150 Random NCLEX Practice Questions 9 150 Random NCLEX Style Practice Questions Questions Change Every Time 1 / 150 1. The home care nurse is preparing to visit a client diagnosed with Ménière’s disease. The nurse reviews the primary health care provider prescriptions and expects to educate the client on which dietary measure? A. A low-fat diet with a restriction of citrus fruits B. A low-fiber diet with decreased fluids C. A low-sodium diet and fluid restriction D. A low-carbohydrate diet and the elimination of red meats 2 / 150 2. A client develops an irregular heart rate. Which statement made by the client who has developed an irregular heart rate indicates to the nurse that the client is ready for learning? A. “All my medications will be changed now.” B. “How can this heart rate problem affect me?” C. “I feel weak with an irregular pulse.” D. “What is it like to have a pacemaker?” 3 / 150 3. The nurse is administering epoetin alfa to a client diagnosed with chronic kidney disease (CKD). For which adverse effect of this therapy should the nurse monitor the client? A. Hypertension B. Anemia C. Iron intoxication D. Bleeding tendencies 4 / 150 4. 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. Daily stool softeners B. Enemas as needed C. Help with ambulation D. Liquid diet 5 / 150 5. 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?”” 6 / 150 6. The nurse caring for a client with Graves’ disease is concerned about the client’s calorie intake because of the resulting hypercatabolic state of the disorder. Which situation indicates a successful outcome for this concern? A. The client verbalizes the need to avoid snacking between meals. B. The client demonstrates knowledge regarding the need to consume a diet that is high in fat and low in protein. C. The client maintains a normal weight or gradually gains weight if it is below normal. D. The client discusses the relationship between mealtime and the blood glucose level. 7 / 150 7. A client is receiving intravenous (IV) antibiotic therapy at home via an intermittent IV catheter. In order to facilitate the early detection of IV therapy complications, which intervention should be included in the client’s education? A. Report local pain, drainage, or edema. B. Apply pressure to the IV site if it dislodges. C. Protect the IV site continually. D. Keep the IV site clean and dry. 8 / 150 8. The nurse is reviewing the results of a sweat test performed on a child diagnosed with cystic fibrosis (CF). Which finding should the nurse identify as supporting this diagnosis? A. A sweat potassium concentration that is consistently less than 40 mEq/L B. An early morning sweat chloride concentration of less than 40 mEq/L C. An evening sweat potassium concentration greater than 60 mEq/L D. A sweat chloride concentration that is consistently greater 60 mEq/L 9 / 150 9. A nursing student is asked to conduct a clinical conference about autism. Which characteristic associated with autism should the student plan to include? A. Normal verbal but abnormal nonverbal communication B. Normal social play that ceases by age 5 C. Lack of social interaction and awareness D. The consistent imitation of others’ actions 10 / 150 10. Ethics; Health Care Law A. A family member must witness the consent B. The client can donate by written consent C. A family member must be present when a client consents to organ donation. D. 1. The donor must be older than 21 years of age. 11 / 150 11. A client diagnosed with trigeminal neuralgia asks the nurse what can be done to minimize the episodes of pain. The nurse’s response is based on an understanding that what can trigger the pain? A. Excessive watering of the eyes or nasal stuffiness B. Infection or stress C. Facial pressure or extreme temperature D. Hypoglycemia and fatigue 12 / 150 12. The nurse provides instructions regarding home care to a parent of a 3-year- old child who has been hospitalized with hemophilia. Which statement by the parent indicates the need for further teaching? A. “I should not leave my child unattended.” B. “I need to remove household items that can tip over.” C. “I need to pad table corners in my home.” D. “My child should not have any immunizations.” 13 / 150 13. The nurse has given instructions to the client diagnosed with chronic kidney disease about reducing pruritus from uremia. The nurse determines that the client needs further teaching if the client states the intention to use which item for skin care? A. Oil in the bath water B. Lanolin-based lotion C. Mild soap D. Alcohol cleansing pads 14 / 150 14. 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. Urine myoglobin B. Serum carboxyhemoglobin levels C. Pulse oximetry D. Sputum carbon levels 15 / 150 15. The nurse is preparing a plan of care for a child diagnosed with leukemia who is beginning chemotherapy. Which intervention should the nurse include? A. Provide meticulous mouth care several times daily using an alcohol-based mouthwash and a toothbrush. B. Monitor rectal temperatures every 4 hours. C. Encourage the child to consume fresh fruits and vegetables to maintain nutritional status. D. Monitor the mouth and anus each shift for signs of breakdown. 16 / 150 16. A toddler with suspected conjunctivitis is crying and refuses to sit still during the eye examination. Which is the most appropriate statement for the nurse to make to the child? A. “If you will sit still, the exam will be over soon.” B. “I know you are upset. We can do this exam later.” C. “Don’t be scared, the light won’t hurt you.” D. “Would you like to see my flashlight?” 17 / 150 17. The nurse is monitoring a client diagnosed with hypercalcemia. Which assessment finding indicates a need for follow-up? A. Decreased capillary refill B. Decreased abdominal circumference C. Increased deep tendon reflexes D. Increased peristalsis 18 / 150 18. Which action is included in the accurate procedure for administering heparin sodium subcutaneously? A. Avoiding aspiration before administration of the medication B. Massaging the injection site after administration C. Injecting the medication via an infusion device D. Injecting the medication 1 inch from the umbilicus 19 / 150 19. The nurse in an ambulatory clinic administers a tuberculin skin test to a client on a Monday. When should the nurse tell the client to return to the clinic to have the results read? A. Wednesday or Thursday B. The following Monday C. Tuesday or Wednesday D. Thursday or Friday 20 / 150 20. The nurse assists a postoperative client from a lying to a sitting position to prepare for ambulation. Which nursing action is most appropriate initially to maintain the safety of the client? A. Secure the assistance of at least one additional staff to help with the ambulation. B. Be sure that the client is wearing slippers with nonslip soles. C. Encourage the client to support the abdomen with a small pillow while walking. D. Assess the client for signs of dizziness and hypotension. 