150 Random NCLEX Practice Questions 28 150 Random NCLEX Style Practice Questions Questions Change Every Time 1 / 150 1. Shortly after a client dies, the nurse asks the family about funeral arrangements. When the family refuses to discuss the issue, which intervention by the nurse is appropriate for their stage of grief? A. Asking the family if they would like time alone with the client B. Displaying acceptance of the family’s issues C. Probing for information about funeral arrangements D. Providing information about funerals in general 2 / 150 2. A client who is experiencing paranoid thinking involving food being poisoned is admitted to the mental health unit. Which communication technique should the nurse use to encourage the client to communicate his fears? A. Offering personal opinions about the need to eat B. Open-ended questions and silence C. Verbalizing reasons why the client may choose not to eat D. Focusing on self-disclosure of the nurse’s own food preferences 3 / 150 3. The nurse has provided instructions to a client who is receiving external radiation therapy. Which statement by the client indicates a need for further teaching regarding self-care related to the radiation therapy? A. “I need to apply pressure on the irritated area to prevent bleeding.” B. “I need to avoid exposure to sunlight.” C. “I need to wash my skin with a mild soap and pat it dry.” D. “I need to eat a high-protein diet.” 4 / 150 4. Which assessment should the nurse complete before beginning the infusion of lipids (fat emulsion) intravenously for a client receiving total parenteral nutrition? A. Vital signs B. Serum glucose level C. Allergies D. History of seizures 5 / 150 5. The nurse caring for a client who recently received an epidural anesthesia for a vaginal delivery suspects the presence of a vaginal hematoma. Which finding would be the best indicator of the presence of this type of hematoma? A. Client reporting intense vaginal pressure B. Client reporting a tearing sensation C. Signs of vaginal bruising D. Changes in vital signs 6 / 150 6. A client admitted to the hospital with a diagnosis of a leaking cerebral aneurysm is scheduled for surgery. Which intervention should the nurse implement during the preoperative period? A. Allow the client to ambulate only in the room. B. Place the client on bed rest. C. Obtain a bedside commode for the client’s use. D. Encourage the client to be up at least twice per day.` 7 / 150 7. A client with a family history of heart disease presents to the primary health care provider ’s office asking to begin oral contraceptive therapy for birth control. What important topic should the nurse ask the client about next? A. Regular exercise B. Smoking C. Alternative birth control methods D. A low-cholesterol diet 8 / 150 8. A clinic nurse is caring for a client with a suspected diagnosis of gestational hypertension. The nurse assesses the client, expecting to note which set of findings if gestational hypertension is present? A. Edema, ketonuria, and obesity B. Edema, tachycardia, and ketonuria C. Glycosuria, hypertension, and obesity D. Elevated blood pressure and proteinuria 9 / 150 9. The nurse caring for a client after right radical mastectomy includes which intervention in the nursing plan of care for this client? A. Positions the client supine and flat with the right arm elevated on a pillow B. Takes blood pressures in the right arm only C. Checks the right posterior axilla area when assessing the surgical dressing D. Draws serum laboratory samples from the right arm only 10 / 150 10. The nurse prepares a client with a peripheral intravenous (IV) site for home IV therapy for discharge. Which should the nurse teach the client to help prevent phlebitis and infiltration? A. Stabilize the cannula with tape. B. Cleanse the site daily with alcohol. C. Massage the IV site daily. D. Immobilize the extremity. 11 / 150 11. A client has been started on a monoamine oxidase inhibitor (MAOI). Which information should the nurse include when teaching the client about the medication? A. The client must avoid foods that contain tyramine. B. The medication will begin to alleviate symptoms of depression almost immediately. C. This medication can cause severe drowsiness. D. The medication is associated with a high rate of abuse. 12 / 150 12. 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. Vitamin B12 C. Protamine sulfate D. Methylene blue 13 / 150 13. The nurse is planning care for a client with a prescription for anticoagulant agents. Which should the nurse identify as a potential concern for this client? A. Bruising B. Dehydration C. Fatigue D. Infection 14 / 150 14. A registered nurse (RN) is providing postmortem care for a deceased client whose eyes will be donated. Which measure should the nurse anticipate will most likely be prescribed that will provide appropriate care of the client’s body? A. 1. Placing the client in a lateral recumbent position rotating right and left sides B. 1. Placing gauze pads wet with saline covered by a small ice pack on the eyes C. 1. Closing the eyes with paper tape D. 1. Maintaining the client in a supine position 15 / 150 15. A client diagnosed with cardiomyopathy stops eating, takes long naps, and turns away from the nurse when the nurse talks to the client. The nurse should make which interpretation about this behavior? A. The client is unable to tolerate activity. B. The client is depressed. C. The client is noncompliant. D. The client has intractable pain. 16 / 150 16. The nurse is administering a dose of prescribed intravenous hydralazine to a client. To provide a safe environment, the nurse should ensure that which safety measure is in place before injecting the medication? A. Foley catheter B. Thermometer C. Central line 17 / 150 17. A client with a history of silicosis is admitted diagnosed with respiratory distress and impending respiratory failure. The nurse should plan to have which intervention supplies/equipment readily available at the client’s bedside to ensure a safe environment? A. Code cart B. Chest tube and drainage system C. Thoracentesis tray D. Intubation tray 18 / 150 18. A client is admitted to the hospital with the diagnosis of Cushing’s disease. The nurse should monitor the client’s laboratory studies for which associated disorder? A. Low white blood cell (WBC) count B. Hypokalemia C. Hyperglycemia D. Decreased plasma cortisol levels 19 / 150 19. A client has been given a prescription for propantheline as adjunctive treatment for peptic ulcer disease. How should the nurse tell the client to take this medication? A. Just after meals B. With antacids C. With meals D. Thirty minutes before meals 20 / 150 20. Clonazepam has been prescribed for the client, and the nurse teaches the client about the medication. Which statement by the client indicates that further teaching is necessary? A. “I can take my medicine at bedtime if it tends to make me feel drowsy.” B. “My drowsiness will decrease over time with continued treatment.” C. “If I experience slurred speech, it will disappear in about 8 weeks.” D. “I should take my medicine with food to decrease stomach problems.” 21 / 150 21. A client being mechanically ventilated after experiencing a fat embolus is visibly anxious. Which action should the nurse take? A. Ask a family member to stay with the client at all times. B. Encourage the client to sleep until arterial blood gas results improve. C. Remain with the client and provide reassurance. D. Ask the primary health care provider to write a prescription for an antianxiety medication. 