NCLEX RN- EXAM

NCLEX RN Case Study Screen 1 of 6 The nurse is caring for a 35-year-old female client in the psychiatric unit. The client has been admitted for major depressive disorder with suicidal ideation.

Nurses' Notes: 2100: The client is awake, alert, and oriented to person, place, and time. The client reports feelings of hopelessness and expresses thoughts of self-harm. The client has a flat affect and avoids eye contact.

Appetite is poor, with the client stating she has not eaten a full meal in three days. The client has not showered or changed clothes in several days. The client reports poor sleep, stating she only sleeps for 23 hours per night. Vital signs: P 88, RR 18, BP 110/70, T 36.5°C (97.7°F), pulse oximetry reading of 98% on room air.

Click the findings below that would require immediate follow-up.

The client is awake, alert, and oriented to person, place, and time. The client reports feelings of hopelessness and expresses thoughts of self-harm. The client has a flat affect and avoids eye contact.

Appetite is poor, with the client stating she has not eaten a full meal in three days. The client has not showered or changed clothes in several days. The client reports poor sleep, stating she only sleeps for 23 hours per night. Vital signs: P 88, RR 18, BP 110/70, T 36.5°C (97.7°F), pulse oximetry reading of 98% on room air.

Case Study Screen 2 of 6 The nurse is caring for a 35-year-old female client in the psychiatric unit. The client has been admitted for major depressive disorder with suicidal ideation.

Nurses' Notes: 0700: The client reports persistent feelings of sadness and worthlessness. The client remains in bed most of the day and has little interest in activities. The client has been taking sertraline (Zoloft) for the past three weeks but reports no improvement in symptoms. The client expresses frustration with the lack of progress and states, "I don't think anything is going to help me." Vital signs: P 84, RR 18, BP 112/72, T 36.7°C (98.1°F), pulse oximetry reading of 99% on room air.

What immediate action should the nurse take regarding the client's lack of response to medication?

1. Increase the dose of sertraline (Zoloft).

2. Reassess the client in one hour.

3. Document the lack of improvement and continue to monitor.

4. Notify the physician immediately.

Answer: 4. Notify the physician immediately.

Case Study Screen 3 of 6 The nurse is caring for a 35-year-old female client in the psychiatric unit. The client has been admitted for major depressive disorder with suicidal ideation.

Nurses' Notes: 2100: The client reports difficulty sleeping and has been pacing the hallways at night. The client appears anxious and is observed wringing her hands frequently. The client states, "I can't stop worrying about everything." The client denies any recent suicidal thoughts but continues to express feelings of hopelessness. The client has a history of generalized anxiety disorder. Vital signs: P 90, RR 20, BP 115/75, T 36.8°C (98.2°F), pulse oximetry reading of 98% on room air.

Which of the following assessment findings would require follow-up? Select all that apply.

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Difficulty sleeping

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Pacing the hallways at night

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Anxious appearance

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Wringing hands frequently

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Denial of recent suicidal thoughts

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Answer: •

Difficulty sleeping

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Pacing the hallways at night

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Anxious appearance

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Wringing hands frequently

Case Study Screen 4 of 6 The nurse is caring for a 35-year-old female client in the psychiatric unit. The client has been admitted for major depressive disorder with suicidal ideation.

Nurses' Notes:

0700: The client reports continued difficulty sleeping despite taking prescribed sleep medication. The client remains anxious and is observed isolating herself from other clients. The client expresses concern about her ability to cope with everyday tasks once discharged. The client is scheduled for a meeting with the psychiatric team to discuss her treatment plan. Vital signs: P 88, RR 18, BP 110/70, T 36.6°C (97.9°F), pulse oximetry reading of 99% on room air.

The nurse is discussing the client's treatment plan with the psychiatric team. For each potential nursing intervention, click to specify whether the intervention is appropriate or inappropriate for the care of the client.

Case Study Screen 5 of 6 The nurse is caring for a 35-year-old female client in the psychiatric unit. The client has been admitted for major depressive disorder with suicidal ideation.

Nurses' Notes:

2100: The client has participated in one-on-one counseling sessions and has attended a group therapy session. The client reports feeling slightly more hopeful but continues to struggle with anxiety and sleep issues. The client has been prescribed lorazepam (Ativan) for anxiety and zolpidem (Ambien) for sleep.

