100 Random NCLEX Practice Questions 12 100 Random NCLEX Style Practice Questions Questions Change Every Time 1 / 100 1. A client is newly diagnosed with chronic obstructive pulmonary disease (COPD). The client returns home after a short hospitalization. The home care nurse should most importantly plan teaching strategies that are designed to do what? A. Improve oxygenation and minimize carbon dioxide retention. B. Identify irritants in the home that interfere with breathing. C. Encourage the client to become a more active person. D. Promote membership in support groups. 2 / 100 2. The nurse is caring for a hospitalized client who is having a prescribed dosage of clonazepam adjusted. Because of the adjustment in the medication administration, which priority safety activity should the nurse plan to implement? A. Weigh the client daily. B. Assess for ecchymoses. C. Monitor blood glucose levels. D. Institute seizure precautions. 3 / 100 3. The nurse is monitoring a client in the telemetry unit who has recently been admitted with the diagnosis of chest pain and notes this heart rate pattern on the monitoring strip (refer to figure). What is the initial action to be taken by the nurse? A. Initiate cardiopulmonary resuscitation (CPR). B. Notify the primary health care provider. C. Administer oxygen with a face mask at 8 to 10 L per minute. D. Continue to monitor the client and the heart rate patterns. 4 / 100 4. The nurse is reviewing the results of the rubella screening (titer) with a pregnant client. The test results are positive, and the client asks if it is safe for her toddler to receive the vaccine. Which response by the nurse is most appropriate? A. “Your titer supports your immunity to rubella, and it is safe for your toddler to receive the vaccine.” B. “You are still susceptible to rubella, so your toddler should receive the vaccine.” C. “It is not advised for children of pregnant women to be vaccinated during their mother ’s pregnancy.” D. “Most children do not receive the vaccine until they are 5 years of age.” 5 / 100 5. A teenager returns to the gynecological clinic for a follow-up visit for a sexually transmitted infection (STI). Which statement by the teenager indicates the need for further teaching? A. I finished all of the antibiotics, just like you said.” B. I always make sure that my boyfriend uses a condom. C. I know you won’t tell my parents I’m sick D. My boyfriend doesn’t have to come in for treatment, does he? 6 / 100 6. Which nursing assessment finding indicates the presence of an inguinal hernia on a child? A. Reports of difficulty defecating B. Reports of a dribbling urinary stream C. Painless groin swelling noticed when the child cries D. Absence of the testes within the scrotum 7 / 100 7. A client with a diagnosis of subarachnoid hemorrhage secondary to ruptured cerebral aneurysm has been placed on aneurysm precautions. To promote safety, the nurse should ensure that which intervention is provided to the client? A. Enemas as needed B. Daily stool softeners C. Liquid diet D. Help with ambulation 8 / 100 8. An adolescent is hospitalized with a diagnosis of Rocky Mountain spotted fever (RMSF). The nurse anticipates that which medication will be prescribed? A. Ganciclovir B. Amantadine C. Amphotericin B D. Doxycycline 9 / 100 9. A client diagnosed with a recent complete T4 spinal cord transection tells the nurse that he will walk again as soon as the spinal shock resolves. Which statement provides the most accurate basis for planning a response to the client? A. The client is projecting by insisting that walking is the rehabilitation goal. B. Denial can be protective while the client deals with the anxiety created by the new disability. C. To speed acceptance, the client needs reinforcement that he will not walk again. D. The client needs to move through the grieving process rapidly to benefit from rehabilitation. 10 / 100 10. A client who survived a house fire is experiencing respiratory distress, and an inhalation injury is suspected. What should the nurse monitor to determine the presence of carbon monoxide poisoning? A. Serum carboxyhemoglobin levels B. Urine myoglobin C. Sputum carbon levels D. Pulse oximetry 11 / 100 11. A client diagnosed with gestational hypertension has just been admitted and is in early active labor. Which assessment finding should the nurse most likely expect to note? A. Decreased fetal heart rate B. Decreased brachial reflexes C. Increased blood pressure D. Increased urine output 12 / 100 12. . The nurse is applying electrocardiogram (ECG) electrodes to a diaphoretic client. Which intervention should the nurse take to keep the electrodes securely in place? A. Apply lanolin to the skin before applying the electrodes. B. Cleanse the skin with alcohol before applying the electrodes C. Secure the electrodes with adhesive tape. D. Place clear, transparent dressings over the electrodes. 