22 / 150 22. A client is given a prescription for an antipsychotic medication. The nurse instructs the client and family to report any signs/symptoms of pseudoparkinsonism and tells the family to monitor for what effects indicative of this medication complication? A. Muscle weakness and decreased salivation B. Stooped posture and a shuffling gait C. Motor restlessness and aphasia D. Tremors and hyperpyrexia 23 / 150 23. A client diagnosed with chronic kidney disease is prescribed epoetin alfa. When discussing measures needed to support this medication therapy, the nurse should include information regarding which supplement? A. Calcium B. Zinc C. Iron D. Magnesium 24 / 150 24. The nurse is teaching a client diagnosed with acquired immunodeficiency syndrome (AIDS) how to avoid foodborne illnesses. The nurse instructs the client to prevent acquiring infection from food by avoiding which item? A. Pasteurized milk B. Bottled water C. Raw oysters D. Products with sorbitol 25 / 150 25. A client diagnosed with diabetes mellitus receives 8 units of regular insulin subcutaneously at 7:30 am. The nurse should be most alert to signs of hypoglycemia at what time during the day? A. 3:30 pm to 5:30 pm B. 1:30 pm to 3:30 pm C. 9:30 am to 11:30 am D. 11:30 am to 1:30 pm 26 / 150 26. A client diagnosed with acute respiratory failure has an oral endotracheal tube attached to a mechanical ventilator and is about to begin the weaning process. The nurse determines that which item, that was previously used to minimize the client’s anxiety, should now be limited? A. Radio B. Antianxiety medications C. Television D. Family visitors 27 / 150 27. A client is being discharged from the hospital after a bronchoscopy that was performed a day earlier. After the discharge teaching, the client makes the following statements to the nurse. Which statement should the nurse identify as indicating a need for further teaching? A. “I will use the throat lozenges as directed by my doctor until my sore throat goes away.” B. “I will get help immediately if I start having trouble breathing.” C. “I can expect to cough up bright red blood.” D. “I will stop smoking my cigarettes.” 28 / 150 28. Which nursing question would elicit the most thorough assessment data regarding the client’s recent sleeping patterns? A. “Do you think you get enough sleep on a nightly basis?” B. “May we talk about how you’ve been sleeping?” C. “Did you get much sleep last night?” D. “Are you sleeping well at home?” 29 / 150 29. A client diagnosed with heart failure and secondary hyperaldosteronism is started on spironolactone to manage this disorder. The nurse informs the client that the need for dosage adjustment may be necessary if which medication is also being taken? A. Alprazolam B. Warfarin sodium C. Potassium chloride D. Verapamil hydrochloride 30 / 150 30. The nurse is admitting a client who recently underwent a bilateral adrenalectomy. Which intervention is essential for the nurse to include in the client’s plan of care? A. Prevent social isolation. B. Avoid stress-producing situations. C. Consider occupational therapy. D. Discuss changes in body image 31 / 150 31. After the surgical repair of a fractured hip, a client has consistently refused to engage in ambulation as prescribed. Which statement by the nurse will best encourage the client’s need to ambulate? A. “If you don’t get up and start walking, your recovery will take much longer.” B. “What is it about getting out of bed that concerns you?” C. “Being dependent on others must be a depressing for an active person like yourself.” D. “If you are afraid of the pain, I can give you medication to help.” 32 / 150 32. A pregnant client at 32 weeks’ gestation is admitted to the obstetrical unit for observation after a motor vehicle crash. When the client begins experiencing slight vaginal bleeding and mild cramps, which action should the nurse take to support the viability of the fetus? A. Insert an intravenous line and begin an infusion at 125 mL per hour. B. Position and connect the ultrasound transducer to the external fetal monitor. C. Administer oxygen to the woman via a face mask at 7 to 10 L per minute. D. Position and connect a spiral electrode to the fetal monitor for internal fetal monitoring. 33 / 150 33. A client diagnosed with incurable cancer has a life expectancy of a few weeks. Which response indicates that the client’s partner is reacting with an expected coping response? A. Sending the children to live with relatives B. Expresses anger with his God C. Refusing to visit the client D. Not allowing the death to occur at home 34 / 150 34. The nurse provides home care instructions to a client diagnosed with Cushing’s syndrome. The nurse determines that the client understands the hospital discharge instructions if the client makes which statement? A. “I need to take aspirin rather than acetaminophen for a headache.” B. “I need to check the temperature of my legs twice a day.” C. “I need to check the color of my stools.” D. “I need to eat foods low in potassium.” 35 / 150 35. The nurse is preparing to assist in the administration of a chemotherapeutic agent via intraperitoneal (IP) therapy. In which position should the nurse plan to place the client before administering this therapy? A. Trendelenburg’s B. Dorsal recumbent C. Supine D. Semi-Fowler ’s 36 / 150 36. A newborn infant is diagnosed with esophageal atresia. Which assessment finding supports this diagnosis? A. Passage of large amounts of frothy stool B. Diaphragmatic breathing C. Continuous drooling D. Slowed reflexes 37 / 150 37. The nurse is preparing to suction an adult client with a tracheostomy who has copious amounts of secretions. Which action should the nurse take to accomplish this procedure safely and effectively? A. Hyperoxygenate the client after the procedure only. B. Apply continuous suction in the airway for up to 20 seconds. C. Set the wall suction pressure range between 80 and 120 mm Hg. D. Occlude the Y-port of the catheter while advancing it into the tracheostomy. 38 / 150 38. The nurse provides dietary instruction to the parents of a child with a diagnosis of cystic fibrosis. The nurse should tell the parents that which diet plan should be followed? A. Fat free B. High in calories C. Low in protein D. Low in sodium 39 / 150 39. 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. Notify the primary health care provider. B. Administer oxygen with a face mask at 8 to 10 L per minute. C. Initiate cardiopulmonary resuscitation (CPR). D. Continue to monitor the client and the heart rate patterns. 40 / 150 40. When assessing a child which finding would indicate the presence of Kernig’s sign? A. Pain when the chin is pulled down to the chest B. The flexion of the hips when the neck is flexed from a lying position C. Calf pain when the foot is dorsiflexed D. The inability of the child to extend the legs fully when lying supine 41 / 150 41. The nurse is caring for a client diagnosed with acquired immunodeficiency syndrome (AIDS). Which sign/symptom indicates the presence of an opportunistic respiratory infection? A. Fever and exertional dyspnea B. Nausea and vomiting C. An arterial blood gas pH of 7.40 D. A respiratory rate of 20 breaths per minute 42 / 150 42. The nurse is providing discharge instructions to the mother of an 8-year-old child who had a tonsillectomy. The mother tells the nurse that the child loves tacos and asks when the child can safely eat one. To prevent complications of the surgical procedure, what should be the appropriate response to the mother? A. “In 3 weeks.” B. “In 1 week.” C. “When the primary health care provider says it is okay.” D. “Six days after surgery.” 