The client reports mild improvement in sleep with the new medication. Vital signs: P 85, RR 18, BP 112/70, T 36.7°C (98.1°F), pulse oximetry reading of 99% on room air.

For each assessment finding, click to specify if the finding indicates that the client's condition has improved or declined.

Case Study Screen 6 of 6 The nurse is caring for a 35-year-old female client in the psychiatric unit. The client has been admitted for major depressive disorder with suicidal ideation.

Nurses' Notes: 0700: The client is preparing for discharge. The client expresses some anxiety about returning home but feels more equipped with coping strategies learned during therapy. The client will continue outpatient therapy and follow up with her primary care provider. The client denies any current suicidal thoughts and reports improved mood and sleep. Vital signs: P 84, RR 18, BP 110/70, T 36.6°C (97.9°F), pulse oximetry reading of 99% on room air.

The nurse is conducting discharge teaching for the client. For each instruction, click to specify if the instruction is essential or non-essential for the client's discharge plan.

Case Study Screen 1 of 6 The nurse is caring for a 45-year-old male client in the medical unit. The client has been admitted for management of hypertension and is currently prescribed multiple antihypertensive medications.

Nurses' Notes: 2100: The client is awake, alert, and oriented to person, place, and time. The client reports no chest pain or shortness of breath. The client states he has been compliant with his medication regimen but has been experiencing occasional dizziness and fatigue. Medications include lisinopril, hydrochlorothiazide, and metoprolol. Vital signs: P 68, RR 16, BP 145/90, T 36.8°C (98.2°F), pulse oximetry reading of 98% on room air.

Click the findings below that would require immediate follow-up.

2100: The client is awake, alert, and oriented to person, place, and time. The client reports no chest pain or shortness of breath. The client states he has been compliant with his medication regimen but has been experiencing occasional dizziness and fatigue. Medications include lisinopril, hydrochlorothiazide, and metoprolol. Vital signs: P 68, RR 16, BP 145/90, T 36.8°C (98.2°F), pulse oximetry reading of 98% on room air.

Case Study Screen 2 of 6 The nurse is caring for a 45-year-old male client in the medical unit. The client has been admitted for management of hypertension and is currently prescribed multiple antihypertensive medications.

Nurses' Notes: 0700: The client reports feeling light-headed when standing up and has experienced one episode of near-fainting. The client states he has been taking his medications as prescribed but feels increasingly tired. The nurse notes the client appears pale and slightly diaphoretic. Vital signs: P 64, RR 16, BP 138/85, T 36.7°C (98.1°F), pulse oximetry reading of 98% on room air.

What immediate action should the nurse take regarding the client's light-headedness and near-fainting episode?

1. Increase the dose of lisinopril.

2. Reassess the client in one hour.

3. Document the symptoms and continue to monitor.

4. Notify the physician immediately.

Case Study Screen 3 of 6 The nurse is caring for a 45-year-old male client in the medical unit. The client has been admitted for management of hypertension and is currently prescribed multiple antihypertensive medications.

Nurses' Notes: 2100: The client reports persistent dizziness, particularly when changing positions. The client denies any recent chest pain or shortness of breath. The nurse observes the client is slightly unsteady on his feet.

Medications include lisinopril, hydrochlorothiazide, and metoprolol. Vital signs: P 70, RR 18, BP 140/88, T 36.8°C (98.2°F), pulse oximetry reading of 98% on room air.

Which of the following assessment findings would require follow-up? Select all that apply.

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Persistent dizziness

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Unsteady on feet

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Denies chest pain

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Denies shortness of breath

Case Study Screen 4 of 6 The nurse is caring for a 45-year-old male client in the medical unit. The client has been admitted for management of hypertension and is currently prescribed multiple antihypertensive medications.

Nurses' Notes: 0700: The client reports continued dizziness and fatigue despite adherence to medication regimen. The client has been prescribed lisinopril, hydrochlorothiazide, and metoprolol. The nurse notes the client's blood pressure readings remain elevated despite medication. The client is scheduled for a follow-up appointment with the cardiologist. Vital signs: P 66, RR 16, BP 142/90, T 36.7°C (98.1°F), pulse oximetry reading of 98% on room air.