13 / 100 13. The significant other of a client diagnosed with Graves’ disease expresses concern regarding the client’s bursts of temper, nervousness, and an inability to concentrate on even trivial tasks. On the basis of this information, the nurse should identify which concern for the client? A. Issues related to sensory perception B. Trouble with coping with a disease process C. Socialization issues D. Grief 14 / 100 14. A primipara is being evaluated in the clinic during her second trimester of pregnancy. The nurse checks the fetal heart rate (FHR) and notes that it is 190 beats/min. What is the appropriate initial nursing action? A. Consult with the primary health care provider. B. Document the finding. C. Recheck the FHR with the client in the standing position. D. Tell the client that the FHR is fast. 15 / 100 15. The nurse is assigned to care for a client with a chest tube attached to closed chest drainage. Which assessment data should the nurse identify as an indicator that the client’s lung has completely expanded? A. The oxygen saturation is greater than 92%. B. Pleuritic chest pain has resolved. C. Suction in the chest drainage system is no longer needed. D. Fluctuations in the water-seal chamber ceased. 16 / 100 16. Which piece of equipment will the nurse routinely use to assess the fetal heart rate of a woman at 16 weeks’ gestation? A. Ultrasound fetoscope B. Bell of a stethoscope C. An adult stethoscope D. Fetal heart monitor 17 / 100 17. A client receiving prescribed heparin therapy for a diagnosis of an acute myocardial infarction has an activated partial thromboplastin time (aPTT) value of 100 seconds. Before reporting the results to the primary health care provider, the nurse verifies that which medication is available for use if prescribed? A. Vitamin K B. Methylene blue C. Protamine sulfate D. Vitamin B12 18 / 100 18. A client diagnosed with acquired immunodeficiency syndrome (AIDS) gets recurrent Candida infections of the mouth (thrush). The nurse has given the client instructions to minimize the occurrence of thrush and determines that the client understands the instructions if which statement is made by the client? A. I should use a mouthwash at least once a week.” B. “Increasing the amount of red meat in my diet will keep this from recurring.” C. “I should brush my teeth and rinse my mouth once a day.” D. “I should use warm saline or water to rinse my mouth.” 19 / 100 19. The nurse is planning the hospital discharge of a young client who has been newly diagnosed with type 1 diabetes mellitus. The client expresses concern about self-administering insulin while in school with other students around. Which statement by the nurse best supports the client’s need for support at this time? A. “You could leave school early and take your insulin at home.” B. “You shouldn’t be embarrassed by your diabetes. Lots of people have this disease.” C. “Ask the school nurse about identifying a private area for you to use for injections D. “Oh, don’t worry about that! You’ll do fine!” 20 / 100 20. An English-speaking Hispanic client has a newly applied long leg cast to stabilize a right proximal fractured tibia. During rounds at night, the nurse finds the client restless, withdrawn, and unusually quiet. Which nursing statement would be most appropriate? A. Are you uncomfortable?” B. “I’ll get your pain medication right away.” C. “You’ll feel better in the morning.” D. “Tell me what you are feeling.” 21 / 100 21. The nurse is preparing to administer a first dose of prescribed pentamidine isethionate intravenously to a client. Before administering the dose, which safety measure should the nurse consider for this client? A. Establish a supine position. B. Assign to a private room. C. Place on respiratory precautions. D. Assist to a semi-Fowler ’s position. 22 / 100 22. The camp nurse provides instructions regarding skin protection from the sun to the parents who are preparing their children for a camping adventure. Which statement by a parent indicates a need for further instructions? A. A protective sunscreen is best to prevent sunburn.“ B. “My child should wear clothes that have a tightly woven material for greater protection from the sun’s rays.“ C. “My child won’t need the sunscreen on cloudy, hazy days.“ D. “I need to pack a hat, long-sleeved shirts, and long pants for my child to wear.“ 23 / 100 23. A client is scheduled for a subtotal gastrectomy (Billroth II procedure). The nurse explains that the procedure will have which surgical results? A. 1. Lower portion of the stomach is removed and the remainder is anastomosed to the jejunum. B. 1. Entire stomach is removed and the esophagus is anastomosed to the duodenum. C. Antrum of the stomach is removed and the remaining portion is anastomosed to the duodenum. D. 1. Proximal end of the distal stomach is anastomosed to the duodenum. 