43 / 150 43. A clinical nurse specialist is asked to present a clinical conference to the student group about brain tumors in children younger than 3 years. The nurse should include which information in the presentation? A. Head shaving is not required before removal of the brain tumor. B. Radiation is the treatment of choice. C. The most significant symptoms are headache and vomiting. D. Surgery is not normally performed because of the increased risk of functional deficits. 44 / 150 44. The nurse caring for a client after shoulder arthroplasty for rheumatoid arthritis monitors the client for brachial plexus compromise. To assess the status of the median nerve, which action would the nurse perform? A. While grasping the nurse’s hand, note the strength of the client’s first and second fingers. B. Have the client move the thumb toward the palm and back to the neutral position. C. Monitor for flexion of the biceps by having the client raise the forearm. D. Have the client spread all of the fingers wide and resist pressure 45 / 150 45. A client wanders in and out of other clients’ rooms, taking their possessions while singing to himself and then giggling for no apparent reason. The nurse reacts therapeutically by taking which action? A. Putting arms around the client, saying, “You’re okay. You just need a hug.” B. Saying, “I can see you are very anxious today. Let’s go and play the piano.” C. Taking the client to the lounge and saying, “Sit here and try to behave yourself.” D. Taking the client to the seclusion room until he cooperates with unit rules. 46 / 150 46. The nurse is caring for a client diagnosed with a herniated lumbar intervertebral disk who is experiencing low back pain. Which position should the nurse place the client in to minimize the pain A. High Fowler’s position with the foot of the bed flat B. Semi-Fowler’s position with the foot of the bed flat C. Supine with the knees slightly raised D. Semi-Fowler’s position with the knees slightly raised 47 / 150 47. The nurse is caring for a dying client who states, “Will you be the executor of my will?” How should the nurse best respond to this client? A. “Tell me more so that I can understand your thinking.” B. “It is an honor to be named the executor of your will.” C. “I must decline your offer because I am your nurse.” D. “I will carry out your will according to your wishes.” 48 / 150 48. The home care nurse visits a client who had a stroke (brain attack) with resultant unilateral neglect who was recently discharged from the hospital. Which instruction should the nurse provide to the family regarding care? A. Assist the client with grooming the unaffected side first. B. Place personal items directly in front of the client. C. Discourage the client from scanning the environment. D. Assist the client from the affected side. 49 / 150 49. The nurse calls the primary health care provider to express concerns about a chemotherapeutic medication dose prescribed by the primary health care provider being too high. The primary health care provider office informs the nurse that the primary health care provider has left town and will not be available for several days. What action should the nurse take next to assure client safety? A. Withhold giving the medication until the primary health care provider ’s partner makes rounds. B. Confer with the pharmacist, who agrees the dose is too high, and then reduces the dose accordingly. C. Telephone the answering service and confer with the on-call primary health care provider. D. Reschedule the client’s chemotherapy until the next week. 50 / 150 50. To assure the desired results, how should the nurse instruct the client prescribed oral bisacodyl to take the medication? A. At bedtime B. On an empty stomach C. At bedtime D. With a glass of milk 51 / 150 51. A client with the diagnosis of acute pyelonephritis who is very shy and modest is scheduled for a voiding cystourethrogram. Why should the nurse determine that this client would benefit from increased support and teaching about the procedure? A. The client must lie on an x-ray table in a cold, barren room. B. Radioactive material is inserted into the bladder. C. Radiopaque contrast is injected into the bloodstream. D. The client must void while the voiding process is filmed. 52 / 150 52. A client is being discharged after undergoing a transurethral resection of the prostate (TURP). The nurse teaches the client to expect which variation in normal urine color for several days after the procedure? A. Cloudy amber B. Pink-tinged C. Dark red D. Clear yellow 53 / 150 53. The nurse is developing a plan of care for a client in Buck’s (extension) traction. The nurse should determine that which is a priority client problem? A. Risk of infection B. Altered independence C. Immobility D. Insufficient sensory stimulation 54 / 150 54. The nurse is developing goals for the postpartum client who is at risk for uterine infection. Which goal is most appropriate for this client? A. The client will identify the presence of Braxton Hicks contractions. B. The client will be able to identify measures to prevent infection. C. The client will report how to treat an infection. D. The client will verbalize a reduction of pain. 55 / 150 55. 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. Administer an enema daily. D. Use a bedside commode. 56 / 150 56. The nurse notes an isolated premature ventricular contraction (PVC) on the cardiac monitor of a client recovering from anesthesia. Which action should the nurse take? A. Notify the primary health care provider immediately. B. Continue to monitor the rhythm. C. Prepare for defibrillation. D. Prepare to administer lidocaine hydrochloride. 57 / 150 57. A client diagnosed with cancer of the bladder is fearful of the potential outcomes of an upcoming cystectomy and urinary diversion. Which statement made to the nurse indicates the client’s fear? A. “I wish I’d never gone to the doctor at all.” B. “I’ll never feel like myself if I can’t go to the bathroom normally.” C. “I’m so afraid that I won’t live through all this.” D. “What if I have no help at home after going through this awful surgery?”” 58 / 150 58. A client newly diagnosed with polycystic kidney disease asks the nurse to explain again what the most serious complication of the disorder might be. The nurse will provide the client with information concerning which condition? A. End-stage renal disease (ESRD) B. Chronic urinary tract infection (UTI) C. Diabetes insipidus D. Syndrome of inappropriate antidiuretic hormone (SIADH) secretion 59 / 150 59. The nurse notes that an assigned client is lying tense in bed and staring at the cardiac monitor. The client states, “There sure are a lot of wires around there. I sure hope we don’t get hit by lightning.” Which is the most appropriate nursing response? A. “Would you like a mild sedative to help you relax?” B. “The hospital is well equipped to shield a lightning strike.” C. “Yes, all the wires must be scary. Let’s talk about the cardiac monitor.” D. Your family can stay tonight if they wish.” 60 / 150 60. The nurse is caring for a client who is receiving total parenteral nutrition through a central venous catheter. Which action should the nurse plan to implement to decrease the risk of infection in this client? A. Track the client’s oral temperature. B. Evaluate the differential of the leukocytes. C. Use sterile technique for dressing changes. D. Administer antibiotics intravenously. 