NEW Free NCLEX-RN Sample Test Questions For Nursing Review (Part 10)

Question 1
A client was re-admitted to the hospital following a recent skull fracture. Which finding requires the nurse's immediate attention?
A) Lethargy
B) Agitation
C) Ataxia
D) Hearing loss




Review Information: The correct answer is A: Lethargy
The level of consciousness or responsiveness is the most important measure of the client''s rising intracranial pressure. Look for lethargy, delay in response to verbal suggestions and slowing of speech. Assess for rising blood pressure or widening pulse pressure and for respiratory irregularities. There may be vomiting, usually projectile, without the presence of nausea.


Question 2
A woman comes to the antepartum clinic for a routine prenatal examination. She is 12 weeks pregnant with her second child. Which of the following shows proper documentation of the client's obstetric history by the nurse?
A) Para 2, Gravida 1
B) Nulligravida 2, Para 1
C) Primigravida 1, Para 1
D) Gravida 2, Para 1




Review Information: The correct answer is D: Gravida 2, Para 1
Gravida describes a woman who is or has been pregnant, regardless of pregnancy outcome. Para describes the number of babies born past a point of viability. Therefore a woman pregnant with her second child would be described as Gravida 2, Para 1. Primipara refers to a woman who has completed one pregnancy to the period of viability. Multipara refers to a woman who has completed 2 or more pregnancies to the stage of viability.



Question 3
The registered nurse (RN) is planning care at a team meeting for a 2 month-old child in bilateral leg casts for congenital clubfoot. Which of these outcomes suggested by the practical nurse (PN) should be considered the priority nursing goal following cast application?
A) The infant will experience minimal pain
B) Muscle spasms will be relieved
C) Mobility will be managed as tolerated
D) Tissue perfusion will be maintained


Review Information: The correct answer is D: Tissue perfusion will be maintained
Immediately following cast application, the chief goal is to maintain circulation and tissue perfusion around the cast. Permanent tissue damage can occur within a few hours if perfusion is not maintained.


Question 4
A client is admitted with the diagnosis of myocardial infarction (MI). Which of the following lab values would be consistent with this diagnosis
A) Low serum albumin
B) High serum cholesterol
C) Abnormally low white blood cell count
D) Elevated creatinine phosphokinase (CPK)


Review Information: The correct answer is D: Elevated creatinine phosphokinase (CPK)
An elevated CPK is a common finding in the client with an MI. CPK levels begin to rise approximately 3 to 12 hours after an acute MI, peak in 24 hours, and return to normal within 2 to 3 days. Troponin levels rise as well.






Question 5
The nurse is providing instructions for a client with asthma who is sensitive to house dust-mites. Which information about prevention of asthma episodes would be the most helpful to include during the teaching?
A) Change the pillow covers every month
B) Wash bed linens in warm water with a cold rinse
C) Wash and rinse the bed linens in hot water
D) Use air filters in the furnace system




Review Information: The correct answer is C: Wash and rinse the bed linens in hot water
For asthma clients who are sensitive to house dust-mites it is essential the mattresses and pillows are encased in allergen-impermeable covers. All bed linens such as pillow cases, sheets and blankets should be washed and rinsed weekly in hot water at temperatures above 130 degrees Fahrenheit, the temperature necessary to kill the dust-mites.


Question 6
The nurse is teaching childbirth preparation classes. One woman asks about her rights to develop a birthing plan. Which response made by the nurse would be best?
A) "What is your reason for wanting such a plan?"
B) "Have you talked with your provider about this?"
C) "Let us discuss your rights as a couple"
D) "Write your ideal plan for the next class"


Review Information: The correct answer is C: "Let us discuss your rights as a couple"
Discussion of the provider''s role and the couple''s rights and limitations in selecting birth options must precede development of a plan.






Question 7
A client is receiving oxygen therapy via a nasal cannula. When providing nursing care, which of the following interventions would be appropriate?
A) Determine that adequate mist is supplied
B) Inspect the nares and ears for skin breakdown
C) Lubricate the tips of the cannula before insertion
D) Maintain sterile technique when handling cannula




Review Information: The correct answer is B: Inspect the nares and ears for skin breakdown
Oxygen therapy can cause drying of the nasal mucosa. Pressure from the tubing can cause skin irritation. Nasal cannula administering oxygen should not be lubricated with petroleum jelly.


Question 8
At a nursing staff meeting, there is discussion of perceived inequities in weekend staff assignments. As a follow-up, the nurse manager should initially
A) Allow the staff to change assignments
B) Clarify reasons for current assignments
C) Help staff see the complexity of issues
D) Facilitate creative thinking on staffing


Review Information: The correct answer is D: Facilitate creative thinking on staffing
The "moving phase" of change involves viewing the problem from a new perspective, and then incorporating new and different approaches to the problem. The manager, as a change agent, can facilitate staff''s solving the problem.







Question 9
A 14 month-old had cleft palate surgical repair several days ago. The parents ask the nurse about feedings after discharge. Which lunch is the best example of an appropriate meal?
A) Hot dog, carrot sticks, gelatin, milk
B) Soup, blenderized soft foods, ice cream, milk
C) Peanut butter and jelly sandwich, chips, pudding, milk
D) Baked chicken, applesauce, cookie, milk




Review Information: The correct answer is B: Soup, blenderized soft foods, ice cream, milk
In a child with cleft palate repair, parents should prepare soft foods and avoid those foods with particles that might traumatize the surgical site.


Question 10
A client tells the nurse he is fearful of planned surgery because of evil thoughts about a family member. What is the best initial response by the nurse?
A) Call a chaplain
B) Deny the feelings
C) Cite recovery statistics
D) Listen to the client




Review Information: The correct answer is D: Listen to the client
Therapeutic communications are based on attentive listening to expressed feelings. If the nurse is not familiar with the cultural beliefs of a client, acceptance of feelings is followed by questions about the beliefs.








Question 11
A child with tetralogy of Fallot visits the clinic several weeks before planned surgery. The nurse should give priority attention to
A) assessment of oxygenation
B) observation for developmental delays
C) prevention of infection
D) maintenance of adequate nutrition




Review Information: The correct answer is A: assessment of oxygenation
All of the above would be important in a child diagnosed with tetralogy of Fallot. However, persistent hypoxemia causes acidosis which further decreases pulmonary blood flow. Additionally, low oxygenation leads to development of polycythemia and resultant neurologic complications.


Question 12
In reviewing the assessment data of a client suspected of having diabetes insipidus, the nurse expects which of the following after a water deprivation test?
A) Increased edema and weight gain
B) Unchanged urine specific gravity
C) Rapid protein excretion
D) Decreased blood potassium




Review Information: The correct answer is B: Unchanged urine specific gravity
When fluids are restricted, the client continues to excrete large amounts of dilute urine. This finding supports the diagnosis. Normally, urine is more concentrated with reduced fluid intake.






Question 13
The nurse is assessing a 12 year-old who has hemophilia A. Which finding would the nurse anticipate?
A) An excess of red blood cells
B) An excess of white blood cells
C) A deficiency of clotting factor VIII
D) A deficiency of clotting factors VIII and IX


Review Information: The correct answer is C: A deficiency of clotting factor VIII
Hemophilia A is characterized by an absence or deficiency of Factor VIII.


Question 14
The nurse is assessing a client with a deep vein thrombosis. Which of the following signs and/or symptoms would the nurse anticipate finding?
A) Rapid respirations
B) Diaphoresis
C) Swelling of lower extremity
D) Positive Babinski's sign


Review Information: The correct answer is C: Swelling of lower extremity
The most common signs of deep vein thrombosis are pain in the region of the thrombus and unilateral swelling distal to the site.










Question 15
When planning the care for a young adult client diagnosed with anorexia nervosa which of these concerns should the nurse determine to be the priority for long term mobility?
A) digestive problems
B) amenorrhea
C) Electrolyte imbalance
D) blood disorders


Review Information: The correct answer is B: amenorrhea
Changes in reproductive hormones and in thyroid hormones can cause absence of menstruation, called amenorrhea, which contributes to osteoporosis and bone fractures.


Question 16
The new graduate nurse interviews for a position in a nursing department of a large health care agency, described by the interviewer as having shared governance. Which of these statements best illustrates the shared governance model?
A) An appointed board oversees any administrative decisions
B) Nursing departments share responsibility for client outcomes
C) Staff groups are appointed to discuss nursing practice and client education issues
D) Non-nurse managers supervise nursing staff in groups of units




Review Information: The correct answer is B: Nursing departments share responsibility for client outcomes
Shared governance or self-governance is a method of organizational design that promotes empowerment of nurses to give them responsibility for client care issues.





Question 17
The nurse is teaching a client about the healthy use of ego defense mechanisms. An appropriate goal for this client would be
A) Reduce fear and protect self-esteem
B) Minimize anxiety and delay apprehension
C) Avoid conflict and leave unpleasant situations
D) Increase independence and communicate more often




Review Information: The correct answer is A: Reduce fear and protect self-esteem
Ego defense mechanisms are unconscious proactive barriers that are used to manage instinct and affect in the presence of stressful situations. Healthy reactions are those in which the client admits that they are feeling various emotions.