24 / 100 24. A client is diagnosed with a flail chest. Which characteristics related to breathing should the nurse observe for in the client? A. Severe dyspnea and paradoxical chest movement B. Pallor and paradoxical chest movement C. Slight bradypnea with shallow breaths D. Cyanosis and slow respirations 25 / 100 25. The nurse is assessing a 3-day-old preterm neonate with a diagnosis of respiratory distress syndrome (RDS). Which assessment finding indicates that the neonate’s respiratory condition is improving? A. Edema of the hands and feet B. Urine output of 3 mL/kg/hour C. Presence of a systolic murmur D. Respiratory rate between 60 and 70 breaths per minute 26 / 100 26. The registered nurse instructs the new nurse that a variance analysis is performed on all clients with respect to which time frame? A. Daily during hospitalization B. Every third day of hospitalization C. Every other day of hospitalization D. Continuously 27 / 100 27. The nurse is caring for a client at risk for suicide. Which client behavior best indicates that the client may be contemplating suicide? A. Sitting and crying for long periods of time B. Sharing that she or he is finally happy C. Reporting a variety of sleep pattern disturbances D. Preferring to spend long periods of time alone 28 / 100 28. A client who is admitted to the hospital for an unrelated medical problem is diagnosed with urethritis caused by chlamydial infection. The unlicensed assistive personnel (UAP) assigned to the client asks the nurse what measures are necessary to prevent contraction of the infection during care. The nurse tells the UAP that which intervention is needed for infection control? A. Contact isolation should be initiated because the disease is highly contagious. B. Gloves and mask should be used when in the client’s room. C. Standard precautions are sufficient because the disease is transmitted sexually. D. Enteric precautions should be instituted for the client. 29 / 100 29. The nurse is teaching a client with a right-leg fracture who has a prescription for partial weight-bearing status how to ambulate with crutches. The nurse determines that the client demonstrates compliance with this restriction to prevent complications of the fracture if the client follows which direction? A. Allows the right foot to only touch the floor B. Does not bear any weight on the right leg/foot C. Puts 30% to 50% of the weight on the right leg/foot D. Puts 60% to 80% of the weight on the right leg/foot 30 / 100 30. A client diagnosed with Parkinson’s disease is having difficulty adjusting to the disorder. The nurse provides education to the family that focuses on addressing the client’s activities of daily living. Which statement indicates that the teaching has been effective? A. “We should encourage and praise efforts to exercise and perform activities of daily living.” B. “We should cluster activities at the end of the day, to help conserve energy.” C. We should plan for only a few activities during the day.” D. “We should assist with activities of daily living as much as possible.” 31 / 100 31. The nurse receives a telephone call from a client who states that he wants to kill himself and has a loaded gun on the table. Which intervention best assures the client’s safety? A. Encouraging him to unload the gun and go to the hospital B. Using therapeutic communication techniques, especially the reflection of feelings C. Telling the client that suicide is not the way to deal with his problem D. Engaging the client while another staff member contacts the police for their assistance 32 / 100 32. A client who has undergone successful femoral-popliteal bypass grafting of the leg states to the nurse, “I hope everything goes well after this and that I don’t lose my leg. I’m so afraid that I’ll have gone through this for nothing.” Which most therapeutic response should the nurse make to the client? A. “Stress isn’t helpful for you. You should probably just try to relax. You shouldn’t worry unless something actually happens.” B. “This surgery is so successful that I wouldn’t be concerned at all if I were you.” C. “I can understand what you mean. I’d be nervous too if I were in your shoes.” D. “Complications are possible, but you have a good deal of control if you make the lifestyle adjustments we talked about.” 33 / 100 33. The nurse is caring for a client diagnosed with acute pulmonary edema. Which psychosocial strategy should the nurse plan to incorporate into the care of the client? A. Promoting a positive body image B. Increasing fluid volume C. Decreasing cardiac output D. Reducing anxiety 34 / 100 34. The nurse is conducting a health history on a client diagnosed with hyperparathyroidism. Which question asked of the client would elicit information about this condition? A. “Are you experiencing pain in your joints?” B. “Do you notice any swelling in your legs at night?” C. “Do you have tremors in your hands?” D. “Have you had problems with diarrhea lately?” 35 / 100 35. A client experiencing empyema is to have a bedside thoracentesis performed. The nurse plans to have which equipment available in the event that the procedure is not effective? A. Chest tube and drainage system B. Extra-large drainage bottle C. A small-bore needle D. Code cart 36 / 100 36. A 17-year-old client is discharged to home with her newborn baby after the nurse provides information about home safety for children. Which statement by the client should alert the nurse that further teaching is required regarding home safety? A. “I will not use the microwave oven to heat my baby’s formula.” B. “I can keep my aluminum pots and pans in my lower cabinets.” C. “I have locks on all my cabinets that contain my cleaning supplies.” D. “I have a car seat that I will put in the front seat to keep my baby safe.” 37 / 100 37. A client is to have arterial blood gases drawn. While the nurse is performing Allen’s test, the client states to the nurse, “What are you doing? No one else has done that!” Which response the nurse makes to the client is most therapeutic? A. “This is a routine precautionary step that simply makes certain your circulation is intact before a blood sample is obtained.” B. “This step is crucial to safe blood withdrawal. I would not let anyone take my blood until they did this.” C. “Oh? You have questions about this? You should insist that they all do this procedure before drawing up your blood.” D. “I assure you that I am doing the correct procedure. I cannot account for what others do.” 38 / 100 38. 