The nurse is discussing the client's treatment plan with the healthcare provider. For each potential nursing intervention, click to specify whether the intervention is appropriate or inappropriate for the care of the client.

Case Study Screen 5 of 6 The nurse is caring for a 45-year-old male client in the medical unit. The client has been admitted for management of hypertension and is currently prescribed multiple antihypertensive medications.

Nurses' Notes: 2100: The client has been educated about managing hypertension and the importance of medication adherence. The client reports feeling slightly better and has not experienced any dizziness since this morning. The client expresses understanding of the medication regimen and the need for lifestyle

changes to manage hypertension. Vital signs: P 68, RR 16, BP 140/85, T 36.8°C (98.2°F), pulse oximetry reading of 98% on room air.

For each assessment finding, click to specify if the finding indicates that the client's condition has improved or declined.

Case Study Screen 6 of 6 The nurse is caring for a 45-year-old male client in the medical unit. The client has been admitted for management of hypertension and is currently prescribed multiple antihypertensive medications.

Nurses' Notes: 0700: The client is preparing for discharge. The client expresses confidence in managing his hypertension at home with the medications and lifestyle changes discussed. The client will continue to monitor his blood pressure at home and follow up with his cardiologist. The client denies any current dizziness or fatigue. Vital signs: P 65, RR 16, BP 138/85, T 36.7°C (98.1°F), pulse oximetry reading of 98% on room air.

The nurse is conducting discharge teaching for the client. For each instruction, click to specify if the instruction is essential or non-essential for the client's discharge plan.

Case Study Screen 1 of 6 The nurse is caring for a 70-year-old female client in the medical-surgical unit. The client has been admitted for management of dehydration and electrolyte imbalance.

Nurses' Notes: 2100: The client is awake, alert, and oriented to person, place, and time. The client reports feeling weak and dizzy. The client has dry mucous membranes and poor skin turgor. The client has been receiving IV fluids at 125 mL/hr. The client has a history of hypertension and takes lisinopril daily. Vital signs: P 92, RR 20, BP 100/60, T 36.7°C (98.1°F), pulse oximetry reading of 97% on room air.

Click the findings below that would require immediate follow-up.

Case Study Screen 2 of 6 The nurse is caring for a 70-year-old female client in the medical-surgical unit. The client has been admitted for management of dehydration and electrolyte imbalance.

Nurses' Notes: 0700: The client reports continued dizziness and weakness. The client's IV site appears slightly swollen and red. The client has voided 200 mL of dark amber urine in the last 8 hours. The client’s oral intake has been minimal. Vital signs: P 94, RR 20, BP 98/58, T 36.8°C (98.2°F), pulse oximetry reading of 97% on room air.

What immediate action should the nurse take regarding the client’s swollen and red IV site?

1. Increase the IV fluid rate.

2. Reassess the client in one hour.

3. Document the IV site condition and continue to monitor.

4. Discontinue the IV and restart it in a different location.

Case Study Screen 3 of 6 The nurse is caring for a 70-year-old female client in the medical-surgical unit. The client has been admitted for management of dehydration and electrolyte imbalance.

Nurses' Notes: 2100: The client reports slight improvement in dizziness but continues to feel weak. The client has received 1500 mL of IV fluids since admission. The client’s oral intake remains low, and she has voided 300 mL of pale yellow urine in the last 8 hours. The client denies any pain or discomfort. Vital signs: P 90, RR 18, BP 100/60, T 36.7°C (98.1°F), pulse oximetry reading of 98% on room air.

Which of the following assessment findings would require follow-up? Select all that apply.

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Slight improvement in dizziness

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Continued weakness

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Low oral intake

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Pale yellow urine output

Case Study Screen 4 of 6 The nurse is caring for a 70-year-old female client in the medical-surgical unit. The client has been admitted for management of dehydration and electrolyte imbalance.

Nurses' Notes: 0700: The client reports feeling slightly better but still weak. The client’s IV site was changed to a different location due to swelling and redness. The client has voided 400 mL of light yellow urine in the last 8 hours. The client has taken a few sips of water but continues to have poor oral intake. Vital signs: P 88, RR 18, BP 102/62, T 36.8°C (98.2°F), pulse oximetry reading of 98% on room air.

