first dose b. Take hot showers to help circulation c. Avoid salt substitutes and use herbs instead d. Use OTC cough syrup if dry cough presents e. Continue using your oral contraceptive f. Increase vegetables intake like tomato and avocado P a g e 62 | 226 a. Weight gain b. Hypersomnia c. Anhedonia d. Irritability e. Flight of ideas Select adequate nursing care for a child with this rash, diarrhea, and fever. SATA a. Administer (Pepto-Bismol®) bismuth subsalicylate ordered for diarrhea b. Place the client in droplets precautions c. Keep the room door closed P a g e 65 | 226 Nurse doesn’t need d. to wear respirator if immune to varicella-zoster virus e. Keep the client’s nails trimmed Put in order steps to follow in case of air embolism Call rapid response team Administer oxygen Clamp central IV catheter Turn to left lateral and Trendelenburg What is the most important recommendation in client with chronic low back pain taking oxycodone? a. Wait until significant pain appears to take the pill, to avoid tolerance and addiction b. Increase the consume of vegetables, fruits, and whole grains c. Take a hot shower after the medication to relax muscles when in pain d. Any antidepressant ordered to you has to be discontinued while taking pain killers Select drugs to avoid in a client with close angle glaucoma, SATA a. Benztropine b. Pilocarpine c. diphenhydramine d. acetazolamide e. amitriptyline Common finding in the history of client with testicular cancer: a. Swelling and erythema in scrotum b. History of testicular trauma c. History of undescended testicle d. Exposition to heat in perineal area P a g e 66 | 226 Finding to report immediately in a client post renal transplant: a. Tenderness in surgical area b. Urinary output 50 mL per hour c. Pink colored urine d. Increased clearance of creatinine The 2-year-old child has iron deficiency anemia. Which intervention by the mother is correct? a. Give oral iron sulfate with folic acid to improve absorption b. Give oral iron sulfate with milk to avoid constipation c. Include beets and orange juice to increase dietary iron d. Give no more than 960 ml of milk each day The nurse is providing prenatal care to four pregnant women. Which of these clients requires immediate follow up? a. 31 weeks with type 2 diabetes mellitus controlled with diet b. 30 weeks taking sulfa for uncomplicated cystitis c. 32 weeks with uterine contractions and receiving terbutaline d. 38 weeks with a positive Mantoux test P a g e 67 | 226 Client is ordered ciprofloxacin for UTI. After four days takin the drug the client reports to the nurse pain and swelling above the right heel. What should the nurse recommend? a. Determine uric acid levels b. Recommend local cool compresses c. Recommend OTC NSAID d. Discontinue the Cipro and consult MD The nurse identifies the ECG as which alteration of the cardiac rhythm? a. Supraventricular tachycardia b. Ventricular tachycardia c. Ventricular fibrillation d. Torsade da Points Place in order of assessment techniques in abdomen: Palpation Inspection Percussion Auscultatio n Pregnant woman HIV positive, dilation 6 cm, engagement 0. Already broken membranes. Contractions: one contraction every 23 minutes lasting 6070 seconds. Intervention to choose: a. Teach mother to avoid bottle feeding and pacifiers b. Avoid vaginal digital explorations c. Initiate fetal intrauterine monitorization P a g e 70 | 226 d. Make the mother walk on the hall The nurse documents this finding in newborn feet the first day of born: P a g e 71 | 226 a. prematurity b. Babinski sign c. acrocyanosis d. hip dysplasia The nurse observes a wound with the following aspect. What should the nurse do first? a. Assess for pain b. Investigate type of footwear used c. Give ordered antibiotic d. Carry out order for glucose tests P a g e 72 | 226 b. Request order for Elisa test c.. Document erythema multiform d. Report bulls eye lesion to provider What statement of client suffering insomnia requires more teaching? a. I have a yogurt before going to bed b. I avoid watching TV or working with computer before bed c. I walk for half an hour every night before bed d. I avoid napping during the day P a g e 75 | 226 The needle is left in subcutaneous tissue o Decreases the frequency of hypoglycemia Risk factors for endometrial cancer. SATA: a. diabetes mellitus b. obesity, c. hormonal replacement therapy d. history of endometrial hyperplasia e. history of cervical cancer Insulin pump. SATA: a. Most commonly used in type I diabetes but can be used in type 2 b. The client avoids finger sticks to check glucose c. Make the diabetic treatment less expensive d. e. f abdomen for three days High fiber is indicated in the following diseases except: a. irritable bowel syndrome b. diverticulosis c. Crohn’s disease d. hemorrhoid disease Main characteristic of histrionic personality disorder: a. superiority feelings b. attention seeking c. social isolation d. hypochondriasis Place in correct order the sequence to don PPE: P a g e 76 | 226 Gloves Gown Face shield Facemask Timolol eye drops are prescribed for open angle glaucoma. Which client antecedent requires clarification of the order? a. diabetes mellitus