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? A. Intubation B. Paracentesis C. Thoracentesis D. Central venous line insertion 39 / 100 39. A primary health care provider is inserting a chest tube. Which materials should the nurse have available to be used as the first layer of the dressing at the chest tube insertion site? A. Sterile 4 × 4 gauze pad B. Petrolatum jelly gauze C. Absorbent gauze dressing D. Gauze impregnated with povidone-iodine 40 / 100 40. 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? A. Ability to purchase foods necessary for disease management B. Familial support systems and financial well-being C. Client perception of body weight and size relative to culture D. Educational background and employment history 41 / 100 41. The nurse performs an Allen’s test before blood is drawn from the radial artery for an arterial blood gas (ABG) assessment. This intervention is done to determine the collateral circulatory adequacy of which arterial vessel? A. Ulnar B. Carotid C. Femoral D. Brachial 42 / 100 42. A client was just told by the primary care primary health care provider that he will have an exercise stress test to evaluate his status after recent episodes of severe chest pain. As the nurse enters the examining room, the client states, “Maybe I shouldn’t bother going. I wonder if I should just take more medication instead.” Which therapeutic response should the nurse make to the client? A. “Most people tolerate the procedure well without any complications.” B. “Don’t you really want to control your heart disease?” C. “Can you tell me more about how you’re feeling?” D. “Don’t worry. Emergency equipment is available if it should be needed.” 43 / 100 43. To ensure that the client self-administers medications safely in the home, which action plan should the nurse implement? A. Ask the client to explain and demonstrate self-administration procedures. B. Instruct the client to double up on a medication when a dose is missed. C. Provide information on the purpose of all the prescribed medications. D. Perform a pill count of each prescription bottle at every home visit. 44 / 100 44. A 16-year-old client with Crohn’s disease is hospitalized. Which statement by the client would alert the nurse to a potential developmental problem? A. I’d like my hair washed before my friends get here.” B. “Please tell my friends not to visit, since I’ll see them back at school next week.” C. “When my friends get here, I would like to play some computer games with them D. “Is it okay if I have a couple of friends in to visit me this evening?” 45 / 100 45. The nurse is receiving a client from the emergency department who has a diagnosis of Guillain-Barré syndrome. The client’s chief sign/symptom is an ascending paralysis that has reached the level of the waist. Which items should the nurse plan to have available for emergency use? A. Blood pressure cuff and flashlight B. Nebulizer and pulse oximeter C. Cardiac monitor and intubation tray D. Flashlight and incentive spirometer 46 / 100 46. A client diagnosed with both a wound infection and osteomyelitis is to receive hyperbaric oxygen therapy. During the therapy, which priority intervention should the nurse implement? A. Ensuring that oxygen is being delivered B. Providing emotional support to the client’s family C. Administering sedation to prevent claustrophobia D. Maintaining an intravenous access 47 / 100 47. What is the nurse’s priority for the postprocedure care of a client who has just returned to the unit after a scheduled intravenous pyelogram (IVP)? A. Ambulating the client in the hallway B. Encouraging the increased intake of oral fluids C. Maintaining the client on bed rest D. Encouraging the client to try to void frequently 48 / 100 48. The nurse is monitoring the nutritional status of a client who is receiving enteral nutrition. Which should the nurse monitor as the best clinical indicator of the client’s nutritional status? A. Calorie count B. Daily weight C. Serum prealbumin level D. Skinfold measurement 49 / 100 49. A community health nurse working in an industrial setting has received a memo indicating that a large number of employees will be laid off during the next 2 weeks. An analysis of previous layoffs suggested that workers experienced role crises, indecision, and depression. Using this information, which actions should the nurse implement to begin assisting employees? A. Reduce the staff in the occupational