21 / 150 21. The nurse is creating a teaching plan for the client with Raynaud’s disease.Which instruction should the nurse include? A. Keeping the hands and feet warm and dry will prevent vasoconstriction. B. Daily cool baths will provide an analgesic effect. C. Vitamin K administration will prevent tendencies toward bleeding. D. A high-protein diet will minimize tissue malnutrition. 22 / 150 22. The nurse is preparing a woman in labor for an amniotomy. Which priority data should the nurse assess before the procedure? A. Fetal heart rate B. Fetal scalp sampling C. Maternal heart rate D. Maternal blood pressure 23 / 150 23. The nurse manager is observing the interaction between a new staff nurse and a client currently receiving hemodialysis. Which intervention should the nurse manager implement when the nurse and client are both drinking coffee and discussing the client’s feeling about the procedure? A. Getting a cup of coffee and join in on the conversation B. Determining whether or not the client should be drinking coffee C. Complementing the staff nurse on the development of a good therapeutic relation D. Asking the staff nurse to refrain from eating and drinking in the hemodialysis area 24 / 150 24. The nurse is about to administer a prescribed intravenous dose of tobramycin when the client reports vertigo and ringing in the ears. Which action should the nurse take next? A. Hang the dose of medication immediately. B. Hold the dose and call the primary health care provider (HCP). C. Give a dose of droperidol with the tobramycin. D. Check the client’s pupillary responses. 25 / 150 25. Which nursing assessment question should be asked to help determine the client’s risk for developing malignant hyperthermia in the perioperative period? A. “Do you or any of your family members have frequent infections?” B. “What is the normal range for your body temperature?” C. “Do you or any of your family members have problems with general anesthesia?” D. “Have you ever had heat exhaustion or heat stroke?” 26 / 150 26. The nurse caring for a client diagnosed with a neurological disorder is planning care to maintain nutritional status. The nurse is concerned about the client’s swallowing ability. Which food item should the nurse eliminate from this client’s diet? A. Spinach B. Mashed potatoes C. Custard D. Scrambled eggs 27 / 150 27. While in the hospital, a client was diagnosed with coronary artery disease (CAD). Which question by the nurse is likely to elicit the most useful response for determining the client’s degree of adjustment to the new diagnosis? A. chedule for your new medications?” B. “Do you understand the s“Did you make a follow-up appointment with your provider?” C. “How do you feel about making changes to your lifestyle?” D. “Is there anyone to help with housework and shopping?” 28 / 150 28. 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. Cool extremities C. Capillary refill of 3 seconds D. Gray, mottled skin 29 / 150 29. A client has been diagnosed with terminal cancer and is using opioid analgesics for pain relief. Which action by the home care nurse would best allay the client’s anxiety about becoming addicted to the pain medication? A. Explaining to the client that the fears are justified but should be of no concern during the final stages of care B. Explaining to the client that addiction rarely occurs in individuals who are taking medication appropriately to relieve pain C. Encouraging the client to take lower doses of medications even though the pain is not well controlled D. Encouraging the client to hold off as long as possible between doses of pain medication 30 / 150 30. 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. Offer to sit with the client during meals. B. Provide three large meals daily. C. Offer in-between meal snacks. D. Provide mouth care before meals. 31 / 150 31. A parent reports that her child has developed a bloody nose. Which action should the nurse instruct the parent to take to control the bleeding? A. Pinch the nostrils for 5 minutes and then recheck for bleeding. B. Maintain the child in a sitting position with the head tilted backward. C. Have the child sit with the head tilted forward and hold pressure on the soft part of the nose for a period of 10 minutes. D. Lay the child down with a pillow tucked under the neck and stay with the child to keep the child calm. 32 / 150 32. The nurse is caring for a client with a diagnosis of Parkinson’s disease who is taking benztropine mesylate daily. When assessing the client, what should the nurse specifically monitor for to determine if the client is experiencing a side effect of this medication? A. Intake and output B. Skin temperature C. Prothrombin time D. Pupil response 33 / 150 33. The nurse is caring for a client diagnosed with type 1 diabetes mellitus. Because the client is at risk for hypoglycemia, which instructions should the nurse teach the client to follow? A. Monitor the urine for acetone. B. Omit the evening dose of NPH insulin if the client has been exercising. C. Keep glucose tablets. D. Report any feelings of drowsiness. 34 / 150 34. 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. Albumin levels C. Activity tolerance D. Weight 35 / 150 35. The nurse is caring for an older client who has been placed in Buck’s extension traction after a hip fracture. During the assessment of the client, the nurse notes that the client is disoriented. Which is the most appropriate nursing intervention for this client? A. Reorient the client to time, place, and person frequently B. Apply restraints to the client. C. Ask the laboratory to perform electrolyte studies. D. Ask the family to stay with the client. 36 / 150 36. The nurse is caring for a newly delivered breast-feeding infant. Which intervention performed by the nurse would best prevent jaundice in this infant? A. Keeping the infant NPO until the second period of reactivity B. Placing the infant under phototherapy C. Encouraging the mother to supplement breast-feeding with formula 37 / 150 37. A client who is receiving total parenteral nutrition (TPN) tells the nurse, “I’m not sure that I want to receive an infusion of lipids because it could make me obese.” Which initial action should the nurse take? A. State that intralipids supply essential fatty acids for life. B. Inquire how illness affects the client’s self-concept. C. Explain how intralipids replace dietary sources of lipids. D. Ask the provider to discuss the benefits of intralipids. 38 / 150 38. 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. “Please tell my friends not to visit, since I’ll see them back at school next week.” B. I’d like my hair washed before my friends get here.” C. “Is it okay if I have a couple of friends in to visit me this evening?” D. “When my friends get here, I would like to play some computer games with them 39 / 150 39. A client having premature ventricular contractions states to the nurse, “I’m so afraid that something bad will happen.” Which action by the nurse provides the most immediate help to the client? A. Telephoning the client’s family B. Using a television to distract the client C. Giving reassurance that nothing will happen to the client D. Having a staff member stay with the client 40 / 150 40. The nurse instructs a parent regarding the appropriate actions to take when the toddler has a temper tantrum. Which statement by the parent indicates a successful outcome of the teaching? A. “I will reward my child with candy at the end of each day without a tantrum.” B. “I will give frequent reminders that only bad children have tantrums.” C. “I will send my child to a room alone for 10 minutes after every tantrum.” D. “I will ignore the tantrums as long as there is no physical danger.” 