The nurse is discussing the client's treatment plan with the healthcare provider. For each potential nursing intervention, click to specify whether the intervention is appropriate or inappropriate for the care of the client.

Case Study Screen 5 of 6 The nurse is caring for a 70-year-old female client in the medical-surgical unit. The client has been admitted for management of dehydration and electrolyte imbalance.

Nurses' Notes: 2100: The client has been encouraged to drink more fluids and has taken small sips throughout the day.

The client reports feeling less dizzy and slightly stronger. The client’s IV fluids were reduced to 75 mL/hr in the afternoon. The client has voided 500 mL of clear urine in the last 8 hours. The client’s skin turgor and mucous membranes appear improved. Vital signs: P 85, RR 18, BP 104/64, T 36.7°C (98.1°F), pulse oximetry reading of 98% on room air.

Which of the following assessment findings indicate that the client's condition has improved? Select all that apply.

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Reports feeling less dizzy

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Slightly stronger

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Clear urine output

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Improved skin turgor and mucous membranes

Answer: •

Reports feeling less dizzy

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Slightly stronger

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Clear urine output

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Improved skin turgor and mucous membranes

Case Study Screen 6 of 6 The nurse is caring for a 70-year-old female client in the medical-surgical unit. The client has been admitted for management of dehydration and electrolyte imbalance.

Nurses' Notes: 0700: The client is preparing for discharge. The client expresses feeling more confident in managing hydration at home. The client has been educated on the importance of adequate fluid intake and recognizing signs of dehydration. The client will follow up with her primary care provider in one week.

Vital signs: P 82, RR 18, BP 106/66, T 36.7°C (98.1°F), pulse oximetry reading of 98% on room air.

The nurse is conducting discharge teaching for the client. Which of the following instructions are essential for the client's discharge plan? Select all that apply.

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Drink at least 8-10 glasses of water daily

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Recognize signs of dehydration

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Schedule follow-up appointment with primary care provider

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Avoid caffeine and alcohol

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Engage in regular physical activity Answer:

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Drink at least 8-10 glasses of water daily

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Recognize signs of dehydration

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Schedule follow-up appointment with primary care provider

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Avoid caffeine and alcohol

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Engage in regular physical activity

DRAG AND DROP The nurse is caring for a 65-year-old female client who was admitted to the hospital with pneumonia.

Health History Client reports a productive cough with yellow sputum for the past five days. She has a history of chronic obstructive pulmonary disease (COPD) and is a current smoker with a 40-pack-year history. The client has been experiencing increased shortness of breath and fatigue. She denies any chest pain. Her medical history includes hypertension and type 2 diabetes. She takes lisinopril, metformin, and albuterol inhaler.

Nurses' Notes 0700: The client is awake, alert, and oriented to person, place, and time. She is in mild respiratory distress. Lung sounds are diminished with crackles heard bilaterally. The client has a persistent productive cough with yellow sputum. Oxygen saturation is 89% on room air. The client is on 2 L of oxygen via nasal cannula. Vital signs: P 92, RR 24, BP 150/90, T 38.2°C (100.8°F), pulse oximetry reading of 94% on 2 L of oxygen.

Vital Signs •

Time: 0700

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Pulse: 92

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Respiratory Rate: 24

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Blood Pressure: 150/90

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Temperature: 38.2°C (100.8°F)

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Oxygen Saturation: 94% on 2 L of oxygen

Laboratory Results •

WBC: 14,000/mm³ (elevated)

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Hemoglobin: 13 g/dL

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Hematocrit: 40%

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Blood Glucose: 140 mg/dL (elevated)

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Sputum Culture: Pending

Drag the assessment findings that require immediate follow-up to the box on the right.

Assessment Findings •

Productive cough

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BP 150/90, P 92, RR 24

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Diminished lung sounds with crackles bilaterally

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Oxygen saturation 89% on room air

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Temperature of 38.2°C (100.8°F)

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Persistent productive cough with yellow sputum

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Pulse oximetry reading of 94% on 2 L of oxygen

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WBC 14,000/mm³ Correct Answers

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Oxygen saturation 89% on room air

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Diminished lung sounds with crackles bilaterally

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Temperature of 38.2°C (100.8°F)

The nurse is caring for a 30-year-old female client who was admitted to the psychiatric unit with acute mania.