health department of the industrial setting. B. Help the workers acquire unemployment benefits to avoid a gap in income. C. Notify insurance carriers of the upcoming event to assist with potential health care alterations. D. Identify referral, counseling, and vocational rehabilitative services for the employees being laid off. 50 / 100 50. The nurse monitors the client for a hypoglycemic reaction, knowing that NPH insulin peaks in approximately how many hours following administration? A. 1 hour B. 2 to 3 hours C. 4 to 12 hours D. 16 to 24 hours 51 / 100 51. The nurse admits a client with a suspected diagnosis of bulimia nervosa. While performing the admission assessment, the nurse expects to elicit which data about the client’s beliefs? A. Is accepting of body size B. Overeats for the enjoyment of eating food C. Views purging as an accepted behavior D. Overeats in response to losing control of diet 52 / 100 52. Cholestyramine is prescribed, and the nurse provides instructions to the client about the medication. Which client statement indicates a need for further teaching? A. “I should increase my fluid intake while taking this medication.” B. “I need to mix the medication with juice or applesauce.” C. “I should call my primary health care provider immediately if it causes constipation.” D. “I should take this medication with meals.” 53 / 100 53. The home care nurse provides instructions about the management of pruritus to a client diagnosed with jaundice. Which statement made by the client suggests to the nurse that the client needs further teaching? A. “Keeping the house warmer is likely to lessen the itching” B. “A tepid water bath should help stop the itching.” C. “I need to take the prescribed antihistamines as I’m supposed to.” D. “I need to wear loose cotton clothing.” 54 / 100 54. The nurse is caring for a young adult client diagnosed with sarcoidosis. The client is angry and tells the nurse that there is no point in learning disease management because there is no possibility of ever being cured. Based on the client’s statement, the nurse determines that the client is experiencing which potential problem? A. Apprehension B. Ineffective thought process C. Powerlessness D. Intellectualization 55 / 100 55. 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? A. Substitute grain cereals with pasta products. B. Restrict fresh vegetables in the diet. C. Restrict corn and rice in the diet. D. Avoid foods that are hidden sources of gluten. 56 / 100 56. To assure the desired results, how should the nurse instruct the client prescribed oral bisacodyl to take the medication? A. With a glass of milk B. At bedtime C. On an empty stomach D. At bedtime 57 / 100 57. The nurse administers digoxin 0.25 mg by mouth rather than the prescribed dose of 0.125 mg to the client. After assessing the client and notifying the health care provider, which action should the nurse implement first? A. Tell the client about the medication error. B. Administer digoxin immune Fab. C. Tell the client about the adverse effects of digoxin. D. Write an incident report. 58 / 100 58. The nurse has applied the patch electrodes of an automatic external defibrillator (AED) to the chest of a client who is pulseless. The defibrillator has interpreted the rhythm to be ventricular fibrillation. Which priority action should the nurse prepare to implement next? A. Order any personnel away from the client, charge the machine, and defibrillate through the console. B. Perform cardiopulmonary resuscitation (CPR) for 1 minute before defibrillating C. Charge the machine and immediately push the “discharge” buttons on the console. D. Administer rescue breathing during the defibrillation. 59 / 100 59. The nurse provides discharge instructions to the mother of a child who was hospitalized for heart surgery. Which instruction should the nurse provide to the mother? A. The child may return to school 1 week after hospital discharge. B. After bathing, rub lotion and sprinkle powder on the incision. C. Notify the primary health care provider if the child develops a fever greater than 100.5° F (38° C). D. The child can play outside for short periods of time. 60 / 100 60. The community health is conducting a health screening clinic. The nurse interprets that which client participating in the screening is the highest priority client to provide instruction to lower the risk of developing respiratory disease? A. A person who does woodworking as a hobby for 8 years B. A person who works with lawn care pesticides C. A smoker who has cracked asbestos lining on the basement pipes D. A smoker who works in an acute care hospital 61 / 100 61. The nurse is preparing to administer oxygen to a client with a diagnosis of chronic obstructive pulmonary disease (COPD) and is at risk for carbon dioxide narcosis. The nurse should check to see that the oxygen flow rate is prescribed at which rate? A. 6 to 8 liters per minute B. 8 to 10 liters per minute C. 2 to 3 liters per minute D. 4 to 5 liters per minute 62 / 100 62. The nurse is working in the emergency department of a small local hospital when a client with multiple stab wounds arrives by ambulance. Which action by the nurse is contraindicated when handling potential legal evidence? A. Initiating a chain of custody log. B. Placing personal belongings in a labeled, sealed paper bag. C. Giving clothing and wallet to the family. D. Cutting clothing along seams, avoiding stab holes. 