41 / 150 41. A client diagnosed with acquired immunodeficiency syndrome (AIDS) is being admitted to the hospital for treatment of a Pneumocystis jiroveci respiratory infection. Which intervention should the nurse include in the plan of care to assist in maintaining the comfort of this client? A. Evaluating arterial blood gas results B. Assessing respiratory rate, rhythm, depth, and breath sounds C. Keeping the head of the bed elevated D. Monitoring for bloody sputum 42 / 150 42. The nurse is assisting with providing a form of psychotherapy in which the client acts out situations that are of emotional significance. Based on this assessment data, which form of therapy should the nurse expect the primary health care provider has prescribed? A. Reality therapy B. Psychodrama C. Psychoanalytic therapy D. Short-term dynamic psychotherapy 43 / 150 43. What is the smallest gauge catheter that the nurse can use to administer blood? A. 22 gauge B. 20 gauge C. 24 gauge D. 12 gauge 44 / 150 44. 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 noncompliant. B. The client is unable to tolerate activity. C. The client has intractable pain. D. The client is depressed. 45 / 150 45. The nurse reviews the record of a client who is receiving external radiation therapy and notes documentation of a skin finding as moist desquamation. Which finding on assessment of the client should the nurse expect to observe? A. Weeping of the skin B. Dermatitis C. A rash D. Reddened skin 46 / 150 46. A client who is scheduled for an abdominal peritoneoscopy states to the home care nurse, “The surgeon told me to restrict food and liquids for at least 8 hours before this procedure and to use a Fleet enema 4 hours before entering the hospital. Do people ever get into trouble after this procedure?” Which is the most appropriate therapeuticresponse the nurse should make to the client? A. “You seem to understand the preparation very well. Are you having any concerns about the procedure?” B. “Trouble? There is never any trouble with this procedure. That’s why the surgeon will use local anesthesia.” C. “Any invasive procedure brings risk with it. You need to report any shoulder pain immediately.” D. “There are relatively few problems, especially if you are having local anesthesia, but vaginal bleeding should be reported immediately.” 47 / 150 47. The nurse is planning preoperative teaching with a client scheduled for a transurethral resection of the prostate (TURP). Which most frequent cause of postoperative pain should the nurse plan to include in the discussion? A. The lower abdominal incision B. Bleeding within the bladder C. Bladder spasms D. Tension on the Foley catheter 48 / 150 48. The nurse is caring for a client who is recovering from an episode of autonomic hyperreflexia. Which statement should the nurse make to the client to most encourage therapeutic communication? A. “I’m sure you now understand the importance of preventing this from occurring.” B. How could your home care nurse let this happen?” C. “Now that this problem is taken care of, I’m sure you’ll be fine.” D. “I have some time if you would like to talk about what happened to you.” 49 / 150 49. A client is admitted after attempting suicide by ingesting a prescribed antipsychotic medication. What is the most important piece of information the nurse should obtain initially? A. If there is a history of previous suicidal attempts B. The name and amount of ingested medication C. If the client continues to have suicidal ideations D. Where and when the medication was ingested 50 / 150 50. The nurse is assigned to care for a child diagnosed with juvenile idiopathic arthritis (JIA). What is the child’s priority problem? A. Acute pain B. Impaired mobility causing potential injury C. Potential difficulty with everyday tasks D. Negative view of body because of activity intolerance 51 / 150 51. A client seeks treatment in an ambulatory clinic for hoarseness that has persisted for 8 weeks. Based on the symptom, the nurse interprets that the client is at risk for which disorder? A. 1. Laryngeal cancer B. 1. Acute laryngitis C. 1. Bronchogenic cancer D. 1. Thyroid cancer 52 / 150 52. 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 urine output D. Increased blood pressure 53 / 150 53. A client previously well controlled with glyburide has recently begun reporting fasting blood glucose to be 180 to 200 mg/dL (10.28 – 11.42 mmol/L). Which medication, noted in the client’s record, may be contributing to the elevated blood glucose level? A. Ciprofloxacin hydrochloride B. Cimetidine C. Prednisone D. Ranitidine 54 / 150 54. The nurse is conducting a health screening on a client with a family history of hypertension. Which assessment finding should alert the nurse to the need for further teaching related to stroke (brain attack) prevention? A. Eats two bowls of high-fiber grain cereal with skim milk for breakfast B. Uses condoms for pregnancy and disease prevention and jogs 2 miles daily C. Uses oral contraceptives for pregnancy prevention and works as a manager of a busy medical-surgical unit D. Has a blood pressure of 118/78 mm Hg and has lost 10 pounds recently 55 / 150 55. The nurse is preparing to administer prescribed heparin sodium 5000 units subcutaneously. Which action should the nurse take to safely administer the medication? A. Inject within 1 inch of the umbilicus. B. Massage the injection site after administration for a full minute. C. Inject via an infusion device. D. Change the needle on the syringe after withdrawing the medication from the vial. 56 / 150 56. 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. Substitute grain cereals with pasta products. C. Restrict corn and rice in the diet. D. Restrict fresh vegetables in the diet. 57 / 150 57. A client with a diagnosis of trigeminal neuralgia is started on a regimen of carbamazepine. The nurse provides instructions to the client about the medication. What statement by the client indicates that the client understands the instructions? A. My urine may turn red in color, but this is nothing to be concerned about. B. I will report a fever or sore throat to my doctor. C. Some joint pain is expected and is nothing to worry about D. I must brush my teeth frequently to avoid damage to my gums. 58 / 150 58. To ensure that the client self-administers medications safely in the home, which action plan should the nurse implement? A. Instruct the client to double up on a medication when a dose is missed. B. Provide information on the purpose of all the prescribed medications. C. Perform a pill count of each prescription bottle at every home visit. D. Ask the client to explain and demonstrate self-administration procedures. 