b. bronchial asthma c. ischemic heart disease d. macular degeneration Client with history of diabetes mellitus and hypertension for 40 years. Lab work reports A1c 9%, glucose 210, creatinine 2.0 and BUN 32. Provider prescribes diet and for medications. What medication nurse should question? P a g e 77 | 226 Four bed positions: which one RN chooses for client with COPD. Dysplastic nevus (melanoma): ABCDE Client with Chron’s disease in adalimumab SQ every three weeks. Which finding the nurse give priority? a. 8 liquid bowel movements per day b. Abdominal right lower quadrant pain c. Temperature 101.2 oF P a g e 80 | 226 d. Fecaloid liquids coming from cutaneous fistula Nurse going to teach drug selfadministration for a new admitted old client. Most important preparation before starting interview: a. Assess vital signs b. Verify hearing aid function c. Provide written instructions d. Assess cognitive functions Asian origin client with round purpuric marks aligned in her back. The nurse asks for: P a g e 81 | 226 a. Coining b. Use of aspirin or anticoagulants c. Cupping d. Acupuncture Expected arterial gases in a client with bulimia: a. pH 7.30, pCO2 28, HCO3 18 b. pH 7.48, pCO2 48, HCO3 27 c. pH 7.50, pCO2 30, HCO3 24 d. pH 7.35, pCO2 34, HCO3 22 Client taking methotrexate for rheumatoid arthritis. Statement requiring follow up: a. I am taking folic acid supplements b. I am taking vitamin B6 c. I am taking acetaminophen for pain d. I am taking hot showers every morning The client is taking orlistat. The nurse knows the decided outcome of taking this medication is: a. Reduction of blood pressure b. Reduction of cholesterol c. Reduction of weight d. Reduction of triglycerides The nurse is teaching the use of a cane for a client with unstable gait. Which of the following is correct? SATA a. Cane height should coincide with the client waist. P a g e 82 | 226 b. Administer warm electrolyte solution c. Administer warm moist oxygen through facial mask d. Administer strong alcoholic drink like brandy or whisky e. Warm and massage the extremities before the trunk f. Avoid CPR if no pulse but pupils are dilated Which of the following statements made by a 30 weeks gestation woman shows correct understanding of explanation of amniocentesis: a. Having a small leaking of fluid is expected for the first hours. b. The technique to be used during the procedure is all sterile c. After the puncture I should not have more than 1 contraction every 10 minutes d. The purpose of this study is to diagnose any chromosomic abnormality Correct delegation of the RN to the nursing student during administration of analgesic to a client with pain 7/10: a. Allow the student to administer IV morphine b. Make the student cosign the wasted portion of narcotic vial. c. RN gives the narcotic and explain the student the mechanism of action of it P a g e 85 | 226 d. RN prepares a nonnarcotic analgesic and asks the student to administer it What the nurse expect to hear from parents of a six months old child born with early onset Tay Sach disease a. Our child can already seat without support b. The child is not gaining weight because vomits frequently c. We need to talk very soft because otherwise the child jumps and extend arms d. Our child sweats very salty Home health nurse is visiting four clients. In which situations the nurse should intervene? a. A client with recent mastectomy is observing cutting her fingernails with scissors b. A client with neurogenic bladder is practicing bladder selfcatheterization without gloves c. The daughter of a visually impaired diabetic client leaves in the refrigerator several prefilled insulin syringes with the needle up, to be administered by the own client. d. The water heater in the house of a chronic diabetic client is set at 120 oF Which one of the following documentations protects the RN of being sued for negligence in case of infiltration of a vesicant chemotherapy in a client complaining of pain at insertion site? a. Dose and client identification was double checked with other RN b. Blood return observed in the IV tubing, infusion continued at a lower rate c. Pain and swelling observed in insertion site, IV discontinued, pressure applied for 3 minutes d. IV site observed swollen, infusion discontinued, IV cannula left in site, 3 ml of blood suctioned. Correct delegation to UAP a. Help the client to choose low cholesterol food from menu b. Observe while a client ambulates with a cane P a g e 86 | 226 c. Place a condom catheter in the incontinent client d. Assist to feed a client with myasthenic crisis Female with 36 weeks of gestation, used to have a heart rate around 60 bpm because she trained to run in marathons. In the last prenatal evaluation her heart rate was found in 90 bpm. What the nurse explains about the possible cause of the increment in the heart? a. The increment is to compensate for an anemia developed in pregnancy b. This finding should make the MD investigate for a hidden congenital heart disease c. The change in heart rate is a physiologic change in pregnancy d. The tachycardia is secondary to loss o blood volume sequestrated in the placenta Client with immunodeficiency develops disseminated