63 / 100 63. The nurse providing emergency treatment for a client in ventricular tachycardia is preparing to defibrillate the client. Which nursing action provides for the safest environment during a defibrillation attempt? A. Holding the client’s upper torso stable while the defibrillation is performed B. Assuring that all assisting personnel are clear of the client and the client’s bed C. Ensuring that no lubricant is on the paddles D. Placing the charged paddles one at a time on the client’s chest 64 / 100 64. A home care nurse is assigned to visit a preschooler who has a diagnosis of scarlet fever and is on bed rest. What data obtained by the nurse would indicate that the child is coping with the illness and bed rest? A. The child insists that his mother stay in the room. B. The child is coloring and drawing pictures in a notebook. C. The mother keeps providing new activities for the child to do. D. The child sucks his thumb whenever he does not get what he asked for. 65 / 100 65. The nurse caring for a client immediately following transurethral resection of the prostate (TURP) notices that the client has suddenly become confused and disoriented. The nurse determines that this may be a result of which potential complication of this surgical procedure? A. Hypochloremia B. Hypernatremia C. Hyponatremia D. Hyperchloremia 66 / 100 66. A perinatal home care nurse has just assessed the fetal status of a client with a diagnosis of partial placental abruption of 20 weeks’ gestation. The client is experiencing new bleeding and reports less fetal movement. The nurse informs the client that the primary health care provider will be contacted for possible hospital admission. The client begins to cry quietly while holding her abdomen with her hands. She murmurs, “No, no, you can’t go, my little man.” The nurse should recognize the client’s behavior as an indication of which psychosocial reaction? A. Grief due to potential loss of the fetus B. Fear of loss and the death of the fetus C. Cognitive confusion as a result of shock D. Fear of hospitalization 67 / 100 67. The nurse creates a plan of care for a client with a spica cast that covers a lower extremity. Which action should the nurse include in the plan of care to promote bowel elimination? A. Use a low-profile (fracture) bedpan. B. Ambulate to the bathroom. C. Use a bedside commode. D. Administer an enema daily. 68 / 100 68. An adult client has undergone a lumbar puncture to obtain cerebrospinal fluid (CSF) for analysis. After reviewing the results of the analysis, the nurse recognizes that the CSF is normal when which element is negative? A. Red blood cells B. Protein C. White blood cells D. Glucose 69 / 100 69. The nurse is caring for a client who is in seclusion. Which client statement indicates to the nurse that the seclusion is no longer necessary? A. “I need to use the restroom right away.” B. “I’d like to go back to my room and be alone for a while.” C. “I am in control of myself now.” D. “I can’t breathe in here. It feels like the walls are closing in on me.” 70 / 100 70. 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? A. “Oh, don’t let this get you down.” B. “It will seem better tomorrow. Now smile.” C. “You shouldn’t get upset. It’ll affect your heart.” D. “You seem upset.” 71 / 100 71. A client receiving total parenteral nutrition (TPN) reports nausea, polydipsia, and polyuria. To determine the cause of the client’s report, the nurse should assess which client data? A. Serum blood urea nitrogen and creatinine B. Rectal temperature C. Last serum potassium D. Capillary blood glucose 72 / 100 72. A client had a colon resection. A nasogastric tube was in place when a regular diet was brought to the client’s room. The client did not want to eat solid food and asked that the primary health care provider be called. The nurse insisted that the solid food was the correct diet. The client ate and subsequently required additional surgery as a result of complications. The determination of negligence is based on which premise in this situation? A. A duty existed and it was breached B. 1. The dietary department sending the wrong food C. Not notifying the primary health care provider D. 1. The nurse’s persistence 73 / 100 73. A client diagnosed with hyperaldosteronism has developed kidney failure and states to the nurse, “This means that I will die very soon.” Which is the most appropriate therapeutic response for the nurse to make to the client? A. “I read that death is a beautiful experience.” B. “You sound discouraged today.” C. You will do just fine.” D. “What are you thinking about?” 74 / 100 74. 