59 / 150 59. Which clinical situation should the nurse identify as an example of slander? A. The laboratory technician restrains the arm of a client refusing to have blood drawn so that the specimen can be obtained. B. The nurse restrains a client at bedtime because the client gets up during the night and wanders around. C. The nurse tells a client that a nasogastric tube will be inserted if the client continues to refuse to eat. D. The primary health care provider tells a client that the nurse “does not know anything.” 60 / 150 60. 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. A foot board C. A bed trapeze D. Extra pillows 61 / 150 61. A client diagnosed with diabetes mellitus is at 36 weeks’ gestation. The client has had weekly reactive nonstress tests for the last 3 weeks. This week, the nonstress test was nonreactive after 40 minutes. Based on these results, the nurse should prepare the client for which intervention? A. A contraction stress test B. A return appointment in 2 days to repeat the nonstress test C. Immediate induction of labor D. Hospitalization with continuous fetal monitoring 62 / 150 62. A client has a positive sputum culture for Mycobacterium tuberculosis and is prescribed streptomycin as part of the treatment. The nurse determines that the client is experiencing a toxic effect of the medication when which test result is abnormal? A. Blood urea nitrogen (BUN) and creatinine B. Vision testing C. Hemoglobin and hematocrit D. Hepatic enzymes 63 / 150 63. The nurse is observing an unlicensed assistive personnel (UAP) care for an older client who had surgery (insertion of a prosthesis) following a hip fracture 4 days ago. To prevent client injury, the nurse should intervene in the care when which action is performed by the UAP? A. Places pillows between the legs when turning the client B. Obtains a bedside commode to keep in the room C. Assists the client in inserting dentures D. Elevates the head of bed 30 degrees 64 / 150 64. The nurse notes that a postoperative client has not been obtaining relief from pain with the prescribed opioid analgesics when a particular licensed coworker is assigned to the client. Which action is most appropriate for the nurse to implement initially? A. Review the client’s medication administration record immediately and discuss the observations with the nursing supervisor. B. Reassign the coworker to the care of clients not receiving opioids. C. Confront the coworker with the information about the client having pain control problems and ask if the coworker is using the opioids personally. D. Notify the primary health care provider that the client needs an increase in opioid dosage. 65 / 150 65. 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. Family visitors B. Antianxiety medications C. Television D. Radio 66 / 150 66. An older client had an open reduction with internal fixation (ORIF) for a hip fracture 4 days ago. Which measure should the nurse implement to provide safe care? A. Instruct the client to call for help before getting up. B. Provide ice chips instead of drinking water. C. Tell the client to roll to the affected side first before getting up. D. Minimize opioid administration to prevent dizziness. 67 / 150 67. In which situation is the nurse manager utilizing an autocratic leadership style? A. The nurse manager allows the staff to solve solution for their own unit problem B. The nurse manager arranges for a staff meeting where all unit employees can share proposals to solve a problem. C. The nurse manager provides the solution for a unit problem D. The nurse manager proposes several alternatives and has the unit staff vote on the best proposal. 68 / 150 68. The nurse is teaching a client how to mix regular and NPH insulins in the same syringe. Which action should the nurse instruct the client to take? A. Keep both bottles in the refrigerator at all times. B. Rotate the NPH insulin bottle in the hands before mixing. C. Take all of the air out of the insulin bottles before mixing. D. Draw up the NPH insulin into the syringe first. 69 / 150 69. The nursing student is listening to a lecture on correcting errors in a written narrative on a medical record. Which statement by the nursing student indicates that the teaching has been effective? A. “The correct procedure is to cover the error completely using a permanent marker.” B. “The correct procedure is to remove the error in a manner approved by the facility.” C. “The correct procedure is to draw a line through the error to identify it.” D. “The correct procedure is to document the correction as a late entry.” 70 / 150 70. A client is intubated and receiving mechanical ventilation. The primary health care provider has added 7 cm of positive end-expiratory pressure (PEEP) to the client’s ventilator settings. The nurse should assess for which expected but adverse effect of PEEP? A. Decreased peak pressure on the ventilator B. Systolic blood pressure decrease from 122 to 98 mm Hg C. Decreased heart rate from 78 to 64 beats per minute D. Increased rectal temperature from 98° F to 100° F 71 / 150 71. 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. 72 / 150 72. The nurse is giving a client diagnosed with heart failure home care instructions for use after hospital discharge. The client interrupts, saying, “What’s the use? I’ll never remember all of this, and I’ll probably die anyway!” The nurse determines that the client’s statement is most likely due to which psychosocial concern? A. The teaching strategies used by the nurse B. Anger about the new medical regimen C. Anxiety about the ability to manage the disease process at home D. Insufficient financial resources to pay for the medications 73 / 150 73. A client experiencing trigeminal neuralgia (tic douloureux) asks the nurse for a snack and something to drink. Which is the best selection the nurse should provide for the client? A. Hot cocoa with honey and toast B. Iced coffee and peanut butter and crackers C. Vanilla pudding and lukewarm milk D. Hot herbal tea with graham crackers 74 / 150 74. A client diagnosed with a thrombotic stroke experiences periods of emotional lability. What should the nurse interpret this behavior as indicating? A. That the problem is likely to get worse before it gets better B. That the client is experiencing the usual sequelae of a stroke C. That the client is not adapting well to the disability D. That the client is experiencing the side effects of prescribed anticoagulants 75 / 150 75. The nurse is performing pin-site care on a client in skeletal traction. Which normal finding should the nurse expect to note when assessing the pin sites? A. Clear drainage from the pin sites B. Redness and swelling around the pin sites C. Clear drainage from the pin sites D. Loose but intact pin sites 76 / 150 76. The nurse has given medication instructions to a client receiving lovastatin. The nurse determines that the client understands the effects of the medication if the client stated the need to adhere to the periodic evaluation of which laboratory test? A. Bleeding times B. Liver function studies C. Blood glucose levels D. Creatinine levels 77 / 150 77. The nurse develops a plan of care for a 1-month-old infant diagnosed with intussusception. Which nursing measure would be most effective to provide psychosocial support for the parent–child relationship? A. Initiate home nutritional support as early as possible. B. Encourage the parents to room-in with their infant. C. Provide educational materials. D. Encourage the parents to go home and get some sleep. 