Question 18
The nurse is caring for a client with Parkinson's disease. The client spends over 1 hour to dress for scheduled therapies. What is the most appropriate action for the nurse to take in this situation?
A) Ask family members to dress the client
B) Encourage the client to dress more quickly
C) Allow the client the time needed to dress
D) Demonstrate methods on how to dress more quickly




Review Information: The correct answer is C: Allow the client the time needed to dress
Clients with Parkinson''s disease often wish to take care of themselves but become very upset when hurried and then are unable to manage at all. Any form of hurrying the client will result in a very upset and immobilized client.







Question 19
The nurse would expect which eating disorder to cause the greatest fluctuations in potassium?
A) binge eating disorder
B) anorexia nervosa
C) bulimia
D) purge syndrome




Review Information: The correct answer is C: bulimia
With bulimia the purging process tends to make the body dehydrated and to lower the level of potassium in the blood. Low potassium levels can cause weakness, abdominal cramping and irregular heart rhythms.


Question 20
While performing an initial assessment on a newborn following a breech delivery, the nurse suspects hip dislocation. Which of the following is most suggestive of the abnormality?
A) Flexion of lower extremities
B) Negative Ortolani response
C) Lengthened leg of affected side
D) Irregular hip symmetry


Review Information: The correct answer is D: Irregular hip symmetry
Early assessment of irregular hip symmetry alerts the nurse and the provider to a correctable congenital hip dislocation.








Question 21
The nurse is evaluating the growth and development of a toddler with AIDS. The nurse would anticipate finding that the child has
A) achieved developmental milestones at an erratic rate
B) delay in musculoskeletal development
C) displayed difficulty with speech development
D) delay in achievement of most developmental milestones




Review Information: The correct answer is D: delay in achievement of most developmental milestones
The majority of children with AIDS have neurological involvement. There is decreased brain growth as evidenced by microcephaly and abnormal neurologic findings. Developmental delays are common, and after achieving normal development, there may be loss of milestones. The other options are accurate but are too limited to be the best response.


Question 22
When caring for a client with advanced cirrhosis of the liver, which nursing diagnosis should take priority?
A) risk for injury: hemorrhage
B) risk for injury related to peripheral neuropathy
C) altered nutrition: less than body requirements
D) fluid volume excess: ascites


Review Information: The correct answer is A: risk for injury: hemorrhage
Liver disease interferes with the production of prothrombin and other factors essential for blood clotting. Hemorrhage, especially from esophageal varices can be life threatening. This takes priority over the other nursing diagnosis.







Question 23
When teaching new parents prevention of sudden infant death syndrome (SIDS) what is the most important practice the nurse should instruct them to do?
A) Place the infant in a supine or side lying position for sleep
B) Do not allow anyone to smoke in the home
C) Follow recommended immunization schedule
D) Be sure to check infant every one hour




Review Information: The correct answer is A: Place the infant in a supine or side lying position for sleep
Current thinking is that infants become hypoxic when they sleep because of positional narrowing of the airway and respiratory inflammation. The most compelling data comes from studies that link sleep habits with an increased risk of SIDS. Sleeping in the prone position may cause oropharyngeal obstruction or affect the thermal balance or arousal state. Sleep apnea is not the cause of SIDS. Because of research findings and the "Back to Sleep" campaign, the incidence of sleep apnea and the number of SIDS deaths have dropped dramatically.













Question 24
In a long term rehabilitation care unit, a client with spinal cord injury complains of a pounding headache. The client is sitting in a wheelchair watching television. Further assessment by the nurse reveals excessive sweating, a splotchy rash, pilomotor erection, facial flushing, congested nasal passages and a heart rate of 50. The nurse should perform which action next?
A) Take the client's respirations, blood pressure (BP), temperature and then pupillary responses
B) Place the client into the bed and administer the ordered PRN analgesic
C) Check the client for bladder distention and the client's urinary catheter for kinks
D) Turn the television off and then assist client to use relaxation techniques




Review Information: The correct answer is C: Check the client for bladder distention and the client''s urinary catheter for kinks
These are findings of autonomic dysreflexia, also called hyperreflexia. This response occurs in clients with a spinal cord injury above the T-6 level. It is typically initiated by any noxious stimulus below the level of injury such as a full bladder, an enema or bowel movement, fecal impaction, uterine contractions, changing of the catheter, and vaginal or rectal examinations. The stimulus creates an exaggerated response of the sympathetic nervous system and can be a life-threatening event. The BP is typically extremely high. The priority action of the nurse is to identify and relieve the cause of the stimulus.










Question 25
A 2 month-old infant has both a cleft lip and palate which will be repaired in stages. In the immediate postoperative period for a cleft lip repair, which nursing approach should be the priority?
A) Remove protective arm devices one at a time for short periods with supervision
B) Initiate by mouth feedings when alert, with the return of the gag reflex
C) Introduce to the parents how to cleanse the suture line with the prescribed protocol
D) Position the infant on the back after feedings throughout the day


Review Information: The correct answer is A: Remove protective arm devices one at a time for short periods with supervision
The major efforts in the postoperative period are directed toward protecting the operative site. Elbow restraints should be used and only 1 arm released at a time with close supervision by the nurse and/or parents.


Question 26
In addition to disturbances in mental awareness and orientation, a client with cognitive impairment is also likely to show loss of ability in
A) Hearing, speech, and sight
B) Endurance, strength, and mobility
C) Learning, creativity, and judgment
D) Balance, flexibility, and coordination


Review Information: The correct answer is C: Learning, creativity, and judgment
Cognitive impairments are due to physiological processes that affect memory and other higher-level cognitive processes.

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Question 27
A client is admitted with a diagnosis of myocardial infarction (MI). The client is complaining of chest pain. The nurse knows that pain related to an MI is due to
A) insufficient oxygenation of the cardiac muscle
B) potential circulatory overload
C) left ventricular overload
D) electrolyte imbalance


Review Information: The correct answer is A: insufficient oxygenation of the cardiac muscle
Due to ischemia of the heart muscle, the client experiences pain. This happens because an MI can block or interfere with the normal cardiac circulation.


Question 28
The nurse is caring for a client admitted to the hospital with right lower lobe (RLL) pneumonia. On assessment, the nurse notes crackles over the RLL. The client has significant pleuritic pain and is unable to take in a deep breath in order to cough effectively. Which nursing diagnosis would be most appropriate for this client based on this assessment data?
A) Impaired gas exchange related to acute infection and sputum production
B) Ineffective airway clearance related to sputum production and ineffective cough
C) Ineffective breathing pattern related to acute infection
D) Anxiety related to hospitalization and role conflict


Review Information: The correct answer is B: Ineffective airway clearance related to sputum production and ineffective cough
Ineffective airway clearance is defined as the inability to cough effectively. While the other diagnoses may be appropriate for this client, this is the only one supported directly by the assessment data given.





Question 29
On initial examination of a 15 month-old child with suspected otitis media, which group of findings would the registered nurse (RN) anticipate?
A) Periorbital edema, absent light reflex and translucent tympanic membrane
B) Irritability, rhinorrhea, and bulging tympanic membrane
C) Diarrhea, retracted tympanic membrane and enlarged parotid gland
D) Vomiting, pulling at ears and pearly white tympanic membrane


Review Information: The correct answer is B: Irritability, rhinorrhea, and bulging tympanic membrane
Clinical manifestations of otitis media include irritability, rhinorrhea, bulging tympanic membrane, and pulling at ears.


Question 30
A Hispanic client refuses emergency room treatment until a curandero is called. The nurse understands that this person brings what to situations of illness?
A) Holistic healing
B) Spiritual advising
C) Herbal preparations
D) Witchcraft potions




Review Information: The correct answer is A: Holistic healing
This traditional folk practitioner uses holistic methods for illnesses not related to witchcraft. Many times, the curandero works with traditional health care providers to restore health.






Question 31
The nurse is caring for a client with left ventricular heart failure. Which one of the following assessments is an early indication of inadequate oxygen transport?
A) crackles in the lungs
B) confusion and restlessness
C) distended neck veins
D) use of accessory muscles




Review Information: The correct answer is B: confusion and restlessness
Neurological changes, including impaired mental status, are early signs of inadequate oxygenation.
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Question 32
Postoperative orders for a client undergoing a mitral valve replacement include monitoring pulmonary artery pressure together with pulmonary capillary wedge pressure with a pulmonary artery catheter. The purpose of these actions by the nurse is to assess
A) right ventricular pressure
B) left ventricular end-diastolic pressure
C) acid-base balance
D) coronary artery stability


Review Information: The correct answer is B: left ventricular end-diastolic pressure
The pulmonary capillary wedge pressure is reflective of left ventricular end-diastolic pressure. Pulmonary artery pressures are an assessment tool used to determine the ability of the heart to receive and pump blood effectively.







Question 33
A 6 year-old female is diagnosed with recurrent urinary tract infections (UTIs). Which one of the following instructions would be best for the nurse to tell the caregiver?
A) Increase bladder tone by delaying voiding
B) When laundering clothing, rinse several times
C) Use plain water for the bath, shampooing hair last
D) Have the child use antibacterial soaps while bathing




Review Information: The correct answer is C: Use plain water for the bath, shampooing hair last
Hair should be shampooed last with a rinsing of plain water over the genital area. The oils in soaps and bubble bath can cause irritation, which may lead to UTI''s in young girls.