Health History Client has a history of bipolar disorder and was brought in by her family due to erratic behavior, hyperactivity, and insomnia. She has been experiencing increased energy, talkativeness, and decreased need for sleep. She denies any suicidal thoughts. Her medical history includes hypothyroidism. She takes levothyroxine and occasionally lithium when she feels it is necessary.

Nurses' Notes 0700: The client is awake, alert, and oriented to person, place, and time. She is hyperactive, talking rapidly, and moving from one activity to another without finishing any task. The client has not slept for the past 48 hours. She is not eating or drinking adequately. Vital signs: P 120, RR 22, BP 130/80, T 37.0°C (98.6°F), pulse oximetry reading of 98% on room air.

Vital Signs •

Time: 0700

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Pulse: 120

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Respiratory Rate: 22

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Blood Pressure: 130/80

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Temperature: 37.0°C (98.6°F)

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Oxygen Saturation: 98% on room air

Laboratory Results •

Lithium Level: 0.4 mEq/L (low)

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TSH: 4.5 µIU/mL (normal)

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Glucose: 90 mg/dL

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Electrolytes: Within normal limits

Drag the assessment findings that require immediate follow-up to the box on the right.

Assessment Findings •

Hyperactivity

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P 120, RR 22, BP 130/80

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Rapid speech

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Not eating or drinking adequately

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Temperature of 37.0°C (98.6°F)

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Not slept for 48 hours

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Pulse oximetry reading of 98% on room air

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Lithium level 0.4 mEq/L Correct Answers

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Not eating or drinking adequately

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Not slept for 48 hours

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Lithium level 0.4 mEq/L

The nurse is caring for a 28-year-old female client who is 34 weeks pregnant and admitted with preeclampsia.

Health History Client reports headaches and visual disturbances for the past two days. She has a history of hypertension and is currently taking methyldopa. The client denies any abdominal pain or contractions. She is a primigravida. Her prenatal course has been otherwise uncomplicated.

Nurses' Notes 0700: The client is awake, alert, and oriented to person, place, and time. She reports a persistent headache and seeing spots. The client has 3+ pitting edema in her lower extremities and elevated blood pressure. Deep tendon reflexes are brisk (+3). Vital signs: P 85, RR 18, BP 160/100, T 37.2°C (99.0°F), pulse oximetry reading of 97% on room air.

Vital Signs •

Time: 0700

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Pulse: 85

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Respiratory Rate: 18

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Blood Pressure: 160/100

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Temperature: 37.2°C (99.0°F)

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Oxygen Saturation: 97% on room air

Laboratory Results •

Urine Protein: +3

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Platelets: 150,000/mm³

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AST/ALT: Elevated

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Creatinine: 1.1 mg/dL

Drag the assessment findings that require immediate follow-up to the box on the right.

Assessment Findings •

Persistent headache

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BP 160/100, P 85, RR 18

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3+ pitting edema in lower extremities

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Deep tendon reflexes +3

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Visual disturbances (seeing spots)

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Temperature of 37.2°C (99.0°F)

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Urine protein +3

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Pulse oximetry reading of 97% on room air

Correct Answers •

BP 160/100

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Visual disturbances (seeing spots)

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Urine protein +3

The nurse is caring for an 82-year-old male client who was admitted to the hospital after a fall at home.

Health History Client reports tripping over a rug and falling. He has a history of osteoporosis, hypertension, and osteoarthritis. The client lives alone and uses a cane for ambulation. He denies any loss of consciousness or dizziness before the fall. His medical history includes previous hip surgery. He takes alendronate, lisinopril, and acetaminophen for pain.

Nurses' Notes 0700: The client is awake, alert, and oriented to person, place, and time. He reports pain in his right hip and is unable to bear weight on the right leg. The client has multiple bruises on his arms and legs. He is anxious about walking again. Vital signs: P 80, RR 16, BP 140/85, T 36.5°C (97.7°F), pulse oximetry reading of 98% on room air.