78 / 150 78. The nurse is caring for a client immediately after a bronchoscopy. The client received intravenous sedation and a topical anesthetic for the procedure. Which priority nursing intervention should the nurse perform to provide a safe environment for the client at this time? A. Place pads on the side rails. B. Connect the client to a bedside ECG. C. Remove all food or fluids within the client’s reach. D. Place a water-seal chest drainage set at the bedside. 79 / 150 79. An adult client has been placed on a fluid restriction of 1200 mL per day. The nurse discusses the fluid restriction with the dietitian and then plans to allow the client to have how many milliliters of fluid from 7:00 am to 3:00 pm? A. 600 mL B. 1000 mL C. 400 mL D. 800 mL 80 / 150 80. A client has been prescribed metoprolol for hypertension. The nurse monitors client compliance carefully because of which common side effect of the medication? A. Increased appetite B. Complete atrioventricular (AV) block C. Impotence D. Mood swings 81 / 150 81. A client has urinary calculi that are composed of uric acid, and the nurse teaches the client dietary measures to prevent the further development of the calculi. The nurse determines that the client understands the dietary measures if the client states that it is necessary to avoid consuming what food products? A. Milk B. Yogurt C. Spinach, chocolate, and tea D. Sardines, herring, and organ meats 82 / 150 82. A client diagnosed with myasthenia gravis is reporting vomiting, abdominal cramps, and diarrhea. The nurse notes that the client is hypotensive and experiencing facial muscle twitching. Which possible situation does this assessment data support? A. Cholinergic crisis B. Reaction to plasmapheresis C. Systemic infection D. Myasthenic crisis 83 / 150 83. A client prescribed albuterol sulfate by inhalation cannot cough up secretions. The nurse should teach the client which action to best help clear the bronchial secretions? A. Get more exercise each day. B. Use a dehumidifier in the home. C. Administer an extra dose before bedtime. D. Increase the amount of fluids consumed every day 84 / 150 84. 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. Protamine sulfate B. Methylene blue C. Vitamin B12 D. Vitamin K 85 / 150 85. The nurse is assessing a client suspected of having a rib fracture. Which typical signs/symptoms should the nurse observe for? A. Pain on inspiration, deep rapid respirations B. Pain on inspiration, shallow guarded respirations C. Pain on expiration, shallow guarded respirations D. Pain on expiration, deep rapid respirations 86 / 150 86. The nurse is monitoring a client who is receiving an oxytocin infusion for the induction of labor. The nurse should suspect water intoxication if which sign or symptom is noted? A. Lethargy B. Fatigue C. Tachycardia D. Sleepiness 87 / 150 87. The nurse is caring for a client with a diagnosis of a mild cerebral bleed resulting from a small cerebral aneurysm rupture. The client reports feeling anxious and restless about family visiting soon. Which comment by the client should assist the nurse in identifying the reason for the anxiety? A. “At least I can speak and answer questions.” B. My son came to visit me yesterday.” C. “I have a problem turning my neck to the side.” D. “Look at me, I can no longer be the head of my family.” 88 / 150 88. The nurse is teaching umbilical cord care to a new mother. What information should the nurse provide to the mother related to cord care? A. The process of keeping the cord clean and dry will decrease bacterial growth. B. Alcohol is the only agent to use to clean the cord. C. It takes at least 21 days for the cord to dry up and fall off. D. Cord care is done only at birth to control bleeding. 89 / 150 89. A primigravida client who came to the clinic has been diagnosed with a urinary tract infection. She repeatedly verbalizes concern regarding the safety of the fetus. Which should the nurse address first? A. Instructions regarding improved hygiene B. Maternal and infant safety C. Obtaining a sedative prescription D. Instructions regarding medication compliance 90 / 150 90. A client diagnosed with Raynaud’s disease tells the nurse that he has a stressful job and does not handle stressful situations well. Which life change should the nurse teach the client to consider to help alleviate his stress? A. Consider a stress management program. B. Change to a less stressful job. C. Use earplugs to minimize environmental noise. D. Seek help from a psychologist. 91 / 150 91. A clinic nurse is assessing a prenatal client who has been diagnosed with heart disease. The nurse carefully assesses the client’s vital signs, weight, and fluid and nutritional status to detect for complications caused by which pregnancy-related concern? A. Fetal cardiomegaly B. Hypertrophy and increased contractility of the heart C. The increase in circulating blood volume D. Rh incompatibility 92 / 150 92. Which action by the nursing student, caring for a child who sustained a head injury from a fall, indicates a need for further teaching? A. Forcing fluids B. Performing neurological assessments C. Keeping the child awake as much as possible D. Keeping the child in a sitting-up position 93 / 150 93. An intravenous dose of lorazepam is prescribed for a client. Which data from the client’s history would indicate the need to consult with the primary health care provider before administering the medication A. Coronary artery disease B. Diabetes mellitus C. Hypothyroidism D. Glaucoma 94 / 150 94. The nurse assists the primary health care provider with the removal of a chest tube. During the procedure, the nurse instructs the client to perform which action? A. Breathe out forcefully. B. Breathe normally. C. Inhale deeply. D. Take a deep breath and hold it. 95 / 150 95. Which statement made by a client who has experienced a spinal cord injury resulting in chronic immobility issues warrants immediate follow-up by the nurse to assure client safety? A. “I’m definitely not looking forward to going home.” B. “I’m so angry that this happened to me.” C. “I really don’t want to live my life like this.” D. “I don’t know if I can make all these major adjustments to my life.” 96 / 150 96. 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 have a car seat that I will put in the front seat to keep my baby safe.” B. “I will not use the microwave oven to heat my baby’s formula.” C. “I can keep my aluminum pots and pans in my lower cabinets.” D. “I have locks on all my cabinets that contain my cleaning supplies.” 