Question 34
The nurse is performing a physical assessment on a client with insulin dependent diabetes mellitus. Which client finding calls for immediate nursing action?
A) Diaphoresis and shakiness
B) Reduced lower leg sensation
C) Intense thirst and hunger
D) Painful hematoma on thigh


Review Information: The correct answer is A: Diaphoresis and shakiness
Diaphoresis is a sign of hypoglycemia which warrants immediate attention.







Question 35
A client is admitted with a distended bladder due to the inability to void. The nurse obtains an order to catheterize the client, and is aware that gradual emptying is preferred over complete emptying because it reduces the
A) potential for renal collapse
B) potential for shock
C) intensity of bladder spasms
D) chance of bladder atrophy




Review Information: The correct answer is B: potential for shock
Complete, rapid emptying can cause shock and hypotension due to sudden changes in the abdominal cavity.


Question 36
A client was admitted with a diagnosis of pneumonia. When auscultating the client's breath sounds, the nurse hears inspiratory crackles in the right base. Temperature is 102.3 degrees Fahrenheit orally. What other finding would the nurse expect?
A) Flushed skin
B) Bradycardia
C) Mental confusion
D) Hypotension


Review Information: The correct answer is C: Mental confusion
Crackles suggest pneumonia, which is likely to be accompanied by mental confusion related to hypoxia.







Question 37
The nurse is assessing a newborn infant and observes low set ears, short palpebral fissures, flat nasal bridge and indistinct philtrum. A priority maternal assessment by the nurse should be to ask about
A) alcohol use during pregnancy
B) usual nutritional intake
C) family genetic disorders
D) maternal and paternal ages




Review Information: The correct answer is A: alcohol use during pregnancy
This cluster of facial characteristics is often linked to fetal alcohol syndrome (FAS). Lifelong developmental delays of varying severity can result.


Question 38
The nurse is planning care for a client with increased intracranial pressure. The best position for this client is
A) Trendelenburg
B) Prone
C) Semi-Fowlers
D) Side-lying with head flat




Review Information: The correct answer is C: Semi-Fowlers
Maintaining the head of the bed at 15-30 degrees reduces cerebral venous congestion.










Question 39
You are teaching a client about the patient controlled analgesia (PCA) planned for post-operative care. Which statement indicates further teaching may be needed by the client?
A) "I will be receiving continuous doses of medication."
B) "I should call the nurse before I take additional doses."
C) "I will call for assistance if my pain is not relieved."
D) "The machine will prevent an overdose."


Review Information: The correct answer is B: "I should call the nurse before I take additional doses."
Patient controlled analgesia offers the client more control. The client should be instructed to initiate additional doses as needed without asking for assistance unless there is insufficient control of the pain.


Question 40
A young child is admitted for treatment of lead poisoning. The nurse recognizes that the most serious effect of chronic lead poisoning is
A) central nervous system damage
B) moderate anemia
C) renal tubule damage
D) growth impairment




Review Information: The correct answer is A: central nervous system damage
The most serious consequences of chronic lead poisoning occur in the central nervous system. Neural cells are destroyed by the toxic effects of the lead, resulting in many problems with the intellect ranging from mild deficits to mental retardation and even death.

NEW Free NCLEX-RN Sample Test Questions For Nursing Review (Part 9)

Question 1
A 67 year-old client is admitted with substernal chest pain with that radiates to the jaw. The admitting diagnosis is acute myocardial infraction (MI). The priority nursing diagnosis for this client during the first 24 hours is
A) constipation related to immobility
B) high risk for infection
C) impaired gas exchange
D) fluid volume deficit


Review Information: The correct answer is C: impaired gas exchange
In the immediate post MI period, impaired gas exchange related to oxygen supply and demand is a major problem.


Question 2
On admission to the hospital a client with an acute asthma episode has intermittent nonproductive coughing and a pulse oximeter reading of 88%. The client states, “I feel like this is going to be a bad time this admission. I wish I would not have gone into that bar with all those people who smoke last night.” Which nursing diagnoses would be most important for this client?
A) Anxiety related to hospitalization
B) Ineffective airway clearance related to potential thick secretions
C) Altered health maintenance related to preventative behaviors associated with asthma
D) Impaired gas exchange related to bronchoconstriction and mucosal edema




Review Information: The correct answer is D: Impaired gas exchange related to bronchoconstriction and mucosal edema
Pulse oximetry reflects oxygenation of arterial blood. While the other diagnoses may be appropriate for this client, they are not the most appropriate priority at the time of admission.



Question 3
While caring for a client with infective endocarditis, the nurse must be alert for signs of pulmonary embolism. Which of the following assessment findings suggests this complication?
A) Positive Homan's sign
B) Fever and chills
C) Dyspnea and cough
D) Sensory impairment


Review Information: The correct answer is C: Dyspnea and cough
Vegetation from the infected heart valves often leads to pulmonary embolism in the client with infective endocarditis. Cough, pleuritic chest pain and dyspnea are early symptoms.


Question 4
With an alert of an internal disaster and the need for beds, the charge nurse is asked to list clients who are potential discharges within the next hour. Which client should the charge nurse select?
A) An elderly client who has had type 2 diabetes for over 20 years, admitted with diabetic ketoacidosis 24 hours ago
B) An adolescent admitted the prior night with Tylenol intoxication
C) A middle-aged client with an internal automatic defibrillator and complaints of “passing out at unknown times” admitted yesterday
D) A school-aged child diagnosed with suspected bacterial meningitis and was admitted at the change of shifts


Review Information: The correct answer is A: An elderly client who has had type 2 diabetes for over 20 years, admitted with diabetic ketoacidosis 24 hours ago
This client is the most stable and has a chronic condition. Tylenol intoxication requires at least 3 to 4 days of intensive observation for the risk of hepatic failure. The other clients would be considered unstable.




Question 5
Which tasks, if delegated by the new charge nurse to a unlicensed assistive personnel (UAP), would require intervention by the nurse manager?
A) To help an elderly client to the bathroom
B) To empty a Foley catheter bag
C) To bathe a woman with internal radon seeds
D) To feed a 2 year-old with a broken arm




Review Information: The correct answer is C: To bathe a woman with internal radon seeds
A client with internal radiation is complex care and not suitable to be assigned to a UAP. Additionally, the client would not receive a complete bath because of the radiation risks.


Question 6
A newly appointed nurse manager is having difficulties with time management. Which advice from an experienced manager should the new manager implement initially?
A) Set daily goals and establish priorities for each hour and each day.
B) Ask for additional assistance when you feel overwhelmed.
C) Keep a time log of your day in hourly blocks for at least 1 week.
D) Complete each task before beginning another activity in selected instances.


Review Information: The correct answer is C: Keep a time log of your day in hourly blocks for at least 1 week.
Apply the nursing process to time management, so the assessment of the current activities is the initial step. A baseline is established for activities and time use so that needed changes can be pinpointed.






Question 7
The nurse is assigned to a client with Parkinson's disease. Which findings would the nurse anticipate?
A) Non-intention tremors and urgency with voiding
B) Echolalia and a shuffling gait
C) Muscle spasm and a bent over posture
D) Intention tremor and jerky movement of the elbows




Review Information: The correct answer is B: Echolalia and a shuffling gait
Clients with Parkinson''s disease have a very distinctive gait with quick short steps (shuffling) which may increase in speed so that they are unable to stop. They also have echolalia which means the repeating of phrases or words that are directed to them during conversation. In the other options, only one of the findings is associated with Parkinson’s disease: non-intention tremors, bent over posture, and the cogwheel or jerky movement of the elbows.


Question 8
A young adult male has been diagnosed with testicular cancer. Which of these statements by this client would need to be explored by the nurse to clarify his understanding?
A) "This surgical procedure involves removing one or both testicles through a cut in the groin. My lymph nodes in my lower belly also may be removed."
B) "I have a good chance to regain my fertility later. However if I am concerned, I can have my sperm frozen and preserved (cryopreserved) before chemotherapy."
C) "If I have cancer at stage 3 it means I have less involvement of the cancer."
D) "After the surgical removal of a testicle, I can have an artificial testicle (prosthesis) placed inside my scrotum. This artificial implant has the weight and feel of a normal testicle."


Review Information: The correct answer is C: "If I have cancer at stage 3 it means I have less involvement of the cancer."
Stage 3 is the most extensive involvement of cancer with any type.


Question 9
A Hispanic client confides in the nurse that she is concerned that staff may give her newborn the "evil eye." The nurse should communicate to other personnel that the appropriate approach is to
A) touch the baby after looking at him
B) talk very slowly while speaking to him
C) avoid touching the child
D) look only at the parents


Review Information: The correct answer is A: touch the baby after looking at him
In many cultures, an "evil eye" is cast when looking at a person without touching him. Thus, the spell is broken by touching while looking or assessing.