61 / 150 61. The nurse has received the client assignment for the day. Which client should the nurse care for first? A. A client with a wound infection who has a temperature of 100.4° F B. A client who had a right arm casted 12 hours ago who is complaining of numbness in the fingers C. A client with chronic obstructive pulmonary disease (COPD) who has a respiratory rate of 22 beats per minute D. A client with a deep vein thrombosis who reports bleeding gums when brushing the teeth 62 / 150 62. The nurse manager reviewing the purposes for applying restraints to a client determines that further education is necessary when a nursing staff member makes which statement supporting the use of a restraint? A. “It is useful in preventing the client from pulling out intravenous lines.” B. “At night it keeps the client in bed instead of wandering about.” C. “It prevents the violent client from injuring self and others.” D. “It limits movement of a limb during a painful procedure.” 63 / 150 63. A client diagnosed with pneumonia reports a decreased sense of taste that has greatly affected the motivation to eat and drink. Which intervention should the nurse implement to help increase the client’s appetite? A. Provide three large meals daily. B. Offer to sit with the client during meals. C. Offer in-between meal snacks. D. Provide mouth care before meals. 64 / 150 64. A postoperative client has been vomiting and has absent bowel sounds, and paralytic ileus has been diagnosed. The primary health care provider prescribes the insertion of a nasogastric tube. The nurse explains the purpose of the tube and the insertion procedure to the client. The client says to the nurse, “I’m not sure I can take any more of this treatment.” Which therapeutic response should the nurse make to the client? A. “It is your right to refuse any treatment. I’ll notify the primary health care provider.” B. “Let’s just put the tube down, so that you can get well.” C. “If you don’t have this tube put down, you will just continue to vomit.” D. “You are feeling tired and frustrated with your recovery from surgery?” 65 / 150 65. The nurse is developing a plan of care for an older client diagnosed with type 1 diabetes mellitus who is also experiencing acute gastroenteritis. To maintain food and fluid intake in order to prevent dehydration, which action should the nurse plan to include? A. Withholding all fluids until vomiting has ceased entirely for at least 4 hours B. Encouraging the client to take 8 to 12 ounces of fluid every hour while awake C. Offering only water until the client is able to tolerate solid foods D. Maintaining a clear liquid diet for at least 5 days before advancing to solid foods 66 / 150 66. A client with a diagnosis of gastroesophageal reflux disease (GERD) has just received a breakfast tray. The nurse notices that which is the only food that will increase the lower esophageal sphincter (LES) pressure and thus lessen the client’s symptoms? A. Nonfat milk B. Coffee C. Whole wheat toast with butter D. Fresh scrambled eggs 67 / 150 67. The nurse assesses the environmental safety of a client receiving home oxygen therapy. Which observation by the nurse indicates that the client needs further teaching to ensure safety? A. Oxygen concentrator propped against a wall B. Oxygen used 30 feet from a gas stove C. Oxygen tank stored in the tank holder D. “No smoking” sign posted at the front door 68 / 150 68. A client diagnosed with chronic respiratory failure is dyspneic. The client becomes anxious, which worsens the feelings of dyspnea. The nurse teaches the client which method to best interrupt the dyspnea–anxiety–dyspnea cycle? A. Guided imagery and limiting fluids B. Distraction and increased dietary carbohydrates C. Relaxation and breathing techniques D. Biofeedback and coughing techniques 69 / 150 69. In which situation is the nurse manager utilizing an autocratic leadership style? A. The nurse manager arranges for a staff meeting where all unit employees can share proposals to solve a problem. B. The nurse manager provides the solution for a unit problem C. The nurse manager proposes several alternatives and has the unit staff vote on the best proposal. D. The nurse manager allows the staff to solve solution for their own unit problem 70 / 150 70. The nurse assesses a peripheral intravenous (IV) dressing and notes that it is damp and the tape is loose. What action should the nurse take initially? A. Gather the supplies needed to insert a new IV. B. Apply a sterile, occlusive dressing. C. Stop the infusion immediately. D. Ensure all IV tubing connections are tight. 71 / 150 71. The nurse is preparing to care for the mother of a preterm infant. When should the nurse plan to begin discharge planning? A. After stabilization of the infant during the early stages of hospitalization B. When the mother is in labor C. When the discharge date is set D. When the parents feel comfortable with and can demonstrate adequate care of the infant 72 / 150 72. The nurse instructs a client diagnosed with oral candidiasis (thrush) about caring for the disorder. Which statement by the client indicates a need for additional teaching? A. “I need to rinse my mouth four times daily with commercial mouthwash.” B. “I can eat foods that are liquid or pureed.” C. “I should eliminate spicy foods from my diet.” D. “It’s best if I don’t drink citrus juices or hot liquids.” 73 / 150 73. A client tells the home care nurse of a personal decision to refuse external cardiac resuscitation measures. Which is the most appropriate initial nursing action? A. Notify the primary health care provider (HCP) of the client’s request. B. Document the client’s request in the home care nursing care plan. C. Discuss the client’s request with the client’s family. D. Conduct a client conference with the home care staff to share the client’s request 74 / 150 74. A client who is taking tranylcypromine sulfate requests information about foods that are acceptable to eat while taking the medication. Which foods are safe to consume while taking this medication? A. Yogurt B. Raisins C. Oranges D. Smoked fish 75 / 150 75. A client prescribed prazosin hydrochloride asks the nurse why the first dose must be taken at bedtime. Which response by the nurse is based on the understanding of the first dose use of prazosin hydrochloride? A. Treatment with prazosin hydrochloride can cause dependent edema. B. Treatment with prazosin hydrochloride can cause dizziness or possible syncope. C. Prazosin hydrochloride should be taken when the stomach is empty. D. Treatment with prazosin hydrochloride results in drowsiness. 76 / 150 76. 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 their fears.” B. “It is primarily done to allow them an opportunity to communicate with each other and staff.” C. “It is primarily done to reduce the possibility of transmitting an environmental infection to the infant.” D. “It is primarily done to minimize the spread of infection to other siblings.” 77 / 150 77. The nurse admits a client who is in sickle cell crisis. The nurse should prepare for which intervention as a priority in the management of the client? A. Pain management with an opioid B. Oxygen administration C. Intravenous fluid therapy D. Blood transfusion 78 / 150 78. The nurse is monitoring a client who was recently prescribed total parenteral nutrition (TPN). Which action should the nurse take when obtaining a finger stick glucose reading of 425 mg/dL (24.28 mmol/L)? A. Decrease the flow rate of the TPN. B. Stop the TPN. C. Notify the primary health care provider. D. Administer insulin. 