97 / 150 97. A client is experiencing acute cardiac and cerebral symptoms as a result of an excess fluid volume. Which nursing measure should the nurse implement to increase the client’s comfort until specific therapy is prescribed by the primary health care provider? A. Administer oxygen at 4 L per minute by nasal cannula. B. Cover the client with warm blankets. C. Elevate the client’s head to at least 45 degrees. D. Minimize visual and auditory stimuli present. 98 / 150 98. The nurse performs an initial assessment on a pregnant client and determines that the client is at risk for toxoplasmosis. The nurse provides education to the client on how to prevent the disease. Which statement by the client indicates that teaching has been effective? A. “It’s alright to eat raw meats.” B. “I should wash hands only before meals.” C. “I should avoid exposure to litter boxes used by my cat.” D. “I should use topical corticosteroid treatments prophylactically.” 99 / 150 99. The nurse is creating a discharge plan for a postoperative client who had a unilateral adrenalectomy. What area of instruction should the nurse include in the plan to minimize the client’s risk for injury? A. Encouraging the adoption of a realistic exercise routine B. Providing a detailed list of the early signs of a wound infection C. Explaining the need for lifelong replacement of all adrenal hormones D. Teaching the client to maintain a diabetic diet 100 / 150 100. Family members of a client who attempted suicide are tearful. Which statement by the nurse would be most helpful in the management of their concerns? A. “Believe me when I say that everything possible is being done.” B. “I’ll check on when you will be able to see your loved one.” C. “Don’t worry. You have absolutely nothing to feel guilty about.” D. “I certainly can see that you are terribly worried about your loved one.” 101 / 150 101. A preschooler has just been diagnosed with impetigo. The child’s mother tells the nurse, “But my children take baths every day.” Which therapeutic response should the nurse make to the mother? A. “You should have seen the doctor before the wound became infected, and then you would not have had to worry about the child having impetigo.” B. “You are concerned about how your child got impetigo?” C. “Not only do you have to do a better job of keeping your children clean, you must also wash your hands more frequently.” D. “There is no need to worry. We will not tell your day care provider why your child is absent.” 102 / 150 102. A client with the diagnosis of hyperparathyroidism states to the nurse, “I can’t stay on this diet. It is too difficult for me.” Which therapeutic response by the nurse is best when intervening in this situation? A. “It is very important that you stay on this diet to avoid forming renal calculi.” B. “Why do you think you find this diet plan difficult to adhere to?” C. “It really isn’t difficult to stick to this diet. Just avoid milk products.” D. “You are having a difficult time staying on this plan. Let’s discuss this.” 103 / 150 103. The nurse is caring for a client diagnosed with heart failure who has a magnesium level of 0.75 Eq/L (0.375 mmol/L). Which action should the nurse take? A. Encourage the intake of antacids with phosphate. B. Monitor the client for irregular heart rhythms. C. Provide a diet of ground beef, eggs, and chicken breast. D. Teach the client to avoid foods high in magnesium 104 / 150 104. The nurse is caring for a client with a nasogastric tube that is attached to low suction. If the client’s HCO3− is 30, which additional value is most likely to be noted in this client? A. pH 7.36 B. pH 7.20 C. pH 7.25 D. pH 7.52 105 / 150 105. 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. Suction in the chest drainage system is no longer needed. B. The oxygen saturation is greater than 92%. C. Pleuritic chest pain has resolved. D. Fluctuations in the water-seal chamber ceased. 106 / 150 106. The nurse is caring for a child diagnosed with Reye’s syndrome. The nurse monitors for manifestations of which condition associated with this syndrome? A. Symptoms of hyperglycemia B. . Increased intracranial pressure C. A history of a staphylococcus infection D. Protein in the urine 107 / 150 107. After a cleft lip repair, the nurse instructs the parents about cleaning of the lip repair site. The nurse should plan to use which solution when demonstrating this procedure to the parents? A. Full-strength hydrogen peroxide B. Half-strength hydrogen peroxide C. Tap water D. Sterile water 108 / 150 108. A client is scheduled for a subtotal gastrectomy (Billroth II procedure). The nurse explains that the procedure will have which surgical results? A. 1. Entire stomach is removed and the esophagus is anastomosed to the duodenum. B. Antrum of the stomach is removed and the remaining portion is anastomosed to the duodenum. C. 1. Proximal end of the distal stomach is anastomosed to the duodenum. D. 1. Lower portion of the stomach is removed and the remainder is anastomosed to the jejunum. 109 / 150 109. 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 are not a loser, you are depressed.” D. “You don’t do anything right?” 110 / 150 110. Which test result should the nurse review to determine the compatibility of blood from two different donors? A. ABO typing B. Direct Coombs’ C. Indirect Coombs’ D. Rh factor 111 / 150 111. The nurse is caring for an infant after a pyloromyotomy is performed to treat hypertrophic pyloric stenosis. In which position should the nurse place the infant after surgery? A. Prone with the head of the bed elevated B. Supine with the head of the bed elevated C. Flat on the operative side D. Flat on the unoperative side 112 / 150 112. The nurse has administered a dose of diazepam to the client. Which most important action should the nurse take before leaving the client’s room? A. Provide the client access to a bedpan. B. Draw the shades closed. C. Instruct the client not to get out of bed without assistance. D. Turn the volume on the television down. 113 / 150 113. During an emergency code situation, a primary health care provider about to defibrillate a client diagnosed in ventricular fibrillation says in a loud voice, “CLEAR!” Which action should the nurse immediately implement? A. Shut off the mechanical ventilator. B. Step away from the bed and make sure that all others have done the same. C. Place the conductive gel pads for defibrillation on the client’s chest. D. Shut off the intravenous infusion going into the client’s arm. 114 / 150 114. The nurse in a rehabilitation center is planning the client assignments for the day. Which client has needs that can be most safely met by the unlicensed assistive personnel (UAP)? A. A client who is going through rehabilitation after undergoing a below-the- knee amputation (BKA) B. A client scheduled for transfer to the hospital for coronary artery bypass surgery C. A client on strict bed rest for whom a 24-hour urine specimen is being collected D. A client scheduled for transfer to the hospital for an invasive diagnostic procedure 115 / 150 115. The home care nurse visits a client who is receiving total parenteral nutrition, and the client states, “I really miss eating dinner with my family.” Which statement from the nurse is the most therapeutic? A. “Tell me more about your family dinners.” B. “What you are feeling is very common.” C. “You can sit down to dinner even if you do not eat.” D. “In a few weeks, you may be allowed to eat.” 116 / 150 116. The nurse provides information to a client who is scheduled for the implantation of an implantable cardioverter defibrillator (ICD) regarding care after implantation. The nurse tells the client that there is a need to keep a diary. What information should the nurse provide concerning the primary purpose of the diary? A. Document events that precipitate a countershock. B. Record a variety of data that are useful for the primary health care provider during medical management. C. Provide a count of the number of shocks delivered. D. Analyze which activities to avoid. 