Question 10
A 74 year-old male is admitted due to inability to void. He has a history of an enlarged prostate and has not voided in 14 hours. When assessing for bladder distention, the best method for the nurse to use is to assess for
A) rebound tenderness
B) left lower quadrant dullness
C) rounded swelling above the pubis
D) urinary discharge


Review Information: The correct answer is C: rounded swelling above the pubis
Swelling above the pubis is representative of a distended bladder in the male client.








Question 11
Which of these statements by the nurse is incorrect if the nurse has the goal to reinforce information about cancers to a group of young adults?
A) "You can reduce your risk of this serious type of stomach cancer by eating lots of fruits and vegetables, limiting all meat, and avoiding nitrate-containing foods."
B) "Prostate cancer is the most common cancer in American men with results to threaten sexuality and life."
C) "Colorectal cancer is the second-leading cause of cancer-related deaths in the United States."
D) "Lung cancer is the leading cause of cancer deaths in the United States. Yet it's the most preventable of all cancers."




Review Information: The correct answer is A: "You can reduce your risk of this serious type of stomach cancer by eating lots of fruits and vegetables, limiting all meat, and avoiding nitrate-containing foods."
It is recommended that only red meat be limited for the prevention of stomach cancer. All of the other statements offer correct information.
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Question 12
Which one of the following statements, if made by the client, indicates teaching about Inderal (propranolol) has been effective?
A) "I may experience seizures if I stop the medication abruptly."
B) "I may experience an increase in my heart rate for a few weeks."
C) ”I can expect to feel nervousness the first few weeks."
D) “I can have a heart attack if I stop this medication suddenly."


Review Information: The correct answer is D: “I can have a heart attack if I stop this medication suddenly."
Discontinuing beta blockers suddenly can cause angina, hypertension, dysrhythmias, or an MI.




Question 13
A 4 month-old child taking digoxin (Lanoxin) has a blood pressure of 92/78; resting pulse of 78 BPM; respirations 28 and a potassium level of 4.8 mEq/L. The client is irritable and has vomited twice since the morning dose of digoxin. Which finding is most indicative of digoxin toxicity?
A) Bradycardia
B) Lethargy
C) Irritability
D) Vomiting


Review Information: The correct answer is A: Bradycardia
The most common sign of digoxin toxicity in children is bradycardia (heart rate below 100 BPM in an infant).


Question 14
A client has been admitted for meningitis. In reviewing the laboratory analysis of cerebrospinal fluid (CSF), the nurse would expect to note
A) high protein
B) clear color
C) elevated sed rate
D) increased glucose


Review Information: The correct answer is A: high protein
A positive CSF for meningitis would include presence of protein, a positive blood culture, decreased glucose, cloudy color with an increased opening pressure, and an elevated white blood cell count.






Question 15
During the beginning shift assessment of a client with asthma who is receiving oxygen per nasal cannula at 2 liters per minute, the nurse would be most concerned about which unreported finding?
A) Pulse oximetry reading of 89%
B) Crackles at the base of the lungs on auscultation
C) Rapid shallow respirations with intermittent wheezes
D) Excessive thirst with a dry cracked tongue


Review Information: The correct answer is C: Rapid shallow respirations with intermittent wheezes
Of the given findings this has the greatest risk for potential complications. Shallow and rapid respirations may indicate that the client is losing muscle strength required to breath. The intermittent wheezes could be an indication of an increase in narrowed small airways and a worsening condition.


Question 16
A client with chronic congestive heart failure should be instructed to contact the home health nurse if which finding occurs?
A) Weight gain of 2 pounds or more in a 48 hour period
B) Urinating 4 to 5 times each day
C) A significant decrease in appetite
D) Appearance of non-pitting ankle edema


Review Information: The correct answer is A: Weight gain of 2 pounds or more in a 48 hour period
It is critical for clients to report and be treated for rapid weight gain, decreased urinary output, worsening nocturnal orthopnea, pitting ankle edema, and other findings of chronic heart failure. Hospitalization may be avoided with early intervention.


Question 17
The nurse manager has a nurse employee who is suspected of a problem with chemical dependency. Which intervention would be the best approach by the nurse manager?
A) Confront the nurse about the suspicions in a private meeting
B) Schedule a staff conference, without the nurse present, to collect information
C) Consult the human resources department about the issue and needed actions
D) Counsel the employee to resign to avoid investigation




Review Information: The correct answer is C: Consult the human resources department about the issue and needed actions
To avoid legal repercussions, the nurse needs to consult with the human resources department for proper procedure for documentation, counseling and available resources. The employee may be protected under the Americans with Disabilities Act.


Question 18
The nurse would teach a client with Raynaud's phenomenon that, after smoking cessation, it is most important to
A) avoid caffeine
B) keep feet dry
C) reduce stress
D) wear gloves


Review Information: The correct answer is A: avoid caffeine
The most important teaching for this client is avoid caffeine after stopping smoking. The question is asking what is the most important teaching. The other approaches tend to be needed less frequently and so are less of a priority.










Question 19
The nurse is caring for a 4 year-old child with a greenstick fracture. In explaining this type of fracture to the parents, the best statement by the nurse should be that,
A) "A child's bone is more flexible and can be bent 45 degrees before breaking."
B) "Bones of children are more porous than adults’ and often have incomplete breaks."
C) "Compression of porous bones produces a buckle or torus type break."
D) "Bone fragments often remain attached by a periosteal hinge."


Review Information: The correct answer is B: "Bones of children are more porous than adults’ and often have incomplete breaks."
This allows the pliable bones of growing children to bend, buckle, and break in a "greenstick" manner. A greenstick fracture occurs when a bone is angulated beyond the limits of bending. The compressed side bends and the tension side fails, causing an incomplete fracture.


Question 20
While assessing an Rh positive newborn whose mother is Rh negative, the nurse recognizes the risk for hyperbilirubinemia. Which of the following should be reported immediately?
A) Jaundice evident at 26 hours
B) Hematocrit of 55%
C) Serum bilirubin of 12mg
D) Positive Coombs' test


Review Information: The correct answer is C: Serum bilirubin of 12mg
The elevated bilirubin is in the range that requires immediate intervention, such as phototherapy. At a serum bilirubin of 12 mg., the neonate is at risk for the development of kernicterus, or bilirubin encephalopathy. The provider determines the therapy appropriate after reviewing all laboratory findings.





Question 21
The nurse is teaching a client with cardiac disease about the anatomy and physiology of the heart. Which is the correct pathway of blood flow through the heart?
A) Right ventricle, left ventricle, right atrium, left atrium
B) Left ventricle, right ventricle, left atrium, right atrium
C) Right atrium, right ventricle, left atrium, left ventricle
D) Right atrium, left atrium, right ventricle, left ventricle


Review Information: The correct answer is C: Right atrium, right ventricle, left atrium, left ventricle
This is the pathway of blood flow through the heart.


Question 22
The nurse uses the DRG (Diagnosis Related Group) manual to
A) classify nursing diagnoses from the client's health history
B) identify findings related to a medical diagnosis
C) determine reimbursement for a medical diagnosis
D) implement nursing care based on case management protocol


Review Information: The correct answer is C: determine reimbursement for a medical diagnosis
DRG''s are the basis of prospective payment plans for reimbursement for Medicare clients.






Question 23
A client comes into the community health center upset and crying stating “I will die of cancer now that I have this disease.” And then the client hands the nurse a paper with one word written on it: "Pheochromocytoma." Which response should the nurse state initially?
A) "Pheochromocytomas usually aren't cancerous (malignant). But they may be associated with cancerous tumors in other endocrine glands such as the thyroid (medullary carcinoma of the thyroid)"
B) This problem is diagnosed by blood and urine tests that reveal elevated levels of adrenaline and noradrenaline
C) "Computerized tomography (CT) or magnetic resonance imaging (MRI) are used to detect an adrenal tumor"
D) "You probably have had episodes of sweating, heart pounding and headaches"




Review Information: The correct answer is A: "Pheochromocytomas usually aren''t cancerous (malignant). But they may be associated with cancerous tumors in other endocrine glands such as the thyroid (medullary carcinoma of the thyroid)"
All of the options are correct information. The best response of the nurse is to address the issue presented by the client “fear of cancer.” Pheochromocytomas may release large amounts of adrenaline into the bloodstream after an injury or during surgery. For this reason, they can be life-threatening if unrecognized or untreated.










Question 24
The hospital is planning to downsize and eliminate a number of staff positions as a cost-saving measure. To assist staff in this change process, the nurse manager is preparing for the "unfreezing" phase of change. With this approach the nurse manager should:
A) discuss with the staff how to deal with any defensive behavior
B) explain to the unit staff why change is necessary
C) assist the staff during the acceptance of the new changes
D) clarify what the changes mean to the community and hospital


Review Information: The correct answer is B: explain to the unit staff why change is necessary
The first phase of change, unfreezing, begins with awareness of the need for change. This can be facilitated by the manager who clearly understands the need and stands behind it. The phase is completed when staff comprehend the need for change.