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? A. Dries from forearm down to fingers B. Washes continuously for 10 to 15 seconds C. Keeps hands lower than elbows D. Uses 3 to 5 mL of soap from the dispenser 75 / 100 75. The nurse is evaluating the effects of care for the client with nephrotic syndrome. Which diagnostic result demonstrates the least amount of improvement over 2 days of care? A. Daily intake and output record of 2100 mL intake and 1900 mL output and 2000 mL intake and 2900 mL output B. Serum albumin 1.9 g/dL (19 g/L), up to 2.0 g/dL (20 g/L) C. Initial weight 208 pounds, down to 203 pounds D. Blood pressure 160/90 mm Hg, down to 130/78 mm Hg 76 / 100 76. A client has become physically aggressive toward staff and other clients. What action by the nurse will best assure the safety of the milieu while preserving the client’s rights? A. Considering all possible alternative measures B. Contacting the client’s primary health care provider C. Sedating the client D. Applying wrist restraints 77 / 100 77. A client seeks medical attention for intermittent signs and symptoms that suggest a diagnosis of Raynaud’s disease. The nurse should assess the trigger of these signs/symptoms by asking which question? A. “Do the signs and symptoms occur while you are asleep?” B. “Have you experienced any injuries that have limited your activity levels lately?” C. “Does being exposed to heat seem to cause the episodes?” D. “Does drinking coffee or ingesting chocolate seem related to the episodes?” 78 / 100 78. A nurse working in the neonatal intensive care unit (NICU) teaches hand- washing techniques to the parents of an infant who is receiving antibiotic treatment for a neonatal infection. The nurse determines that the parents understand the primary purpose of hand washing if which statement is made? A. “It is primarily done to reduce the possibility of transmitting an environmental infection to the infant.” B. “It is primarily done to minimize the spread of infection to other siblings.” C. “It is primarily done to allow them an opportunity to communicate with each other and staff.” D. “It is primarily done to reduce their fears.” 79 / 100 79. The nurse should tell a client who is scheduled for a bone marrow biopsy that the specimen can be withdrawn from which site? A. Scapula B. Ribs C. Femur D. Sternum 80 / 100 80. A client is admitted to a surgical unit with a diagnosis of cancer. The client is scheduled for surgery in the morning. When the nurse enters the room and begins the surgical preparation, the client states, “I’m not having surgery. You must have the wrong person! My test results were negative. I’ll be going home tomorrow.” The nurse recognizes the client’s statement as indicative of which defense mechanism? A. Delusions B. Displacement C. Psychosis D. Denial 81 / 100 81. The nurse obtains a finger-stick glucose of 400 mg/dL (22.85 mmol/L) for a client who receives total parenteral nutrition (TPN). Which follow-up intervention should the nurse implement? A. Decrease the infusion rate of the TPN. B. Discontinue the current TPN infusion. C. Replace TPN with 5% dextrose solution. D. Confer with provider for glucose control. 82 / 100 82. The nurse is performing an assessment on a postterm infant. Which physical characteristic should the nurse expect to observe in this infant? A. Vernix that covers the body in a thick layer B. Peeling of the skin C. Lanugo covering the entire body D. Smooth soles without creases 83 / 100 83. A preschooler with a history of cleft palate repair comes to the clinic for a routine well-child checkup. To determine whether this child is experiencing a long-term effect of cleft palate, which question should the nurse ask the parent? A. “Has the child had any difficulty swallowing food?” B. “Does the child respond when called by name?” C. “Does the child play with an imaginary friend?” D. “Was the child recently treated for pneumonia?” 84 / 100 84. The nurse is planning to instruct a client with a diagnosis of chronic vertigo about safety measures to prevent exacerbation of symptoms or injury. Which instruction is most important for the nurse to incorporate in a teaching plan? A. Drive at times when the client does not feel dizzy. B. Turn the head slowly when spoken to. C. Walk to the bedroom and lie down when vertigo is experienced. D. Remove throw rugs and clutter in the home. 85 / 100 85. Which important parameter should the nurse assess on a daily basis for a client diagnosed with nephrotic syndrome? A. Blood urea nitrogen (BUN) level B. Weight C. Activity tolerance D. Albumin levels 86 / 100 86. Which is the most important laboratory result for the nurse to present to the primary health care provider on a client who is receiving total parenteral nutrition (TPN)? A. Hemoglobin and hematocrit levels B. Arterial blood gas levels C. Serum electrolyte levels D. White blood cell count 87 / 100 87. An infant has been diagnosed with acute chalasia. During the nursing history, the mother tells the nurse, “I am concerned that I am somehow causing my infant to vomit after feeding her.” Considering this statement, which concern should the nurse identify for the mother? A. Lack of understanding about feeding an infant with chalasia B. An unrealistic expectation of herself C. Denial that chalasia is a physiological defect D. Anxiety about the need for hospitalization of the infant for chalasia 88 / 100 88. Which nursing assessment question should be asked to help determine the client’s risk for developing malignant hyperthermia in the perioperative period? A. “Have you ever had heat exhaustion or heat stroke?” B. “Do you or any of your family members have frequent infections?” C. “What is the normal range for your body temperature?” D. “Do you or any of your family members have problems with general anesthesia?” 