117 / 150 117. 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. Administer antibiotics intravenously. B. Evaluate the differential of the leukocytes. C. Track the client’s oral temperature. D. Use sterile technique for dressing changes. 118 / 150 118. A client who is taking an antipsychotic medication is preparing for discharge. To facilitate health promotion for this client, what instruction should the nurse provide? A. Adhere to a strict tyramine-restricted diet. B. Recognize the signs and symptoms of a relapse of depression. C. Avoid prolonged exposure to the sun. D. Have therapeutic blood levels drawn because the medication has a narrow therapeutic range. 119 / 150 119. When the home care nurse arrives, the client with a diagnosis of emphysema is smoking. Which statement by the nurse would be most therapeutic? A. “I wonder if you realize that by smoking you are slowly killing yourself.” B. “Did you explore the stop smoking program at the senior citizens center?” C. “Well, I can see you never got to the stop smoking clinic.” D. “Now that your secret is out, may we decide what you are going to do?” 120 / 150 120. A coronary care unit (CCU) nurse is caring for a client admitted with acute myocardial infarction (MI). The nurse should monitor the client for which most common complication of MI? A. Heart failure B. Cardiogenic shock C. Recurrent myocardial infarction D. Cardiac dysrhythmias 121 / 150 121. The nurse is delivering care to a client who is diagnosed with toxic shock syndrome (TSS). Which complication of this syndrome should the nurse monitor the client for? A. Pulmonary embolism B. Disseminated intravascular coagulopathy (DIC) C. Vitamin K deficiency D. Factor VIII deficiency 122 / 150 122. 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. Notify the primary health care provider if the child develops a fever greater than 100.5° F (38° C). C. After bathing, rub lotion and sprinkle powder on the incision. D. The child can play outside for short periods of time. 123 / 150 123. After a client diagnosed with pleural effusion had a thoracentesis, a sample of fluid was sent to the laboratory. Analysis of the fluid reveals a high red blood cell count. Based on this test result, what was the case of this client’s pleural effusion? A. Trauma B. Heart failure C. Liver failure D. Infection 124 / 150 124. The nurse assesses the client’s peripheral intravenous (IV) site and notes that it is cool, pale, and swollen, and the fluid is not infusing. Which condition should the nurse document? A. Infiltration B. Thrombosis C. Infection 125 / 150 125. The nurse inserts an indwelling urinary catheter into a client. As the catheter moves into the bladder, urine begins to flow into the tubing. Which action should the nurse implement next? A. Secure the catheter to the client. B. Inflate the balloon with water. C. Measure the initial urine output. D. Advance the catheter 2.5 to 5 cm. 126 / 150 126. An older client has been admitted to the hospital diagnosed with a hip fracture. The nurse prepares a plan of care for the client and identifies desired outcomes related to surgery and impaired physical mobility. Which statement by the client supports a positive adjustment to the surgery and impairment in mobility? A. “I wish you nurses would leave me alone! You are all telling me what to do!” B. “What took you so long? I called for you 30 minutes ago.” C. “Hurry up and go away. I want to be alone.” D. “I find it a little difficult to concentrate since the surgeon talked with me about the surgery tomorrow.” 127 / 150 127. A client had arterial blood gases drawn. The results are a pH of 7.34, a partial pressure of carbon dioxide of 37 mm Hg (37 mm Hg), a partial pressure of oxygen of 79 mm Hg (79 mm Hg), and a bicarbonate level of 19 mEq/L (19 mmol/L). Which disorder should the nurse interpret that the client is experiencing? A. Metabolic alkalosis B. Metabolic acidosis C. Respiratory alkalosis D. Respiratory acidosis 128 / 150 128. The nurse, while caring for a hospitalized infant being monitored for increased intracranial pressure (ICP), notes that the anterior fontanel bulges when the infant cries. Based on this assessment finding, which conclusion should the nurse draw? A. The head of the bed needs to be lowered. B. The infant needs to be placed on NPO status. C. That no action is required. D. The primary health care provider should be notified immediately. 129 / 150 129. 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. Denial B. Displacement C. Delusions D. Psychosis 130 / 150 130. A client diagnosed with gastritis asks the nurse at a screening clinic about analgesics that will not cause epigastric distress. The nurse should tell the client to take which medication? A. Naproxen B. Ibuprofen C. Aspirin D. Acetaminophen 131 / 150 131. 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. Contacting the client’s primary health care provider B. Sedating the client C. Considering all possible alternative measures D. Applying wrist restraints 132 / 150 132. The home care nurse is evaluating a client’s understanding of the self- management of trigeminal neuralgia. Which client statement indicates that there is a need for further teaching? A. “An analgesic will relieve my pain.” B. “Taking my carbamazepine will help control my pain.” C. “I should chew on my good side.” D. “I should use warm mouthwash for oral hygiene.” 133 / 150 133. 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. “When the primary health care provider says it is okay.” B. “In 3 weeks.” C. “In 1 week.” D. “Six days after surgery.” 134 / 150 134. What action should the nurse take to assess the pharyngeal reflex on a child? A. Shine a light toward the bridge of the nose. B. Ask the client to swallow. C. Stimulate the back of the throat with a tongue depressor. D. Pull down on the lower eyelid. 135 / 150 135. A client tells the clinic nurse that her skin is very dry and irritated. Which product should the nurse suggest that the client apply to the dry skin? A. Acetic acid solution B. Topical emollient C. Myoflex D. Aspercreme 136 / 150 136. The client diagnosed with prostatitis asks the nurse, “Why do I need to take a stool softener? The problem is with my urine, not my bowels!” Which response should the nurse make to the client? A. “This will keep the bowel free of feces, which helps decrease the swelling inside.” B. “This is a standard medication prescription for anyone with a urine problem.” C. “Being constipated puts you at more risk for developing complications of prostatitis.” D. “This will help you prevent constipation because straining is painful with prostatitis.” 