79 / 150 79. Which action demonstrates a situational leadership style by the nurse A. The nurse manager delegates tasks to each team member. B. The nurse manager quickly delegates activities to team members during an emergency situation. C. The nurse manager invites team members to provide input about a unit problem. D. The nurse manager allows team members to work without supervision. 80 / 150 80. A client hospitalized after a stroke is prepared for discharge. The primary health care provider has prescribed range-of-motion (ROM) exercises for the client’s right side. Which intervention should the home care nurse’s plan include when planning for the client’s care? A. Develops a schedule involving ROM exercises every 3 hours during daylight hours B. Encourages dependence on the home care nurse to complete the exercise program C. Considers the use of active, passive, or active-assisted exercises in the home D. Implements ROM exercises to the point of pain for the client 81 / 150 81. A teenaged client is discharged from the hospital after surgery with instructions to use a cane for the next 6 months. What question best demonstrates the nurse’s ability to use therapeutic communication techniques to effectively assess the teenager ’s feelings about using a cane? A. “How do you feel about needing a cane to walk?” B. “What types of problems do you think you’ll have ambulating with a cane?” C. “Are you worried about what your friends will think about your cane?” D. “Do you have questions about ambulating with a cane?” 82 / 150 82. The nurse creates a plan of care to facilitate effective communication for a client who requests assistance in order to live independently. Which intervention has highest priority? A. Focusing directly on the client’s message regarding needs B. Reflecting only facts related to the client’s expressed concerns C. Directing the discussions so that teaching needs are met D. Reacting to the client’s responses in a matter-of-fact, professional manner 83 / 150 83. The nurse assesses the water seal chamber of a closed chest drainage system and notes fluctuations in the chamber. What intervention should the nurse implement? A. Unkinking the tubing B. Documenting that the lung has reexpanded C. Assessing for an air leak D. Documenting that the lung has not yet reexpanded 84 / 150 84. A mother states to the nurse, “I am afraid that my child might have another febrile seizure.” Which therapeutic statement is best for the nurse to make to the mother? A. “Tylenol can prevent another seizure from occurring.” B. “Most children will never experience a second seizure.” C. “Tell me what frightens you the most about seizures.” D. “Why worry about something that you cannot control?” 85 / 150 85. The nurse caring for an infant demonstrating diarrhea should monitor the infant for which early sign of dehydration? A. Apical pulse rate of 200 beats per minute B. Gray, mottled skin C. Capillary refill of 3 seconds D. Cool extremities 86 / 150 86. The nurse cares for a client receiving fludrocortisone acetate for the treatment of Addison’s disease. When monitoring the client for improvement, what anticipated therapeutic effect of this medication will the nurse focus on? A. Stimulate thyrotropin production B. Stimulate thyroid production. C. Stimulate the immune response. D. Promote electrolyte balance. 87 / 150 87. The nurse has done preoperative teaching with a client scheduled for percutaneous insertion of an inferior vena cava (IVC) filter. Which client statement indicates the need for further teaching about the procedure? A. “This is done under general anesthesia.” B. “It may cause congestion when clots get trapped at the filter.” C. “This procedure is rarely associated with complications.” D. “This could possibly eliminate the need for anticoagulant therapy.” 88 / 150 88. The home care nurse is caring for a client with lung cancer with acute cancer pain. Which is the most appropriate way to assess the client’s pain? A. Pain relief after appropriate nursing intervention B. The client’s pain rating C. Verbal and nonverbal clues from the client D. The nurse’s impression of the client’s pain 89 / 150 89. When a client experiences frequent runs of ventricular tachycardia, the primary health care provider prescribes flecainide. Because of the effects of the medication, which nursing intervention is specific to this client’s safety? A. Monitor the client’s urinary output. B. Monitor the client’s vital signs and electrocardiogram (ECG) frequently. C. Ensure that the bed rails remain in the up position. D. Assess the client for neurological problems. 90 / 150 90. 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. Telling the client that suicide is not the way to deal with his problem B. Engaging the client while another staff member contacts the police for their assistance C. Using therapeutic communication techniques, especially the reflection of feelings D. Encouraging him to unload the gun and go to the hospital 91 / 150 91. A child is admitted to the pediatric unit with a diagnosis of celiac disease. Based on this diagnosis, the nurse expects that the child’s stools will have which characteristic? A. Unusually hard B. Malodorous C. Dark in color D. Abnormally small in amount 92 / 150 92. A client weighs 165 pounds (75 kg) at admission. During hospitalization, the nurse determines that the client is maintaining adequate nutritional status if the client’s weight is how many pounds? A. 153 pounds (69.5 kg) B. 160 pounds (72.7 kg) C. 155 pounds (70.4 kg) D. 157 pounds (71.3 kg) 93 / 150 93. The client is scheduled for a bronchoscopy. Which priority action should the nurse plan to implement? A. Administer preprocedure antibiotics prophylactically. B. Ask the client about allergies to shellfish. C. Obtain informed consent. D. Restrict the diet to clear liquids on the day of the test. 94 / 150 94. A client diagnosed with chronic kidney disease has been prescribed epoetin alfa. The nurse reminds the client about the importance of taking which prescribed medication to enhance the effects of this therapy? A. Aluminum hydroxide gel B. Ferrous gluconate C. Calcium carbonate D. Aluminum carbonate 95 / 150 95. An adult client who experienced a fractured left tibia has a long leg cast and is using crutches to ambulate. In caring for the client, the nurse assesses for which sign/symptom that indicates a complication associated with crutch walking? A. Triceps muscle spasms B. Left leg discomfort C. Weak biceps brachii D. Forearm muscle weakness 96 / 150 96. The nurse is caring for a pregnant client with preeclampsia who is receiving a prescribed intravenous (IV) infusion of magnesium sulfate. To provide a safe environment, the nurse should ensure that which priority item is available? A. Percussion hammer B. Potassium chloride injection C. Calcium gluconate injection D. Tongue blade 97 / 150 97. A client with a diagnosis of thrombophlebitis is being treated with prescribed heparin sodium therapy. In planning a safe environment, the nurse should ensure that which medication is available if the client develops a significant bleeding problem? A. Fresh frozen plasma B. Retaplase C. Protamine sulfate D. Phytonadione 98 / 150 98. The nurse prepares for a client in leg traction to be admitted to the nursing unit. The nurse asks the unlicensed assistive personnel to obtain which essential item that will be needed to assist the client to move in bed while in leg traction? A. An electric bed B. Extra pillows C. A foot board D. A bed trapeze 99 / 150 99. A client with a known history of panic disorder comes to the emergency department and states to the nurse, “Please help me. I think I’m having a heart attack.” What is the priority nursing action? A. Identify the manifestations related to the panic disorder. B. Determine what the client’s activity involved when the pain started. C. Assess the client’s vital signs. D. Encourage the client to use relaxation techniques. 