NCLEX-PN Practice Questions And Answers (Solved) The nurse is administering sublingual nitroglycerin to a client. Immediately afterward, the client may experience: - throbbing headache or dizziness. A client with iron deficiency anemia has been admitted to the medical-surgical unit. Which assessment findings are characteristic of this type of anemia? - Dyspnea, tachycardia, and pallor The nurse is caring for a client taking an anticoagulant. Which instruction regarding anticoagulant therapy should the nurse give the client? - Limit foods high in vitamin K. The nurse delivers a client's 10 a.m. medications. The client is away from his room for a diagnostic study. Which action is most appropriate for the nurse to take? - Lock the medications in the medicine preparation area until the client returns. The nurse is caring for a client receiving patient-controlled analgesia (PCA) for pain management. Which statement about PCA is true? - Pain relief is initiated by the client as needed. The nurse is caring for a client with type 1 diabetes mellitus who exhibits confusion, lightheadedness, and aberrant behavior. The client is still conscious. The nurse should first administer: - 15 to 20 g of a fast-acting carbohydrate such as orange juice. The nurse is caring for an elderly female with osteoporosis. When teaching the client, the nurse should include information about which major complication? - Bone fracture The nurse is speaking to a group of women about early detection of breast cancer. The average age of the women in the group is 47. Following the American Cancer Society guidelines, the nurse should recommend that the women: - have a mammogram annually. The nurse is instructing a premenopausal woman about breast self-examination. The nurse should tell the client to do her self-examination: - immediately after her menses. The nurse is teaching a group of women to perform breast self-examination. The nurse should explain that the purpose of performing the examination is to discover: - changes from previous self-examinations. The American Cancer Society recommends routine screening to detect colorectal cancer. Which screening test for colorectal cancer should the nurse recommend? - Flexible sigmoidoscopy beginning at age 50
Which nursing diagnosis should the nurse expect to see in a care plan for a client in sickle cell crisis? - Acute pain related to sickle cell crisis What can the nurse do to prevent lipodystrophy when administering insulin to a diabetic client? - Rotate the injection sites. For a diabetic client with a foot ulcer, the physician orders bed rest, a wet-to-dry dressing change every shift, and blood glucose monitoring before meals and at bedtime. Why are the wet-to-dry dressings used for this client? - Because they debride the wound and promote healing by secondary intention. An obese client is admitted to the hospital for abusing amphetamines in an attempt to lose weight. Which nursing intervention is appropriate for this client? - Identify alternative ways for the client to lose weight. Policy and procedure dictate that hand washing is a requirement when caring for clients. Which statement about hand washing is true? - Frequent hand washing reduces transmission of pathogens from one client to another. The nurse is evaluating a postoperative client for infection. Which sign or symptom would be most indicative of infection? - Red, warm, tender incision The nurse is caring for a client with a fractured hip. The client is combative, confused, and trying to get out of bed. The nurse should: - obtain a physician's order to restrain the client when less restrictive interventions fail. The nurse is caring for a bedridden, elderly adult. To prevent pressure ulcers, which intervention should the nurse include in the care plan? - Post a turning schedule at the client's bedside. A client who has recently had surgery for prostate cancer expresses to the nurse feelings of anger toward God, his church, and the clergy. Which intervention is appropriate for this client? - Encouraging the client to discuss concerns with the clergy The nurse is working in a support group for clients with acquired immunodeficiency syndrome (AIDS). Which point about preventing transmission of the human immunodeficiency virus (HIV) is most important for the nurse to stress? - Following safersex practices The nurse is preparing to begin one-person cardiopulmonary resuscitation. The nurse should first: - establish unresponsiveness. The nurse is providing home care instructions to a client who has recently had a skin graft. It's most important that the client remember to: - protect the graft from direct sunlight.
The nurse is caring for a client who underwent a subtotal gastrectomy 24 hours earlier. The client has a nasogastric (NG) tube. The nurse should: - irrigate the NG tube gently with normal saline solution as prescribed. A client is to be discharged from an acute care facility following treatment for right leg thrombophlebitis. The nurse notes that the client's leg is pain-free, without redness or edema. The nurse's actions reflect which step of the nursing process? - Evaluation The nurse is caring for a client who recently underwent a total hip replacement. The nurse should: - limit client hip flexion while sitting. When caring for a client who's being treated for hyperthyroidism, it's important to: balance the client's periods of activity and rest. Which intervention should the nurse try first with a client who exhibits signs of sleep disturbance? - Provide the client with sleep aids, such as pillows, back rubs, and snacks. When preparing a client for an enema, the nurse should help him into the: - left-lateral Sims' position. The nurse is caring for a client with a right ankle sprain. When applying cold to the client's injury, the nurse should: - apply it immediately after the injury occurs. The nurse is teaching a client with a family history of atherosclerosis. To decrease the risk of atherosclerosis, the nurse should encourage the client to: - increase his activity level. The nurse is teaching a client diagnosed with basal cell epithelioma. The most common cause of basal cell epithelioma is: - exposure to the sun. The nurse is giving instructions to a client who's going home with a cast on his leg. Which point is most critical? - Reporting signs of impaired circulation A client undergoes a surgical procedure that requires the use of general anesthesia. Following general anesthesia, the client is most at risk for: - atelectasis. The nurse is caring for a client who recently underwent a tracheostomy. The first priority when caring for a client with a tracheostomy is: - keeping his airway patent. The nurse is working on a surgical floor. The nurse must logroll a client following a: laminectomy. A client underwent cataract removal with an intraocular lens implant. The nurse is giving the client discharge instructions. These instructions should include which of the following? - Avoid straining during bowel movements.