137 / 150 137. A client with superficial varicose veins states to the nurse, “I hate these things. They’re so ugly. I wish I could get them to go away.” Which therapeutic response would be most appropriate for the nurse to make to the client? A. “What makes you so upset about having ugly varicose veins?” B. “What have you been educated about varicose veins and their management?” C. “I understand how you feel, but you know, they really don’t look all that bad.” D. “You should try sclerotherapy. It’s great.” 138 / 150 138. A client diagnosed with moderate dementia is prescribed oral anticoagulant therapy while hospitalized. The nurse identifies which discharge scenario as being the best support system for successful anticoagulant therapy monitoring A. The client has a home health aide coming to the house for 9 weeks. B. The client has a good friend living next door who would take the client to the doctor. C. The client was going to stay with a daughter in the daughter ’s home indefinitely. D. The client was going to have blood work drawn in the home by a local laboratory. 139 / 150 139. A client diagnosed with renal cell carcinoma of the left kidney is scheduled for a nephrectomy. The right kidney appears to be normal at this time. The client is anxious about whether dialysis will ultimately be a necessity. Which information should the nurse initially provide to the client? A. There is absolutely no chance of the client needing dialysis because of the nature of the surgery. B. It is very likely that the client will need dialysis within 5 to 10 years. C. Dialysis could become likely, but it depends on how well the client complies with fluid restriction after surgery. D. One kidney is adequate to meet the needs of the body, as long as it has normal function. 140 / 150 140. A client has been taking benzonatate as prescribed. The nurse should tell the client this medication performs which action? A. Increases comfort level B. Vigorous range of motion to the right leg C. Calms the persistent cough D. Decreases anxiety level 141 / 150 141. When a client’s nasogastric (NG) tube stops draining, which intervention should the nurse implement to maintain client safety? A. Instill 10 to 20 mL of fluid to dislodge any clots. B. Verify the tube placement according to agency procedure. C. Retract the tube by 2 inches to be above and possible obstruction. D. Clamp the tube for 2 hours to allow the drainage to accumulate. 142 / 150 142. A client who has sustained a burn injury receives a prescription for a regular diet. Which is the best meal for the nurse to provide to the client to promote wound healing? A. Peanut butter and jelly sandwich, apple, tea B. Pasta with tomato sauce, garlic bread, ginger ale C. Chicken breast, broccoli, strawberries, milk D. Veal chop, boiled potatoes, Jell-O, orange juice 143 / 150 143. client is scheduled for hydrotherapy for a burn dressing change. Which action should the nurse take to ensure that the client is comfortable during the procedure? A. Schedule the therapy at a time when the client generally takes a nap. B. Administer an opioid analgesic 30 to 60 minutes before therapy. C. Ensure that the client is appropriately dressed D. Assign an unlicensed assistive personnel (UAP) to stay with the client during 144 / 150 144. The nurse is planning the discharge instructions for an adult client who is a victim of family violence. The nurse should understand that it is most important that which information is included in the discharge plans? A. Instructions to call the police the next time the abuse occurs B. Specific information about current opportunities to enroll in local self- defense classes C. Exploration of the pros and cons of remaining with the abusive family member D. Specific information regarding “safe havens” or shelters in the client’s neighborhood 145 / 150 145. A client diagnosed with chronic kidney disease is about to begin hemodialysis therapy. The client asks the nurse about the frequency and scheduling of hemodialysis treatments. What information should the nurse supply to the client regarding the typical hemodialysis schedule? A. It is 2 to 3 hours of treatment 5 days per week. B. It is 3 to 4 hours of treatment 3 days per week. C. It is 5 hours of treatment 2 days per week. D. It is 2 hours of treatment 6 days per week. 146 / 150 146. 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 get help immediately if I start having trouble breathing.” B. “I will stop smoking my cigarettes.” C. “I will use the throat lozenges as directed by my doctor until my sore throat goes away.” D. “I can expect to cough up bright red blood.” 147 / 150 147. During electroconvulsive therapy (ECT), the client receives oxygen by mask via positive pressure ventilation. The nurse understands that positive pressure ventilation is necessary for which reason? A. Muscle relaxants are given to prevent injury during the seizure. B. Seizure activity depresses respirations. C. Decreased oxygen to the brain increases confusion and disorientation. D. Anesthesia is routinely administered during the ECT procedure. 148 / 150 148. The nurse inserted a nasogastric (NG) tube to the level of the oropharynx and has repositioned the client’s head in a flexed-forward position. The client has been asked to begin swallowing, but as the nurse starts to slowly advance the NG tube with each swallow, the client begins to gag. Which action if taken by the nurse at this point would indicate a need for further instruction regarding the insertion of an NG tube? A. Pulling the tube back slightly B. Instructing the client to breathe slowly C. Checking the back of the pharynx using a tongue blade and flashlight D. Continuing to advance the tube to the desired distance 149 / 150 149. The nurse has been working with a victim of rape in an outpatient setting for the past 4 weeks. The nurse should recognize that which client objective is an unrealistic short-term goal? A. The client will verbalize feelings about the rape event. B. The client will experience physical healing of the wounds that were incurred during the rape. C. The client will resolve feelings of fear and anxiety related to the rape trauma. D. The client will participate in the treatment plan by following through with treatment options. 150 / 150 150. A postmastectomy client has been found to have an estrogen receptor– positive tumor. The nurse interprets after reading this information in the pathology report that the client will most likely have which common follow- up treatment prescribed? A. Administration of tamoxifen B. Removal of the ovaries C. Administration of estrogen D. Administration of progesterone Your score is The average score is 31% Restart quiz Home/Practice NCLEX Questions/150 Random Free NCLEX Questions