Question 25
A child and his family were exposed to Mycobacterium tuberculosis about 2 months ago, to confirm the presence or absence of an infection, it is most important for all family members to have a
A) chest x-ray
B) blood culture
C) sputum culture
D) PPD intradermal test


Review Information: The correct answer is D: PPD intradermal test
The administration of the PPD intradermal test determines the presence of the infection with the Mycobacterium tuberculosis organism. It is effective at 3 to 6 weeks after the initial infection.





Question 26
During the care of a client with Legionnaire's disease, which finding would require the nurse's immediate attention?
A) Pleuritic pain on inspiration
B) Dry mucus membranes in the mouth
C) A decrease in respiratory rate from 34 to 24
D) Decrease in chest wall expansion


Review Information: The correct answer is D: Decrease in chest wall expansion
The respiratory status of a client with this acute bacterial pneumonia known as Legionnaires'' disease is critical. Note that all of these findings would be of concern -- the task is to select the priority. Chest wall expansion reflects a possible decrease in the depth and effort of respirations. Further findings of restlessness may indicate hypoxemia. If these occurred the client may then need mechanical ventilation. Option A is expected with such infections of the lung. Option B indicates dehydration which may result in


Question 27
The school nurse is called to the playground for an episode of mouth trauma. The nurse finds that the front tooth of a 9 year-old child has been avulsed ("knocked out"). After recovering the tooth, the initial response should be to
A) rinse the tooth in water before placing it in the socket
B) place the tooth in a clean plastic bag for transport to the dentist
C) hold the tooth by the roots until reaching the emergency room
D) ask the child to replace the tooth even if the bleeding continues


Review Information: The correct answer is A: rinse the tooth in water before placing it in the socket
Following avulsion of a permanent tooth, it is important to rinse the dirty tooth in water, saline solution or milk before re-implantation. If possible, replace the tooth in its socket within 30 minutes, avoiding contact with the root. The child should be taken to the dentist as soon as possible.




Question 28
A hospitalized child suddenly has a seizure while his family is visiting. The nurse notes whole body rigidity followed by general jerking movements. The child vomits immediately after the seizure. A priority nursing diagnosis for the child is
A) high risk for infection related to vomiting
B) altered family processes related to chronic illness
C) fluid volume deficit related to vomiting
D) risk for aspiration related to loss of consciousness


Review Information: The correct answer is D: risk for aspiration related to loss of consciousness
The tonic-clonic seizure appears suddenly and often leads to brief loss of consciousness. The greatest risk for the child is from airway blockage, as might follow aspiration.


Question 29
A female client diagnosed with genital herpes simplex virus 2 (HSV 2) complains of dysuria, dyspareunia, leukorrhea and lesions on the labia and perianal skin. A primary nursing action with the focus of comfort should be to
A) suggest 3 to 4 warm sitz baths per day
B) cleanse the genitalia twice a day with soap and water
C) spray warm water over genitalia after urination
D) apply heat or cold to lesions as desired


Review Information: The correct answer is A: suggest 3 to 4 warm sitz baths per day
Frequent sitz baths may sooth the area and reduce inflammation. The other actions are correct actions however, they would not address the entire group of findings.





Question 30
An 82 year-old client is prescribed eye drops for treatment of glaucoma. What assessment is needed before the nurse begins teaching proper administration of the medication?
A) Determine third party payment plan for this treatment
B) The client’s manual dexterity
C) Proximity to health care services
D) Ability to use visual assistive devices




Review Information: The correct answer is B: The client’s manual dexterity
Inability to self administer eye drops is a common problem among the elderly due to decreased finger dexterity.


Question 31
The nurse is caring for a client on mechanical ventilation. When performing endotracheal suctioning, the nurse will avoid hypoxia by
A) inserting a fenestrated catheter with a whistle tip without suction
B) completing suction pass in 30 seconds with pressure of 150 mm Hg
C) hyperoxygenation with 100% O2 for 1 to 2 minutes before and after each suction pass
D) minimizing suction pass to 60 seconds while slowly rotating the lubricated catheter


Review Information: The correct answer is C: hyperoxygenation with 100% O2 for 1 to 2 minutes before and after each suction pass
Administer supplemental 100% oxygen through the mechanical ventilator or manual resuscitation bag for 1 to 2 minutes before, after and between suctioning passes to prevent hypoxemia.






Question 32
Which finding would be the most characteristic of an acute episode of reactive airway disease?
A) auditory gurgling
B) inspiratory laryngeal stridor
C) auditory expiratory wheezing
D) frequent dry coughing




Review Information: The correct answer is C: auditory expiratory wheezing
In an acute episode of reactive airway disease, breathing is likely to be characterized by wheezing on expiration. This sound is made as air is forced through the narrowed passages and often can be heard by the naked ear without a stethoscope.


Question 33
The nurse and a student nurse are discussing the specific points about infants born to HBsAg-positive mothers. Which of these comments by the student indicates a need for clarification of information?
A) "The infant will get the hepatitis B vaccine and the hepatitis B immune globulin within 12 hours at birth at separate injection sites."
B) "The second dose can be given at 1 to 2 months of age."
C) "The third dose should be given at least 16 weeks from the second dose."
D) "The last dose in the series is not to be given before age 24 weeks."


Review Information: The correct answer is C: "The third dose should be given at least 16 weeks from the second dose."
The third dose is to be given 16 weeks from the first dose and 8 weeks from the second dose. All of the other options are correct information. These infants will also need to have the blood tested for hepatitis titers and antibodies between 9 and 15 months.





Question 34
The nurse is caring for a client with status epilepticus. The most important nursing assessment(s) of this client is/are
A) intravenous drip rate
B) level of consciousness
C) pulse and respiration
D) injuries to the extremities




Review Information: The correct answer is B: level of consciousness
Cerebral blood flow undergoes a 250% increase during seizure activity depleting oxygen at the neuronal level. Cerebral anoxia may result in progressive brain tissue injury and destruction. The nurse should monitor the client’s level of consciousness continuously. Even when seizures are controlled, the client may be unconscious for a while.


Question 35
At a routine health assessment, a client tells the nurse that she is planning a pregnancy in the near future. She asks about pre-conception diet changes. Which of the statements made by the nurse is best?
A) "Include fibers in your daily diet."
B) "Increase green leafy vegetable intake."
C) "Drink a glass of milk with each meal."
D) "Eat at least 1 serving of fish weekly."


Review Information: The correct answer is B: "Increase green leafy vegetable intake."
Folic acid sources should be included in the diet and are critical in the pre-conceptual and early gestational periods to foster neural tube development and prevent birth defects such as spina bifida.






Question 36
A client returned from surgery for a perforated appendix with localized peritonitis. In view of this diagnosis, how would the nurse position the client?
A) Prone
B) Dorsal recumbent
C) Semi-Fowler
D) Supine


Review Information: The correct answer is C: Semi-Fowler
The semi-Fowler position assists drainage and prevents spread of infection throughout the abdominal cavity.


Question 37
A 6 month-old infant who is being treated for developmental dysplasia of the hip has been placed in a hip spica cast. The nurse should teach the parents to
A) gently rub the skin with a cotton swab to relieve itching
B) place the favorite books and push-pull toys in the crib
C) check every few hours for the next day or 2 for swelling in the baby's feet
D) turn the baby with the abduction stabilizer bar every 2 hours


Review Information: The correct answer is C: check every few hours for the next day or 2 for swelling in the baby''s feet
A child in a hip spica cast must be checked for circulatory impairment. The extremities are observed for swelling, discoloration, movement and sensation. For children beyond the neonatal period, traction and/or surgery followed by hip spica casting are usually needed.






Question 38
A client is admitted for COPD. Which findings would require the nurse's immediate attention?
A) Nausea and vomiting
B) Restlessness and confusion
C) Low-grade fever and cough
D) Irritating cough and liquefied sputum




Review Information: The correct answer is B: Restlessness and confusion
Respiratory failure may be signaled by excessive somnolence, restless, aggressiveness, confusion, central cyanosis and shortness of breath. When these findings occur, arterial blood gases (ABGs) should be obtained.


















Question 39
Which of these tests would the nurse expect to monitor for the evaluation of clients aged 18 and older with poor glycemic control?
A) A glycosylated hemoglobin (A1c) should be performed during an initial assessment and during follow-up assessments, which should occur at no longer than 3-month intervals
B) A glycosylated hemoglobin is to be obtained at least twice a year
C) A fasting glucose and a glycosylated hemoglobin is to be obtained at 3 months intervals after the initial assessment
D) A glucose tolerance test, a fasting glucose and a glycosylated hemoglobin should be obtained at 6-month intervals after the initial assessment




Review Information: The correct answer is A: A glycosylated hemoglobin (A1c) should be performed during an initial assessment and during follow-up assessments, which should occur at no longer than 3-month intervals
The American Diabetes Association (ADA) recommends obtaining a glycosylated hemoglobin during an initial assessment and then routinely as part of continuing care. In the absence of well-controlled studies that suggest a definite testing protocol, expert opinion recommends glycosylated hemoglobin be obtained at least twice a year in patients who are meeting treatment goals and who have stable glycemic control and more frequently (quarterly assessment) in patients whose therapy was changed or who are not meeting glycemic goals. The goals for persons with diabetes define the target A1c level as less than or equal to 6.5% or less than 7.0%. American Association of Clinical Endocrinologists/American College of Endocrinology (AACE/ACE) recommends that a glycosylated hemoglobin be performed during an initial assessment and during follow-up assessments, which should occur at no longer than three-month intervals. Most would agree, however, that an A1c level greater than 9.0% is poor control for all patient types.