When caring for a client with a nursing diagnosis of Impaired swallowing related to neuromuscular impairment, the nurse should: - elevate the head of the bed 90 degrees during meals. When performing an assessment, the nurse collects the following data: impaired coordination, decreased muscle strength, limited range of motion, and the client's reluctance to move. This data indicates which nursing diagnosis? - Impaired mobility The nurse is teaching a client with genital herpes. Education for this client should include an explanation of: - the importance of informing his partner of the disease. A 25-year-old client asks the nurse how often and when she should perform breast selfexaminations. The nurse should tell her: - every month, 7 to 10 days after menses starts. A male client should be taught about testicular examinations: - before age 20. When performing an abdominal assessment, the nurse should follow which examination sequence? - Inspection, auscultation, percussion, and palpation The nurse is providing teaching to a client who's at risk for coronary artery disease (CAD). The nurse tells the client that CAD has many risk factors. Risk factors that can be controlled or modified include: - obesity, inactivity, diet, and smoking. The nurse is collecting data on a client admitted with a diagnosis of small bowel obstruction. When assessing the client's pulse rate, the nurse should: - count the apical or radial pulse for 60 seconds. When inserting a urinary catheter, the nurse can facilitate the insertion by asking the client to: - breathe deeply. The nurse is caring for a client with a colostomy. The client tells the nurse that he makes small pin holes in the drainage bag to help relieve gas. The nurse should teach him that this action: - destroys the odor-proof seal. A client is prescribed transcutaneous electrical nerve stimulation (TENS) for pain relief. The rationale for using TENS is to: - block painful stimuli traveling over small nerve fibers. The nurse must assess skin turgor of an elderly client. When evaluating skin turgor, the nurse should remember that: - inelastic skin turgor is a normal part of aging. The nurse is assessing a client who may be in the early stages of dehydration. Early manifestations of dehydration include: - thirst or confusion. A client who recently had a stroke requires a cane to ambulate. When teaching about cane use, the rationale for holding a cane on the uninvolved side is to: - distribute weight away from the involved side.
The nurse is developing a teaching plan for a client who must undergo an above-the-knee amputation of the left leg. After a leg amputation, exercise of the remaining limb: - should begin the day after surgery. The nurse is preparing to remove a previously applied topical medication from a client. The rationale for removing previously applied topical medications before applying new medications is to: - avoid administering more than the prescribed dose. The nurse is administering eyedrops to a client with glaucoma. To achieve maximum absorption, the nurse should instill the eyedrop into the: - conjunctival sac. The nurse is administering eardrops to an adult client. To straighten the ear canal in an adult client before instilling the drops, the nurse should gently pull the: - auricle up and back. The nurse is teaching a client about using vaginal medications. The nurse should instruct the client to: - use only a water-soluble lubricant when inserting a suppository. The nurse is administering sublingual nitroglycerin to a client with chest pain. The nurse should place the medication: - under the tongue. A client has an order for 5,000 units of subcutaneous heparin every 12 hours. When injecting heparin subcutaneously, the nurse should: - use a 45- to 90-degree angle to insert. The nurse is collecting data on a client who has developed a paralytic ileus. The client's bowel sounds will be: - hypoactive The nurse is instructing a client about the use of antiembolism stockings. Antiembolism stockings help prevent deep vein thrombosis (DVT) by: - forcing blood into the deep venous system. The nurse is caring for a client who's showing signs of hypoglycemia. This client will most likely have a blood glucose level: - below 70 mg/dl. A client has sustained a right tibial fracture and has just had a cast applied. Which instruction should the nurse provide regarding cast care? - Keep your right leg elevated above heart level. The nurse is developing a teaching plan for a client with diabetes mellitus. A client with diabetes mellitus should: - wash and inspect feet daily. The nurse is with a group of patient-care attendants reviewing infection-control measures. The nurse tells the group that the first line of intervention for preventing the spread of infection is: - washing hands.