100 / 150 100. After delivery, the postpartum nurse instructs the client with known cardiac disease to call for the nurse when she needs to get out of bed or when she plans to care for her newborn infant. Which rationale is the basis for these instructions? A. Provide an opportunity for the nurse to teach newborn infant care techniques. B. Avoid maternal or infant injury caused by the potential for syncope or overexertion. C. Help the mother assume the parenting role. D. Minimize the potential of postpartum hemorrhage. 101 / 150 101. The nurse teaches the mother of a newly circumcised infant about postcircumcision care. Which statement by the mother indicates an understanding of the care required? A. My baby will not urinate for the next 24 hours because of swelling. B. I need to clean the penis every hour with baby wipes. C. I need to wrap the penis completely in dry sterile gauze, making sure that it is dry when I change his diaper. D. I need to check for bleeding every hour for the first 12 hours. 102 / 150 102. The nurse prepares to transfer the client with a newly applied arm cast into the bed using which method? A. Using the palms of the hands and soft pillows to support the cast B. Supporting the cast with the fingertips only C. Placing ice on top of the cast D. Asking the client to support the cast during transfer 103 / 150 103. A medication nurse is supervising a newly hired nurse who is administering pyridostigmine orally to a client diagnosed with myasthenia gravis. Which instruction provided to the client indicates safe practice by the newly hired nurse regarding the administration of this medication? A. Void within at least 10 minutes before taking the medication. B. Hyperextend the neck for 30 seconds before swallowing. C. Lie on the right side after taking the medication. D. Take the medication with sips of water. 104 / 150 104. The nurse is assessing a client to determine the client’s adjustment to presbycusis. Which indicates successful adaptation by the client to this problem A. Proper use of a hearing aid B. Withdrawal from social activities C. Denial of a hearing impairment D. Reluctance to answer the telephone 105 / 150 105. The nurse is assessing a client with a diagnosis of polycythemia vera.Which clinical manifestation should the nurse expect to note in this client? A. Pallor B. Pale mucous membranes C. A low hematocrit level D. Hypertension 106 / 150 106. The nurse performing a prenatal assessment on a client in the first trimester of pregnancy discovers that the client frequently consumes beverages containing alcohol. Why should the nurse initiate interventions immediately to assist the client in avoiding alcohol consumption? A. To promote the normal psychosocial adaptation of the mother to pregnancy B. To minimize the potential for placental abruptions during the intrapartum period C. To reduce the risk of teratogenic effects to embryo’s developing fetal organs and tissue D. To reduce the potential for fetal growth restriction in utero 107 / 150 107. A client has been taking nadolol for the past month. Which finding would indicate a therapeutic effect of the medication? A. The client has a blood pressure of 118/72 mm Hg. B. The client has clear breath sounds. C. The client reports no episodes of headache. D. The client is afebrile. 108 / 150 108. A home care nurse is providing instructions to a client who is prescribed zolpidem for insomnia. To produce maximum effectiveness of the medication, what instruction should the nurse provide the client regarding how the medication should be taken? A. Following the evening meal B. With a full glass of water on an empty stomach C. At bedtime with a snack D. With milk or an antacid 109 / 150 109. A home care nurse is assessing a client who is prescribed prazosin. Which statement by the client would support the need for further teaching regarding medication compliance? A. “I understand why I have to keep taking the pills even when my blood pressure is normal.” B. “If I have a cold, I shouldn’t take any over-the-counter remedies without consulting my doctor.” C. “If I feel dizzy, I’ll skip my dose for a few days.” D. “I can’t see the numbers on the label to know how much salt is in the food.” 110 / 150 110. A client was admitted to the hospital with a diagnosis of frequent symptomatic premature ventricular contractions (PVCs). After sitting up in a chair for a few minutes, the client reports feeling lightheaded. Which finding should the nurse anticipate on auscultation of the heartbeat? A. A regular apical pulse B. A very slow regular apical pulse C. A very rapid regular apical pulse D. An irregular apical pulse 111 / 150 111. A hospitalized client diagnosed with active pulmonary tuberculosis has been receiving multidrug therapy for the past month and is being prepared for discharge. Which finding indicates that respiratory isolation is no longer required and that medication therapy has been effective? A. Stools are clay colored. B. Nausea and vomiting have stopped. C. Sputum cultures are negative. D. Tuberculin skin test is negative. 112 / 150 112. A charge nurse is supervising a new nurse who is providing care to a client diagnosed with end-stage heart failure. The client is withdrawn and reluctant to talk, and shows little interest in participating in hygienic care or activities. Which statement, if made by the new nurse to the client, indicates that the new nurse has a need for further teaching regarding the use of therapeutic communication techniques? A. “These dreams you mentioned, what are they like?” B. “Why don’t you feel like getting up for your bath?” C. “Many clients with end-stage heart failure fear death.” D. “What are your feelings right now?” 113 / 150 113. A client in the second trimester of pregnancy is being assessed at the primary health care clinic. The nurse notes that the fetal heart rate (FHR) is 100 beats/min. Which nursing action would be appropriate initially? A. Instruct the mother to return to the clinic in 8 hours for reevaluation of the FHR. B. Notify the primary health care provider of the finding. C. Inform the mother that the assessment is normal and everything is fine. D. Document the findings as normal. 114 / 150 114. The nurse employed in a preschool agency is planning a staff education program to prevent the spread of an intestinal parasitical disease. Which prevention measure should the nurse include in the educational session? A. Standard precautions will be used when assisting children with toileting B. All food will be cooked before eating. C. Only bottled water will be used for drinking. D. All toileting areas will be cleansed daily with soap and water. 115 / 150 115. The mother of a child with celiac disease asks the nurse how long a special diet is necessary. The nurse provides which instruction to the mother to promote dietary compliance? A. Added dietary sodium will help prevent episodes of celiac crisis B. A gluten-free diet will need to be followed for life. C. Supplemental vitamins, iron, and folate will prevent complications D. A lactose-free diet will need to be followed temporarily 116 / 150 116. The spouse of a client who is scheduled for the insertion of an implantable cardioverter-defibrillator (ICD) expresses anxiety about what would happen if the device discharges during physical contact. Which information is most appropriate for the nurse to provide to the spouse? A. The shock would be felt, but it would not cause the spouse any harm. B. A warning device sounds before countershock, so there is time to move away. C. The spouse would not feel or be harmed by the countershock. D. Physical contact should be avoided whenever possible. 