Question 40
The nurse is assessing a newborn the day after birth. A high pitched cry, irritability and lack of interest in feeding are noted. The mother signed her own discharge against medical advice. What intervention is appropriate nursing care?
A) Reduce the environmental stimuli
B) Offer formula every 2 hours
C) Talk to the newborn while feeding
D) Rock the baby frequently


Review Information: The correct answer is A: Reduce the environmental stimuli
This newborn appears to be withdrawing from substances taken by the mother before its birth. Reducing noise and light will reduce the central nervous system responses to stimuli.

NEW Free NCLEX-RN Sample Test Questions For Nursing Review (Part 8)

A client is scheduled to have a blood test for cholesterol and triglycerides the next day. The nurse would tell the client
A) "Be sure and eat a fat-free diet until the test."
B) "Do not eat or drink anything but water for 12 hours before the
blood test."
C) "Have the blood drawn within 2 hours of eating breakfast."
D) "Stay at the laboratory so 2 blood samples can be drawn an hour
apart."


Review Information: The correct answer is B: "Do not eat or drink anything but water for 12 hours before the blood test."
Blood lipid levels should be measured on a fasting sample.


Question 2
A woman who delivered 5 days ago and had been diagnosed with pregnancy induced hypertension (PIH) calls the hospital triage nurse hotline to ask for advice. She states, “I have had the worst headache for the past 2 days. It pounds and by the middle of the afternoon everything I look at looks wavy. Nothing I have taken helps.” What should the nurse do next?
A) Advise the client that the swings in her hormones may have that effect. However, suggest for her to call her provider within the next day.
B) Advise the client to have someone bring her to the emergency room as soon as possible.
C) Ask the client to stay on the line, get the address and send an ambulance to the home.
D) Ask what the client has taken? How often? Ask about other specific complaints.


Review Information: The correct answer is C: Ask the client to stay on the line, get the address and send an ambulance to the home.
The woman is at risk for seizure activity. The ambulance needs to bring the woman to the hospital. For at risk clients, PIH (preeclampsia and eclampsia) may occur prior to, during or after delivery. After delivery, the window of time can be up to ten days.


Question 3
A client has been taking alprazolam (Xanax) for 3 days. Nursing assessment should reveal which expected effect of the drug?
A) Tranquilization, numbing of emotions
B) Sedation, analgesia
C) Relief of insomnia and phobias
D) Diminished tachycardia and tremors associated with anxiety




Review Information: The correct answer is A: Tranquilization, numbing of emotions
The anti-anxiety drugs produce tranquilizing effects and may numb the emotions.


Question 4
A confused client has been placed in physical restraints by order of the provider. Which task could be assigned to an unlicensed assistive personnel (UAP)?
A) Assist the client with activities of daily living
B) Monitor the clients physical safety
C) Evaluate for basic comfort needs
D) Document mental status and muscle strength


Review Information: The correct answer is A: Assist the client with activities of daily living
The person to whom the activity is delegated must be capable of performing it . The UAP is capable of assisting clients with basic needs.


Question 5
The nurse is caring for an acutely ill 10 year-old client. Which of the following assessment findings would require the nurses immediate attention?
A) Rapid bounding pulse
B) Temperature of 101.3 degrees Fahrenheit (38.5 degrees Celsius)
C) Profuse diaphoresis
D) Slow, irregular respirations


Review Information: The correct answer is D: Slow, irregular respirations
A slow and irregular respiratory rate is a sign of fatigue in an acutely ill child. Fatigue can rapidly lead to respiratory arrest.


Question 6
While caring for a child with Reye's syndrome, the nurse should give which action the highest priority?
A) monitor intake and output
B) provide good skin care
C) assess level of consciousness
D) assist with range of motion


Review Information: The correct answer is C: assess level of consciousness
An altered level of consciousness suggests increasing intracranial pressure related to cerebral edema.


Question 7
A client on warfarin therapy following coronary artery stent placement calls the clinic to ask if he can take Alka-Seltzer for an upset stomach. What is the best response by the nurse?
A) Avoid Alka-Seltzer because it contains aspirin
B) Take Alka-Seltzer at a different time of day than the warfarin
C) Select another antacid that does not inactivate warfarin
D) Use on-half the recommended dose of Alka-Seltzer


Review Information: The correct answer is A: Avoid Alka-Seltzer because it contains aspirin
Alka-Seltzer is an over-the-counter aspirin-antacid combination. Aspirin, an antiplatelet drug, will potentiate the anticoagulant effect of warfarin, which may result in excess bleeding.




Question 8
A 67 year-old client with non-insulin dependent diabetes should be instructed to contact the out-patient clinic immediately if the following findings are present
A) Temperature of 99.5 degrees Fahrenheit with painful urination
B) An open, reddened wound on the heel
C) Insomnia and daytime fatigue
D) Nausea with 2 episodes of vomiting


Review Information: The correct answer is B: An open, reddened wound on the heel
When signs of trauma and/or infection occur in their feet, elderly clients who have diabetes and/or vascular disease should seek health care quickly and continue treatment until the problem is resolved. Without treatment, serious infection, gangrene, limb loss, and death may result.


Question 9
The nurse is caring for a client with active tuberculosis who has a history of noncompliance. Which of the following actions by the nurse would represent appropriate care for this client?
A) Instruct the client to wear a high efficiency particulate air mask in public places.
B) Ask a family member to supervise daily compliance
C) Schedule weekly clinic visits for the client
D) Ask the health care provider to change the regimen to fewer medications


Review Information: The correct answer is B: Ask a family member to supervise daily compliance
Direct-observed therapy (DOT) is a recognized method for ensuring client compliance to the drug regimen. A program can be set up to directly observe the client taking the medication in the clinic, home, workplace or other convenient location.





Question 10
The nurse is caring for a client with Rheumatoid Arthritis. Which nursing diagnosis should receive priority in the plan of care?
A) Risk for injury
B) Self care deficit
C) Alteration in comfort
D) Alteration in mobility




Review Information: The correct answer is C: Alteration in comfort
Relieving pain is the number one objective of this client''s plan of care.


Question 11
A client with hepatitis A (HAV) is newly admitted to the unit. Which action would be the priority to include in this client’s plan of care within the initial 24 hours?
A) Wear masks with shields if there is potential for fluid splash
B) Use disposable utensils and plates for meals
C) Wear gown and gloves during client contact
D) Provide soft easily digested food with frequent snacks




Review Information: The correct answer is C: Wear gown and gloves during client contact
HAV is usually transmitted via the fecal-oral route, i.e., someone with the virus handles food without washing his or her hands after using the bathroom. The virus can also be contracted by drinking contaminated water, eating raw shellfish from water polluted with sewage or by being in close contact with a person who''s infected — even if that person has no signs and symptoms. In fact, the disease is most contagious before signs and symptoms ever appear. The nurse should recognize the importance of isolation precautions from the initial contact with the client on admission until the noncontagious convalescence period.






Question 12
The nurse is teaching a group of adults about modifiable cardiac risk factors. Which of the following should the nurse focus on first?
A) Weight reduction
B) Stress management
C) Physical exercise
D) Smoking cessation


Review Information: The correct answer is D: Smoking cessation
Stopping smoking is the priority for clients at risk for cardiac disease, because of its effects of reducing oxygenation and constricting blood vessels.


Question 13
A parent tells the nurse that their 6 year-old child who normally enjoys school, has not been doing well since the grandmother died 2 months ago. Which statement most accurately describes thoughts on death and dying at this age?
A) Death is personified as the bogeyman or devil
B) Death is perceived as being irreversible
C) The child feels guilty for the grandmother's death
D) The child is worried that he, too, might die


Review Information: The correct answer is A: Death is personified as the bogeyman or devil
Personification of death is typical of this developmental level.


Question 14
The nurse is caring for a 75 year old client in congestive heart failure. Which finding suggests that digitalis levels should be reviewed?
A) Extreme fatigue
B) Increased appetite
C) Intense itching
D) Constipation




Review Information: The correct answer is A: Extreme fatigue
Extreme fatigue and weakness are common, early signs of digitalis toxicity, which would be confirmed by a high blood serum level of digitalis.


Question 15
The community health nurse has been caring for an adolescent with a history of morbid obesity, asthma, and hypertension, and is 22 weeks pregnant. Which of these lab reports need to be called to the teen’s provider within the next hour?
A) hemoglobin 11 g/L and calcium 6 mg/dl
B) magnesium 0.8 mEq/L and creatinine 3 mg/dl
C) blood urea nitrogen 28 and glucose 225 mg/dl
D) hematocrit 33% and platelets 200,000


Review Information: The correct answer is B: magnesium 0.8 mEq/L and creatinine 3 mg/dl
The magnesium is low and the creatinine is high which indicates renal failure. With the history of hypertension, the findings exhibit the risk of preeclampsia. The client’s lab values are all abnormal except for the platelets. The client needs to be referred for immediate follow up with a provider.