Vital Signs •

Time: 0700

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Pulse: 80

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Respiratory Rate: 16

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Blood Pressure: 140/85

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Temperature: 36.5°C (97.7°F)

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Oxygen Saturation: 98% on room air

Laboratory Results •

Calcium: 8.5 mg/dL (low)

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Hemoglobin: 13 g/dL

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Hematocrit: 39%

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Serum Creatinine: 1.0 mg/dL

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Vitamin D: 20 ng/mL (low)

Drag the assessment findings that require immediate follow-up to the box on the right.

Assessment Findings •

Pain in right hip

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BP 140/85, P 80, RR 16

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Multiple bruises on arms and legs

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Unable to bear weight on right leg

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Anxious about walking again

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Temperature of 36.5°C (97.7°F)

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Calcium 8.5 mg/dL

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Vitamin D 20 ng/mL

Correct Answers •

Pain in right hip

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Unable to bear weight on right leg

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Calcium 8.5 mg/dL

8. Question: A client with a new diagnosis of type 1 diabetes is learning to administer insulin. What is the nurse's priority teaching?

1. The importance of rotating injection sites 2. The signs of hypoglycemia 3. How to store insulin 4. How to draw up and mix different types of insulin Answer: 2. The signs of hypoglycemia 9. Question: A client is receiving chemotherapy and reports nausea and vomiting. Which intervention should the nurse implement first?

1. Administer prescribed antiemetic medication 2. Provide small, frequent meals 3. Encourage oral fluids 4. Offer ginger ale and crackers Answer: 1. Administer prescribed antiemetic medication 10. Question: A client with chronic kidney disease is experiencing hyperkalemia. Which medication should the nurse anticipate administering?

1. Furosemide 2. Sodium polystyrene sulfonate (Kayexalate) 3. Spironolactone 4. Erythropoietin Answer: 2. Sodium polystyrene sulfonate (Kayexalate) 11. Question: A client with COPD is prescribed a bronchodilator and corticosteroid inhaler. What is the correct sequence for using these medications?

1. Use the corticosteroid first, then the bronchodilator 2. Use the bronchodilator first, then the corticosteroid 3. Use both medications simultaneously 4. Use the medications on alternate days Answer: 2. Use the bronchodilator first, then the corticosteroid 12. Question: A client with heart failure is prescribed furosemide. Which laboratory value should the nurse monitor?

1. Serum sodium 2. Serum potassium 3. Serum calcium

4. Serum creatinine Answer: 2. Serum potassium 13. Question: A client with a stroke is experiencing dysphagia. What is the most appropriate nursing intervention?

1. Provide a regular diet 2. Offer thin liquids 3. Encourage the client to feed themselves 4. Consult with a speech therapist for a swallowing evaluation Answer: 4. Consult with a speech therapist for a swallowing evaluation 14. Question: A client with sepsis has a temperature of 39.5°C (103.1°F), a heart rate of 120 bpm, and a blood pressure of 85/50 mmHg. What should the nurse do first?

1. Administer prescribed antibiotics 2. Start an IV infusion of normal saline 3. Apply cooling blankets 4. Administer acetaminophen Answer: 2. Start an IV infusion of normal saline 15. Question: A client with rheumatoid arthritis is prescribed methotrexate. What is an important nursing consideration?

1. Monitor liver function tests 2. Encourage a high-calcium diet 3. Administer with food to prevent GI upset 4. Monitor for signs of infection Answer: 1. Monitor liver function tests 16. Question: A client with depression is receiving electroconvulsive therapy (ECT). What is a common side effect that the nurse should monitor for?

1. Hypertension 2. Memory loss 3. Weight gain 4. Dry mouth Answer: 2. Memory loss 17. Question: A client with asthma is prescribed a corticosteroid inhaler. What is an important instruction for the nurse to give the client?

1. Use the inhaler only during asthma attacks 2. Rinse the mouth after each use 3. Shake the inhaler before each use

4. Avoid using a spacer Answer: 2. Rinse the mouth after each use 18. Question: A client with a urinary tract infection (UTI) is prescribed ciprofloxacin. What should the nurse include in the client’s teaching?

1. Take the medication with milk 2. Avoid sunlight and wear protective clothing 3. Expect a reddish-brown discoloration of urine 4. Limit fluid intake to prevent frequent urination Answer: 2. Avoid sunlight and wear protective clothing 19. Question: A client with a new ileostomy is concerned about the appearance of the stoma. What is the best nursing response?