89 / 100 89. A newborn diagnosed with respiratory distress syndrome (RDS) is prescribed surfactant replacement therapy. The nurse evaluates the infant 1 hour after the therapy and determines that the infant’s condition has improved somewhat. Which finding indicates improvement? A. Slight increase in the respiratory rate B. An audible respiratory grunt C. Arterial blood pH increases to ≥7.35 D. Fine inspiratory crackles heard over both lungs 90 / 100 90. The nurse observes a client during a seizure and notes that the client’s entire body became rigid, and the muscles in all four extremities alternated between relaxation and contraction. Which type of seizure should the nurse document that the client had experienced? A. Tonic-clonic seizure B. Partial seizure C. Absence seizure D. Complex partial seizure 91 / 100 91. A client with peripheral arterial disease has received instructions from the nurse about how to limit the progression of the disease. The nurse determines that the client needs further teaching if which statement was made by the client? A. “I need to take special care of my feet to prevent injury.” B. “I need to eat a balanced diet.” C. “I should walk daily to increase the circulation to my legs.” D. “A heating pad on my leg will help soothe the leg pain.” 92 / 100 92. A nursing student is preparing to conduct a clinical conference regarding cerebral palsy. Which characteristic related to this disorder should the student plan to include in the discussion? A. Cerebral palsy is a chronic disability characterized by difficulty with muscle control. B. Cerebral palsy is an inflammation of the brain as a result of a viral illness. C. Cerebral palsy is an infectious disease of the central nervous system. D. Cerebral palsy is a congenital condition that results in moderate to severe retardation. 93 / 100 93. The nurse reviews the serum laboratory results for a client prescribed hydrochlorothiazide. Which most frequent side effect of this medication should the nurse specifically monitor for? A. Hypernatremia B. Hypocalcemia C. Hyperphosphatemia D. Hypokalemia 94 / 100 94. A client states to the nurse, “I don’t do anything right. I’m such a loser.” Which therapeutic statement should the nurse make to the client? A. “Can we identify things you do right?” B. “You do things right all the time.” C. “You don’t do anything right?” D. “You are not a loser, you are depressed.” 95 / 100 95. The nurse has developed a plan of care for a client with a diagnosis of anterior cord syndrome. Which intervention should the nurse include in the plan of care to minimize the client’s long-term risk for injury? A. Change the client’s positions slowly B. Teach the client about loss of motor function and decreased pain sensation C. Assess the client for decreased sensation to vibration D. Assess the client for decreased sensation to touch 96 / 100 96. The home care nurse is doing an assessment interview with an older adult client who asks the nurse to buy some groceries for her because she is not feeling well today. Which statement should the nurse use in response? A. “Let’s discuss how we can solve this problem.” B. “Do you have any support systems for shopping?” C. “Do you often need help with food shopping?” D. “I wish I could but I don’t have time to run errands.” 97 / 100 97. A pregnant client tells the nurse that she felt wetness on her peripad and found some clear fluid. The nurse inspects the perineum and notes the presence of the umbilical cord. What is the immediate nursing action? A. Place the client in the Trendelenburg position B. Monitor the fetal heart rate. C. Transfer the client to the delivery room. D. Notify the primary health care provider. 98 / 100 98. A client with a spinal cord injury is at risk of developing footdrop. What intervention should the nurse use as a preventive measure? A. Avoiding dorsal flexion of the foot B. Application of pneumatic boots C. Regular use of posterior splints D. Mole skin–lined heel protectors 99 / 100 99. 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? A. Request a prescription for antibiotics for all household members. B. Ensure that the child uses a separate bathroom for elimination. C. Isolate the child until the skin vesicles have dried and crusted. D. Bring all household members to the clinic for a varicella vaccine. 100 / 100 100. The nurse is collecting a sputum specimen for culture and sensitivity testing from a client who has a productive cough. Which intervention should the nurse implement to obtain the specimen? A. Use a sterile plastic container for obtaining the specimen. B. Ask the client to expectorate a small amount of sputum into the emesis basin. C. Provide tissues for expectoration and obtaining the specimen. D. Ask the client to obtain the specimen after breakfast. 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