Question 16
A pre-term baby develops nasal flaring, cyanosis and diminished breath sounds on one side. The provider's diagnosis is spontaneous pneumothorax. Which procedure should the nurse prepare for first?
A) Cardiopulmonary resuscitation
B) Insertion of a chest tube
C) Oxygen therapy
D) Assisted ventilation




Review Information: The correct answer is B: Insertion of a chest tube
Because a portion of the lung has collapsed, a chest tube will be inserted to restore negative pressure in the chest cavity.


Question 17
A nurse who is a native English speaker admits an elderly Mexican-American migrant worker after an accident that occurred during work. To facilitate communication the nurse should initially
A) Request a Spanish interpreter
B) Speak through the family or co-workers
C) Use pictures, letter boards, or monitoring
D) Assess the client's ability to speak English




Review Information: The correct answer is D: Assess the client''s ability to speak English
Despite the cultural heritage, the nurse cannot make assumptions. Stereotyping is to be avoided. The nurse should assess the client''s comfort and ability in speaking English.


Question 18
The nurse is teaching a client with atrial fibrillation about the use of Coumadin (warfarin) at home. The need to avoid which of these should be emphasized to the client?
A) Large indoor gatherings
B) Exposure to sunlight
C) Active physical exercise
D) Foods rich in vitamin K


Review Information: The correct answer is D: Foods rich in vitamin K
Vitamin K acts as an antidote to the pharmacologic action of Coumadin therapy, decreasing Coumadin''s effectiveness. Foods high in vitamin K include dark greens, tomatoes, bananas, cheese, and fish.







Question 19
A child is diagnosed with poison ivy. The mother tells the nurse that she does not know how her child contracted the rash since he had not been playing in wooded areas. As the nurse asks questions about possible contact, which of the following would the nurse recognize as highest risk for exposure?
A) Playing with toys in a back yard flower garden
B) Eating small amounts of grass while playing "farm"
C) Playing with cars on the pavement near burning leaves
D) Throwing a ball to a neighborhood child who has poison ivy




Review Information: The correct answer is C: Playing with cars on the pavement near burning leaves
Smoke from burning leaves or stems of the poison ivy plant can produce a reaction. Direct contact with the toxic oil, urushiol, is the most common cause for this dermatitis.


Question 20
In assessing a post partum client, the nurse palpates a firm fundus and observes a constant trickle of bright red blood from the vagina. What is the most likely cause of these findings?
A) Uterine atony
B) Genital lacerations
C) Retained placenta
D) Clotting disorder


Review Information: The correct answer is B: Genital lacerations
Continuous bleeding in the absence of a boggy fundus indicates undetected genital tract lacerations.




Question 21
To prevent keratitis in an unconscious client, the nurse should apply moisturizing ointment to the
A) finger and toenail quicks
B) eyes
C) perianal area
D) external ear canals




Review Information: The correct answer is B: eyes
Keratitis is a corneal ulcer or abrasion. Keratitis is caused by exposure and requires application of moisturizing ointment to the exposed cornea and a plastic bubble shield or eye patch.


Question 22
A nurse manager is using the technique of brainstorming to help solve a problem. One nurse criticizes another nurse’s contribution and begins to find objections to the suggestion. The nurse manager's best response is:
A) "Let’s move on to a new action that deals with the problem."
B) "I think you need to reserve judgment until after all suggestions are offered."
C) "Very well thought out. Your analytic skills and interest are incredible."
D) "Let’s move to the ‘what if…’ as related to these objections and explore spin off ideas."


Review Information: The correct answer is D: "Let’s move to the ‘what if…’ as related to these objections and explore spin off ideas."
The goal of brainstorming is to gather as many ideas as possible without judgment that slows the creative process and may discourage innovative ideas. Exploration of the nurses objections would encourage the generation of new ideas.


Question 23
An infant has just returned from surgery for placement of a gastrostomy tube as an initial treatment for tracheoesophageal fistula. The mother asks: ”When can the tube can be used for feeding?” The nurse's best response would be which of these comments?
A) "Feedings can begin in 5 to 7 days."
B) "The feeding tube can be used immediately."
C) "The stomach contents and air must be drained first."
D) "Healing of the incision must be complete before feeding."




Review Information: The correct answer is C: "The stomach contents and air must be drained first."
After surgery for gastrostomy tube placement, the catheter is left open and attached to gravity drainage for 24 hours or more.


Question 24
A client who is terminally ill has been receiving high doses of an opioid analgesic for the past month. As death approaches and the client becomes unresponsive to verbal stimuli, what orders would the nurse expect from the health care provider?
A) Decrease the analgesic dosage by half
B) Discontinue the analgesic
C) Continue the same analgesic dosage
D) Prescribe a less potent drug


Review Information: The correct answer is C: Continue the same analgesic dosage
Dying patients who have been in chronic pain will probably continue to experience pain even though they cannot communicate their experience. Pain medication should be continued at the same dose, if effective.









Question 25
The nurse is working with parents to plan home care for a 2 year-old with a heart problem. A priority nursing intervention would be to
A) encourage the parents to enroll in cardiopulmonary resuscitation (CPR) class
B) assist the parents to plan quiet play activities at home
C) stress to the parents that they will need relief care givers
D) instruct the parents to avoid contact with persons with infection




Review Information: The correct answer is A: encourage the parents to enroll in cardiopulmonary resuscitation (CPR) class
While all suggestions are appropriate, the education of the parents/caregivers should include techniques of cardiopulmonary resuscitation in order to provide for emergency care of their child.


Question 26
A nurse caring for premature newborns in an intensive care setting carefully monitors oxygen concentration. What is the most common complication of this therapy?
A) Intraventricular hemorrhage
B) Retinopathy of prematurity
C) Bronchial pulmonary dysplasia
D) Necrotizing enterocolitis


Review Information: The correct answer is B: Retinopathy of prematurity
While there are other causes for retinal damage in the premature infant, maintaining the oxygen concentration below 40% reduces this important risk factor.







Question 27
The nurse observes a staff member caring for a client with a left unilateral mastectomy. The nurse would intervene if she notices the staff member is
A) advising client to restrict sodium intake
B) taking the blood pressure in the left arm
C) elevating her left arm above heart level
D) compressing the drainage device


Review Information: The correct answer is B: taking the blood pressure in the left arm
Clients who have had a unilateral mastectomy should not have their blood pressure measured on the affected side. This helps avoid the possibility of lymphedema post-operatively and in the future.


Question 28
Which of these clients would the triage nurse request the provider examine immediately?
A) A 5 month-old infant who has audible wheezing and grunting
B) An adolescent who has soot over the face and shirt
C) A middle-aged man with second degree burns over the right hand
D) A toddler with singed ends of long hair that extends to the waist


Review Information: The correct answer is A: A 5 month-old infant who has audible wheezing and grunting
The age and the findings suggest this client is at immediate risk for respiratory complications.


Question 29
The nurse is assessing a client with portal hypertension. Which of the following findings would the nurse expect?
A) Expiratory wheezes
B) Blurred vision
C) Ascites
D) Dilated pupils


Review Information: The correct answer is C: Ascites
Portal hypertension can occur in a client with right-sided heart failure or cirrhosis of the liver. Portal hypertension can lead to ascites due to the increased portal pressure as well as a lowered colloid osmotic pressure because of low albumin. When liver functioning deteriorates, protein metabolism suffers.


Question 30
The primary teaching for a client following an extracorporeal shock-wave lithotripsy (ESWL) procedure is
A) "Drink 3000 to 4000 cc of fluid each day for one month."
B) "Limit fluid intake to 1000 cc each day for one month."
C) "Increase intake of citrus fruits to three servings per day."
D) "Restrict milk and dairy products for one month."


Review Information: The correct answer is A: "Drink 3000 to 4000 cc of fluid each day for one month."
Drinking three to four quarts (3000 to 4000 cc) of fluid each day will aid passage of fragments and help prevent formation of new calculi.


Question 31
A newborn presents with a pronounced cephalhematoma following a birth in the posterior position. Which nursing diagnosis should guide the plan of care?
A) Pain related to periosteal injury
B) Impaired mobility related to bleeding
C) Parental anxiety related to knowledge deficit
D) Injury related to intracranial hemorrhage




Review Information: The correct answer is C: Parental anxiety related to knowledge deficit
This hematoma is related to pressure at the time of labor and birth. The condition resolves within a few days. Parental anxiety must be addressed by listening to their fears and explaining the nature of this common alteration.


Question 32
The nurse manager identifies that time spent by staff in charting is excessive, requiring overtime for completion. The nurse manager states that "staff will form a task force to investigate and develop potential solutions to the problem, and report on this at the next staff meeting." The nurse manager's leadership style is best described as
A) Laissez-faire
B) Autocratic
C) Participative
D) Group


Review Information: The correct answer is C: Participative
A participative style of management involves staff in decision-making processes. Staff/manager interactions are open and trusting. Most work efforts are joint endeavors.