herpes zoster. What infection precautions take the nurse? SATA a. Keep the client in a negative pressure room but leave the door open b. Cohort the client with other with varicella c. Allow immune personnel entering the isolation room without respirator mask d. Provide disposable utensils to eat and drink P a g e 87 | 226 Fluids recommended after tonsillectomy. SATA a. Cool water b. Cherry ice chips c. Cold black tea d. Apple juice diluted with water e. Orange juice Client in first stage, active phase of labor. Recommended position: a. Leg elevation b. Lateral c. Supine semi Fowlers d. Prone Nurse from outpatient ambulatory center has to float to E.D. What activity to assign? a. Assist provider doing a pericardiocentesis b. Triage clients with neurologic problems c. Complete the admission histories of elective surgery d. Help in the trauma unit What is doing wrong a client with rheumatoid arthritis? a. receive influenza vaccine while in treatment with glucocorticoids b. take folic acid supplement while treated with methotrexate c. take meloxicam on empty stomach d. shower with cold water to improve stiffness Client presents numbness on fingers and toes after thyroidectomy. Which nursing intervention is correct? a. Asses patellar reflex to rule out hypomagnesemia P a g e 90 | 226 b. Asses respiratory rate and lung sounds c. Administer ordered calcium gluconate IV d. Administer oxygen by nasal cannula at 2 L/min Alzheimer’s male client is affectively wishing happy New Year to all the nurses and other persons in the floor (it is March). Which intervention is the best? a. Thanks the client and wish happy New Year to him b. Show the date in the newspaper to the client c. Take the client to the lounge and offer him a snack d. Administer the ordered PRN sedative Nurse calls MD for patient with signs of fluid volume deficit and hypovolemic shock; MD recommend continuing monitoring and calling again in 1 hour. What nurse should do? a. Initiate IV Isotonic fluids through 18 G catheter at 75 ml/h and call in 1 hour b. Place the client in modified Trendelemburg and administer oxygen by nasal cannula c. Ask for nurse supervisor evaluation of the case P a g e 91 | 226 d. Document the call and MD orders, making emphasis in the client condition Client is to receive enoxaparin SQ. Select all the correct interventions a. Remove any bubble of air from the syringe b. Penetrate the skin at an angle of 45 degrees c. Release the pinch before removing the needle d. Make pressure after removing the needle e. Aspirate for blood before injecting the solution The circulating nurse is receiving a client from the floor and noticed that the client has not signed the informed consent and surgery is in one hour. What nurse does first? A. Determine if the has received the required information for the surgery B. Communicate the situation to the surgeon C. Find if there is a designated proxy who could sign for the client D. Determine if client received any premedication Priority finding to follow up in a 12 hours newborn: a. Acrocyanosis in hands b. Dark green feces, c. Bluish gray spot in sacral area. d. Head circumference 40 cm Normal finding in a seven month child: a. Posterior fontanelle almost closed b. Can hold a cup with both hands c. Can seat without support d. Presents startle reflex P a g e 92 | 226 MD orders 2 ml IM stat of a medication for an infant. How should the nurse carry out the order? a. Administer 2 ml IM in one vastus lateralis b. Administer 2 ml IM in ventral gluteal c. Administer 1 ml IM in both vastus lateralis d. Administer 1 ml IM in both dorsal gluteal Doctor orders magnesium hydroxide with aluminum hydroxide antacid PO every six hours, and the antibiotic amoxicillin with Clavulonate every 12 hours. How should the nurse administer the medications? a. Administer antacid every 6 hours and the antibiotic on hour after the first and third dose of antacid b. Consult with provider to change antacid for omeprazole P a g e 95 | 226 c. Consult with provider to change antibiotic to parenteral d. Administer antibiotic one hour before the first and third dose of antacid every 6 hours Food rich in vitamin A. SATA a. Bell pepper b. Egg white c. Sweet potatoes d. spinach e. apricots Signs and symptoms of left heart failure. SATA a. Crackles b. Dependent edema c. Hepatomegaly d. Neck vein distension e. Nocturia Complications of IV drug users. SATA a. Hepatitis C b. Thrombophlebitis c. Soft tissue abscess d. Overdose e. Hepatitis A Female 25 presented two episodes of abundant hematemesis. MD orders upper GI series. What should the nurse assessing the client evaluate? SATA a. Allergy to shellfish P a g e 96 | 226 b. Dysphagia c. Last menstrual period d. NPO status e. Other abdominal exams ordered Client with multiple myeloma, bone metastasis, and hypercalcemia. Nurse expects order for: a. Thiazide diuretics b. Recombinant parathyroid hormone c. IV normal saline at 150 mL/h d. Calcium carbonate Client with systemic erythematous lupus, nephritis treated with prednisone and cyclosporine. Which herbal consumed by the client could interfere with the lupus treatment? a. St. John Wort b. Black cohosh c. Echinacea P a g e 97 | 226