117 / 150 117. A client, admitted to the emergency department reporting severe, radiating chest pain, is extremely restless, frightened, and dyspneic. Immediate admission prescriptions include oxygen by nasal cannula at 4 L per minute; troponin, creatinine phosphokinase, and isoenzymes blood levels; a chest x-ray; and a 12-lead ECG. Which action should the nurse take first? A. Schedule the chest x-ray study. B. Apply the oxygen to the client. C. Draw the blood specimens. D. Obtain the 12-lead ECG. 118 / 150 118. A hospitalized client has participated in substance abuse therapy group sessions. Which statement by the client would best indicate that the client has assimilated session topics, understood coping response styles, and processed information effectively for self-use? A. “I’m looking forward to leaving here, but I know that I will miss all of you. So, I’m happy, and I’m sad. I’m excited, and I’m scared. I know that I have B. “This group has really helped a lot. I know that it will be different when I go home. But I’m sure that my family and friends will all help me, like the people in this group have. They’ll all help me, I know they will. They won’t let me go back to old ways.” C. “I’ll keep all my appointments, and I’ll do everything I’m supposed to. That way nothing will go wrong.” D. “I know I’m ready to be discharged. I feel like I’ll have no problem saying no and leaving a group of friends if they are drinking.” 119 / 150 119. The nurse is caring for a client who is receiving tacrolimus daily. Which finding indicates to the nurse that the client is experiencing an adverse effect of the medication? A. Profuse sweating B. Photophobia C. Decrease in urine output D. Hypotension 120 / 150 120. The nurse is performing an assessment on a 6-month-old infant suspected of having hydrocephalus. Which finding is associated with this diagnosis? A. A drop in blood pressure from baseline B. A bulging anterior fontanel C. An elevated apical heart rate D. The presence of protein in the urine 121 / 150 121. A client has a prescription to have a set of arterial blood gases (ABGs) drawn, and the intended site is the radial artery. The nurse ensures that which is positive before the ABGs are drawn? A. Allen test B. Turner ’s sign C. Babinski reflex D. Brudzinski’s sign 122 / 150 122. A nursing instructor asks a student to identify risk factors for and methods of preventing prostate cancer. Which statement by the student indicates the need for further teaching? A. “A high-fat diet will assist in preventing this type of cancer.” B. “Men more than 50 years old should be monitored with a yearly digital rectal exam.” C. “Smoking increases the risk for this type of cancer.” D. “A history of a sexually transmitted infection is a risk for this disease.” 123 / 150 123. A client has been scheduled for a barium swallow (esophagography). The nurse determines that the client understands preprocedure instructions when the client states the intention to take which action before the test? A. Eat a regular breakfast on the day of the test. B. Remove metal objects and jewelry, especially from the neck and chest area C. Take all oral medications as scheduled. D. Monitor own bowel movement pattern for constipation. 124 / 150 124. 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. Providing emotional support to the client’s family B. Maintaining an intravenous access C. Ensuring that oxygen is being delivered D. Administering sedation to prevent claustrophobia 125 / 150 125. A client diagnosed with anxiety disorder is prescribed buspirone orally. When the client reports that it is difficult to swallow the tablets, the nurse provides which instruction to promote compliance? A. Crush the tablets before taking them. B. Call the primary health care provider for a change in medication. C. Purchase the liquid preparation with the next refill. D. Mix the tablet uncrushed in applesauce. 126 / 150 126. Which arterial blood gas (ABG) values should the nurse anticipate in the client with a nasogastric tube attached to continuous suction? A. pH 7.25, Paco2 55, HCO3 24 B. pH 7.49, Paco2 38, HCO3 30 C. pH 7.48, Paco2 30, HCO3 23 D. pH 7.30, Paco2 38, HCO3 20 127 / 150 127. When a rubella vaccine is administered to a client who delivered a healthy newborn 2 days ago, the nurse provides instructions to the client regarding the potential risks associated with this vaccination. Which statement by the client indicates an understanding of the medication? A. “I need to avoid sexual intercourse for 2 to 3 days after the vaccination.” B. “The injection site may itch, but I can scratch it if I need to.” C. “I need to prevent becoming pregnant for 2 to 3 months after the vaccination.” D. “I need to stay out of the sunlight for 3 days.” 128 / 150 128. A client is being admitted to the hospital after receiving a radiation implant after being diagnosed with cervical cancer. Which priority action should the nurse implement in the care of this client? A. Encourage the family to visit. B. Admit the client to a private room. C. Place the client on protective isolation. D. Encourage the client to take frequent rest periods. 129 / 150 129. A registered nurse (RN) is supervising a licensed practical nurse (LPN) providing care to a client with end-stage heart failure. The client is withdrawn, is reluctant to talk, and shows little interest in participating in hygienic care or activities. Which statement by the LPN to the client indicates that the LPN needs further teaching in the use of therapeutic communication skills? A. “What are your feelings right now?” B. “You are very quiet today.” C. “Tell me more about your difficulty with sleeping at night.” D. “Why don’t you feel like getting up?” 130 / 150 130. The nurse monitors a patient with acute pancreatitis. Which assessment finding indicates that paralytic ileus has developed? A. Loss of anal sphincter control B. Severe, constant pain with rapid onset C. Firm, nontender mass palpable at the lower right costal margin D. Inability to pass flatus 131 / 150 131. A client receiving total parenteral nutrition (TPN) through a subclavian catheter suddenly develops dyspnea, tachycardia, cyanosis, and decreased level of consciousness. Based on these findings, which is the best intervention for the nurse to implement for the client? A. Turn the client to the left side in Trendelenburg’s position. B. Perform a stat finger-stick glucose level. C. Examine the insertion site for redness. D. Obtain a stat oxygen saturation level. 132 / 150 132. A pregnant client tests positive for the hepatitis B virus. The client asks the nurse if she will be able to breast-feed the baby as planned after delivery. Which therapeutic response should the nurse communicate to the client? A. “Breast-feeding is not advised, and you should seriously consider bottle- feeding the baby.” B. “Breast-feeding is not a problem, and you will be able to breast-feed immediately after delivery.” C. “You will not be able to breast-feed the baby until 6 months after delivery.” D. Breast-feeding is allowed if the baby receives prophylaxis treatment at birth and scheduled immunizations.” 