Question 33
The nurse notes an abrupt onset of confusion in an elderly patient. Which of the following recently-ordered medications would most likely contribute to this change?
A) Anticoagulant
B) Liquid antacid
C) Antihistamine
D) Cardiac glycoside


Review Information: The correct answer is C: Antihistamine
Elderly people are susceptible to the side effect of anticholinergic drugs, such as antihistamines. Antihistamines often cause confusion in the elderly, especially at high doses.






Question 34
The nurse is caring for a 5 year-old child whose left leg is in skeletal traction. Which of the following activities would be an appropriate diversional activity?
A) Kicking balloons with right leg
B) Playing "Simon Says"
C) Playing hand held games
D) Throw bean bags




Review Information: The correct answer is C: Playing hand held games
Immobilization with traction must be maintained until bone ends are in satisfactory alignment. Activities that increase mobility interfere with the goals of treatment.


Question 35
The nurse has identified what appears to be ventricular tachycardia on the cardiac monitor of a client being evaluated for possible myocardial infarction. The first action the nurse would perform is to
A) begin cardiopulmonary resuscitation
B) prepare for immediate defibrillation
C) notify the "Code" team and provider
D) assess airway breathing and circulation


Review Information: The correct answer is D: assess airway breathing and circulation
The nurse must first assess the client to determine the appropriate next step. In this case the first step the nurse must take is to evaluate the A, B, C''s.








Question 36
A 70 year-old post-operative client has elevated serum BUN, HCT, Cl, and Na+. Creatinine and K+ are within normal limits. The nurse should perform additional assessments to confirm that an actual problem is:
A) Impaired gas exchange
B) Metabolic acidosis
C) Renal insufficiency
D) Fluid volume deficit




Review Information: The correct answer is D: Fluid volume deficit
In fluid volume deficit, serum BUN, Na+ and hematocrit may be elevated secondary to hemoconcentration.


Question 37
The nurse is teaching a 27 year-old client with asthma about their therapeutic regime. Which statement would indicate the need for additional instruction?
A) "I should monitor my peak flow every day."
B) "I should contact the clinic if I am using my medication more often."
C) "I need to limit my exercise, especially activities such as walking and running."
D) "I should learn stress reduction and relaxation techniques."




Review Information: The correct answer is C: "I need to limit my exercise, especially activities such as walking and running."
Limiting physical activity in an otherwise healthy, young client should not be necessary. If exercise intolerance exists, the asthma management plan should include specific medications to treat the problem such as using an inhaled beta-agonist 5 minutes before exercise. The goal is always to return to a normal lifestyle.







Question 38
The nurse is providing foot care instructions to a client with arterial insufficiency. The nurse would identify the need for additional teaching if the client stated
A) "I can only wear cotton socks."
B) "I cannot go barefoot around my house."
C) "I will trim corns and calluses regularly."
D) "I should ask a family member to inspect my feet daily."




Review Information: The correct answer is C: "I will trim corns and calluses regularly."
Clients who are elderly, have diabetes, and/or have vascular disease often have decreased circulation and sensation in one or both feet. Their vision may also be impaired. Therefore, they need to be taught to examine their feet daily or have someone else do so. They should wear cotton socks which have not been mended, and always wear shoes when out of bed. They should not cut their nails, corns, and calluses, but should have them trimmed by their provider, nurse, or another provider who specializes in foot care.


Question 39
A nursing student asks the nurse manager to explain the forces that drive health care reform. The appropriate response by the nurse manager should include
A) The escalation of fees with a decreased reimbursement percentage
B) High costs of diagnostic and end-of-life treatment procedures
C) Increased numbers of elderly and of the chronically ill of all ages
D) A steep rise in provider fees and in insurance premiums


Review Information: The correct answer is A: The escalation of fees with a decreased reimbursement percentage
The percentage of the gross national product representing health care costs rose dramatically with reimbursement based on fee for service. Reimbursement for Medicare and Medicaid recipients based on fee for service also escalates health care costs.


Question 40
The nurse is caring for a child with cystic fibrosis. The nurse would anticipate that the child would be deficient in which vitamins?
A) B, D, and K
B) A, D, and K
C) A, C, and D
D) A, B, and C


Review Information: The correct answer is B: A, D, and K
The uptake of fat soluble vitamins is decreased in children with Cystic Fibrosis. Vitamins A, D, and K are fat soluble and are likely to be deficient in clients with Cystic Fibrosis.

ebooks and books for Nursing School




Written for undergraduate or graduate students, this valuable text will help develop critical thinking skills and the knowledge needed to ensure an evidence-based and theory-based nursing practice. What sets this book apart from others is that chapters are written by the actual theorists themselves, along with chapters written by practicing nurses that explain how the theories presented can be applied.




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Providing guidelines on the construction of care plans for various psychiatric clients is the focus of this text. This remains the most complete, easy-to-use resource available to help students develop practical, individual care plans. The concepts can be applied to various types of health-care setting from inpatient hospitalization, outpatient clinic, home health, and private practice.


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Looking For RNs for Santa Monica Healthcare Systems

Do you have what it takes to be the best nurse for the job? Want to join the team of highly dedicated individuals that provides the most comprehensive and advanced healthcare systems.

Check out our job openings and listings and be a part of our team today:

RN, PICU/PED's: Our Medical Center and Orthopaedic Hospital is accepting applications for our Pediatric Unit. Current CA RN License required. BCLS Certification required. Training programs for non PICU RN's will be provided. $44.88 / $7809 Maximum, $31.41 / $5466 Minimum To learn more or apply, please go to RN PICU Ped's

Experienced Nurse-Resource Team: As a RN's on the Resource Team you will float between patient care areas at all of our facilities. This is a per diem position. Maximum $58.63 / $10202 $54.63 / $9506 minimum To learn more or apply, please go to RN Resource Nurse


Experienced Nurse- Emergency Medicine:Qualifications Current CA RN license required. ACLS/BLS Certification required. Experienced Nurses are welcome to apply. Training Programs are available. New grad programs are also available. Maximum $44.00 / $7656 $30.80 / $5359 minimum

Unit Director Neuro Surgery: Functions are in the areas of management, clinical and leadership responsibilities. Management responsibilities include assessment, planning and evaluating unit staffing, nursing care and unit management. Operate within budgeted parameters for staffing, and supplies. Monitor established standards for the environment for patient care and safety. Graduation from an accredited School of Nursing and current, active California R.N. licensure. To learn more or apply, please go to Unit Director Neuro Surgery

Clinical Nurse Specialist -Pulmonary Hypertension: The Clinical Nurse V is a Clinical Nurse Specialist (CNS) with educational preparation at a minimum of a Master's degree in Nursing that includes the five components of the CNS role (practitioner, educator, administrator/manager, consultant, researcher). In addition, the CNS is certified by the California BRN to practice as a CNS. Maximum $57.57 / $10,017 Minimum $32.04 / $5,575 To learn more about this position, please go to Clinical Nurse Pulmonary Hypertension


RN- PDRN - ER Level 1 Trauma Center: Under general supervision provide professional nursing care of patients in a Level 1 Trauma ER. Assess, plan, develop, implement and evaluate patient care plans. Provide guidance to team members by supervising nursing interventions and assigning related tasks. Assess patient, family and staff learning needs and promote effective working relationships. Current RN license. Maximum $44.00 / $7656 $30.80 / $5359 minimum To learn more or apply, please go to RN Emergency Dept

Rn Jobs In Southern California

A privately held, diversified service organization comprised of a team of innovative people dedicated to providing the highest quality care is in need of devoted nurses for the following positions:

RN OR / PACU: These registered nurses positions are for per diem shifts with multiple clients. Our client base is growing and our clients needs are growing so we have IMMEDIATE NEED for experienced OR and PACU RN's. Excellent opportunity to add to your fiancial base outside your full time position or to fill in if only want part time. THese positions are in Beverly Hills, Santa Monica and Los Angeles. To learn more or apply, please go to RN Operating Room/PACU


Chemo RN: These chemo certified registered nurses positions are for per diem shifts with multiple clients. Opportuniy to set your own schedule and see and try out new facilities. To learn more or apply, please go to Chemo RN

RN Spine Surgery Center: Provides professional and technical skills to ensure the safety, comfort, personal hygiene of al patients in the provision of patient care. Reports to the RN Manager in a Post Anasthesia Unit. Hours are Monday through Friday full time, great benefits, paid holidays (they are closed on holidays), no on-call. To learn more or apply, please go to RN Post Anathesia Unit


RN Medical Bill Auditing Specialist: Acts as a resource to Bill Review and communicates appropriate payment amounts. Develops and maintains relationships and partnerships with medical providers and facilities. Active and clear RN license. 3-5 years of clinical experience in Orthopedics, ER, Occupational Health and/or Neurology/Neurosurgery. 3-5 years of national Workers´ Compensation Bill Audit experience. Top Pay To learn more or apply, please go to RN Medical Billing Specialist


RN Pre-Op / OR Circulator / PACU: These registered nurse positions are for a surgical center specializing in spinal care. They are full-time, M-F composed of 8hr shifts, with the possiblity for over-time. Monday through Friday full time, great benefits, paid holidays. $83,000 to $100,000 per year. This position is in Bakersfield. To learn more or apply, please go to RN Pre-Op OR