A client receiving total parental nutrition is prescribed a 24-hour urine test. When initiating a 24-hour urine specimen, the collection time should: - start after a known voiding. A client has undergone a left hemicolectomy for bowel cancer. Which activities prevent the occurrence of postoperative pneumonia in this client? - Coughing, breathing deeply, frequent repositioning, and using an incentive spirometer When developing a care plan for an older adult (age 65 and older), the nurse should consider which challenges faced by clients in this age-group? - Adjusting to retirement, deaths of family members, and decreased physical strength The nurse is administering I.M. injections to an older client. The nurse should remember that an older client has: - less subcutaneous tissue and muscle mass than a younger client. The nurse is collecting data on an elderly client. When collecting data, the nurse should consider that one normal aging change is: - diminished reflexes. A person's psychosocial needs during the dying process of a relative may include: - flexible visitation, participation in client care, and rest breaks. When taking a dietary history from a newly admitted client, the nurse should remember that which of the following foods is a common allergen? - Strawberries While obtaining a health history, the nurse learns that the client is allergic to bee stings. When obtaining this client's medication history, the nurse should determine if the client keeps which medication on hand? - Diphenhydramine hydrochloride (Benadryl) Which behavior suggests that a client has obtained relief from urticaria? - The client no longer scratches his arms. Which nursing intervention is most appropriate for a client with multiple myeloma? Preventing bone injury When prioritizing a client's care plan based on Maslow's hierarchy of needs, the nurse's first priority would be: - administering pain medication. When developing a therapeutic relationship with a client, the nurse should begin preparing the client for termination of the relationship: - during the first meeting. In the stages of death and dying as defined by Elizabeth Kubler-Ross, feelings of loss, grief, and intense sadness are symptoms of: - depression. To maintain a therapeutic environment with a client and his family, the nurse can use communication techniques such as the clarification technique. An example of the clarification technique is: - "What do you mean when you say...?"
The nurse is caring for a client admitted to the hospital with a bowel obstruction. The nurse should wear sterile gloves when: - inserting an indwelling urinary catheter. The nurse is placing a client on airborne precautions. The client asks the nurse to leave his door open. The best reply to this is: - "I must keep your door closed to prevent the spread of infection. I'll open the curtains so that you don't feel so closed in." A client is confused and continuously attempts to get out of bed. The physician prescribes a vest restraint. When applying a vest restraint, the nurse should: - allow room for the client to turn. The nurse is about to administer a medication to a client. To verify the client's identity, the nurse should: - check the client's identification bracelet. The nurse is caring for a client with end-stage heart failure. Which statement by the client best demonstrates understanding of an advanced directive? - "A living will allows my decisions for health care to be known if I'm not able to speak for myself." A client has undergone a colon resection. While turning him, wound dehiscence with evisceration occurs. The nurse's first response is to: - place saline-soaked sterile dressings on the wound. The nurse is caring for a client who has suffered a severe stroke. During data collection, the nurse notices Cheyne-Stokes respirations. Cheyne-Stokes respirations are: - progressively deeper breaths followed by shallower breaths with apneic periods. A triple-lumen indwelling urinary catheter is inserted for continuous bladder irrigation following a transurethral resection of the prostate. In addition to balloon inflation, the functions of the three lumens include: - continuous inflow and outflow of irrigation solution. A client with seizure disorder is having a grand mal seizure. During the active seizure phase, the nurse should: - place the client on his side, remove dangerous objects, and protect his head. A client's blood glucose level is 45 mg/dl. The nurse should be alert for which signs and symptoms? - Decreased level of consciousness (LOC), anxiety, confusion, headache, and cool, moist skin. The nurse is providing care for a client who has a sacral pressure ulcer with a wet-to-dry dressing. Which guideline is appropriate for a wet-to-dry dressing? - The wound should remain moist from the dressing. As a nurse is talking to a client, the client begins choking on his lunch. He's coughing forcefully. The nurse should: - stay with him but not intervene at this time.
In community-based nursing, primary responsibility for decisions related to health care belongs to the: - client. A client's left leg is in skeletal traction with a Thomas leg splint and Pearson attachment. Which intervention should the nurse include in this client's care plan? - Teach the client how to prevent problems caused by immobility. A client with rheumatoid arthritis reports GI irritation after taking piroxicam (Feldene). To prevent GI upset, the nurse should provide which instruction? - Take piroxicam with food or an antacid. The nurse is providing care for a client who underwent mitral valve replacement. The best example of a measurable client outcome goal is to: - walk from his room to the end of the hall and back before discharge. The nurse is caring for a client who was given pain medication before leaving the postanesthesia care unit. Upon returning to her room, the client complains of pain and requests more pain medication. Which is the best action for the nurse to take? - Notify the physician that the client is continuing to complain of pain. The nurse is caring for a client infected with methicillin-resistant Staphylococcus aureus (MRSA). What's the major infection control measure to reduce MRSA and other nosocomial pathogens in a health care setting? - Ensuring that personnel wash their hands before and after contact with every client A nurse received an accidental needle stick while giving an I.M. injection. The greatest threat for the nurse is: - hepatitis B (HBV). The nurse is caring for a client with a history of falls. The first priority when caring for a client at risk for falls is: - keeping the bed in the lowest possible position. A client has three children and his mother lives with them. This is called: - an extended family. The nurse is collecting data on a 47-year-old client who has come to the physician's office for his annual physical. One of the first physical signs of aging is: - failing eyesight, especially close vision.