133 / 150 133. A perinatal client is admitted to the obstetric unit during an exacerbation of a heart condition. When planning for the nutritional requirements which dietary intervention should the nurse consult the dietitian about? A. A diet adequate in fluids and fiber to decrease constipation B. Unlimited sodium intake to increase circulating blood volume C. A diet low in fluids and fiber to decrease blood volume D. A low-calorie diet to prevent weight gain 134 / 150 134. A client with a history of pulmonary emboli is scheduled for the insertion of an inferior vena cava filter. The nurse checks on the client 1 hour after the primary health care provider has explained the procedure and obtained informed consent from the client. The client is lying in bed, wringing his hands, and states to the nurse, “I’m not sure about this. What if it doesn’t work and I’m just as bad off as before?” Which concern for the client should the nurse identify at this time? A. Fear about the potential risks and outcomes of surgery B. Lack of knowledge about the surgical procedure C. Anxiety and depression D. Inability to handle the treatment regimen 135 / 150 135. Before inserting a peripheral intravenous (IV) catheter into a preoperative client, the nurse notes that the client’s muscles are tense and the client is fidgeting with the bed sheet, stating that she does not understand why she has to have the IV. Which statement should the nurse first verbalize to the client? A. “Inserting the IV does not hurt very much.” B. “The IV catheter is an 18-gauge angiocatheter, which is small.” C. “This will be finished before you know it.” D. “The IV adds needed fluid into your bloodstream.” 136 / 150 136. 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. Avoid foods that are hidden sources of gluten. B. Restrict fresh vegetables in the diet. C. Substitute grain cereals with pasta products. D. Restrict corn and rice in the diet. 137 / 150 137. A 30-week-gestation client admitted in preterm labor is prescribed betamethasone. What should the nurse tell the client is the purpose for this medication? A. Promote fetal lung maturity. B. Delay delivery for at least 48 hours. C. Prevent premature closure of the ductus arteriosus. D. Stop the premature uterine contractions. 138 / 150 138. A client diagnosed with obsessive-compulsive rituals often misses the unit’s morning activities because of a bed-making ritual. What nursing action would be therapeutic? A. Help the client to make the bed so that the task can be finished quicker. B. Discuss the social implications of the behavior with the client. C. Verbalize tactful, mild disapproval of the behavior. D. Offer reflective feedback, such as, “I see that you have made your bed several times.” 139 / 150 139. The nurse is teaching a client with hypertension about items that contain sodium and reviews a written list of items sent from the cardiac rehabilitation department. The nurse tells the client that which item is lowest in sodium content? A. Antacids B. Laxatives C. Demineralized water D. Toothpaste 140 / 150 140. The community health nurse teaches a group of females how to prevent pelvic inflammatory disease (PID). What instruction should the nurse include? A. To douche monthly B. To avoid unprotected intercourse C. To use only ultra-low dose oral contraceptive pills D. To consult with a gynecologist regarding the placement of an intrauterine device (IUD) 141 / 150 141. The nurse is reviewing the client’s arterial blood gas results. Which finding would indicate that the client is experiencing respiratory acidosis? A. pH 7.5, HCO3 of 30 B. pH 7.3, HCO3 of 19 C. pH 7.5, Pco2 of 30 D. pH 7.3, Pco2 of 50 142 / 150 142. A visiting home care nurse finds a client unconscious in the bedroom. The client has a history of abusing the selective serotonin reuptake inhibitor, sertraline. The nurse should immediately conduct which assessment? A. Pulse B. Blood pressure C. Urinary output D. Respirations 143 / 150 143. A client who has been receiving long-term diuretic therapy is admitted to the hospital with a diagnosis of dehydration. The nurse should assess for which sign that correlates with this fluid imbalance? A. Increased urinary specific gravity B. Decreased pulse C. Bibasilar crackles D. Increased blood pressure 144 / 150 144. The nurse assesses a client after abdominal surgery who has a nasogastric (NG) tube in place that is connected to suction. Which observation by the nurse indicates most reliably that the tube is functioning properly? A. The client indicates that pain is a 3 on a scale of 1 to 10. B. The distal end of the NG tube is pinned to the client’s gown. C. The suction gauge reads low intermittent suction. D. The client denies nausea and has 250 mL of fluid in the suction collection container. 145 / 150 145. A client is being discharged from the hospital after removal of chest tubes that were inserted following thoracic surgery. When providing home care instructions to the client, which client statement indicates a need for further teaching? A. “I need to avoid heavy lifting for the first 4 to 6 weeks.” B. “I need to remove the chest tube site dressing as soon as I get home.” C. “I need to report any difficulty with breathing to the primary health care provider.” D. “I need to take my temperature to detect a possible infection.” 146 / 150 146. The nurse is planning dietary counseling for the client with chronic heart failure taking triamterene. The nurse plans to include which item in a list of foods that are acceptable? A. Bananas B. Baked potato C. Canned pears D. Oranges 147 / 150 147. A client in a long-term care facility has had a series of gastrointestinal (GI) diagnostic tests, including an upper and lower GI series and endoscopies. Upon return to the long-term care facility, which priority assessment should the nurse focus on? A. The hydration and nutrition status B. The level of consciousness C. The comfort level D. Activity tolerance 148 / 150 148. . A hospital administrator has implemented a change in the method of assigning nurses to client care units. A group of registered nurses is resistant to the change, and the nursing administrator anticipates that the nurses will not facilitate the process of change. Which approach is best for the administrator to take initially in dealing with the resistance? A. Implement the change first on a trial basis. B. Cancel the implementation of the change. C. Encourage the nurses to verbalize feelings regarding the change. D. Delay implementing the change for a few weeks. 149 / 150 149. A client with the diagnosis of leukemia is receiving chemotherapy. When the registered nurse (RN) notes that the white blood cell (WBC) count is 4000 mm3 (4 × 109/L), the new nurse caring for the client is informed about the results. Which intervention identified by the new nurse indicates a need for further teaching? A. Removing all live plants, flowers, and stuffed animals in the client’s room B. Restricting visitors with colds or respiratory infections C. Padding the side rails and removing all hazardous and sharp objects from the room D. Placing the client on a low-bacteria diet that excludes raw foods and vegetables 150 / 150 150. 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. Document the finding. B. Tell the client that the FHR is fast. C. Recheck the FHR with the client in the standing position. D. Consult with the primary health care provider. Your score is The average score is 19% Restart quiz Home/Practice NCLEX Questions/150 Random Free NCLEX Questions