1. "The stoma will shrink and become less noticeable over time."

2. "It’s normal to feel this way, and you’ll get used to it."

3. "Let’s talk about your feelings regarding the stoma."

4. "You can wear clothing that will hide the stoma." Answer: 1. "The stoma will shrink and become less noticeable over time."

20. Question: What is the most important nursing intervention for a client receiving total parenteral nutrition (TPN)?

1. Monitor blood glucose levels 2. Check for signs of infection at the IV site 3. Change the IV tubing every 72 hours 4. Administer oral supplements as needed Answer: 1. Monitor blood glucose levels 21. Question: A client with heart failure is prescribed digoxin. What should the nurse assess before administering the medication?

1. Blood pressure 2. Heart rate 3. Respiratory rate 4. Oxygen saturation Answer: 2. Heart rate 22. Question: A client with type 2 diabetes is prescribed metformin. Which statement by the client indicates a need for further teaching?

1. "I should take this medication with meals."

2. "I will monitor my blood sugar levels regularly."

3. "I can stop the medication if my blood sugar is normal."

4. "I should avoid alcohol while taking this medication." Answer: 3. "I can stop the medication if my blood sugar is normal."

23. Question: What is the primary nursing intervention for a client with a chest tube following thoracic surgery?

1. Ensure the chest tube is clamped 2. Monitor the chest tube for drainage and air leaks 3. Encourage deep breathing and coughing exercises 4. Change the chest tube dressing daily Answer: 2. Monitor the chest tube for drainage and air leaks 24. Question: A client with osteoporosis is prescribed alendronate (Fosamax). What is an important teaching point for the nurse to include?

1. Take the medication with a full glass of water 2. Take the medication before bedtime 3. Lie down for 30 minutes after taking the medication 4. Avoid calcium-rich foods while on this medication Answer: 1. Take the medication with a full glass of water 25. Question: A child with a history of febrile seizures is admitted with a high fever. What is the nurse’s priority intervention?

1. Administer antipyretics as prescribed 2. Place the child in a cool bath 3. Apply ice packs to the groin and axilla 4. Monitor the child for signs of seizure activity Answer: 1. Administer antipyretics as prescribed 26. Question: A client with a history of alcohol abuse is experiencing withdrawal symptoms. What is the nurse’s priority action?

1. Administer prescribed benzodiazepines 2. Provide a calm and quiet environment 3. Offer fluids and nutritious snacks 4. Encourage participation in group therapy Answer: 1. Administer prescribed benzodiazepines 27. Question: What is the primary nursing intervention for a client with hyperthyroidism?

1. Monitor for signs of thyroid storm

2. Encourage a high-calorie diet 3. Administer levothyroxine as prescribed 4. Provide a warm environment Answer: 1. Monitor for signs of thyroid storm 28. Question: A client with Parkinson’s disease is experiencing difficulty swallowing. What is the most appropriate nursing intervention?

1. Offer thin liquids to make swallowing easier 2. Instruct the client to tilt their head back when swallowing 3. Provide small, frequent meals 4. Encourage the client to eat quickly Answer: 3. Provide small, frequent meals 29. Question: A client with chronic obstructive pulmonary disease (COPD) is prescribed a bronchodilator. What is the primary nursing assessment?

1. Monitor oxygen saturation 2. Assess lung sounds before and after administration 3. Check blood pressure before administration 4. Monitor for signs of infection Answer: 2. Assess lung sounds before and after administration 30. Question: A postpartum client is breastfeeding and concerned about nipple soreness. What should the nurse suggest?

1. Apply lanolin cream to the nipples after feeding 2. Use a breast pump instead of direct breastfeeding 3. Feed the baby less frequently 4. Apply ice packs to the breasts before feeding Answer: 1. Apply lanolin cream to the nipples after feeding 31. Question: A client with HIV/AIDS is prescribed antiretroviral therapy. What is an important teaching point for the nurse to emphasize?

1. Take the medication with food 2. Adherence to the medication regimen is crucial 3. Avoid all forms of exercise 4. Limit fluid intake Answer: 2. Adherence to the medication regimen is crucial 32. Question: A client with a peptic ulcer is prescribed omeprazole. What is the mechanism of action of this medication?

1. Neutralizes stomach acid

2. Coats the stomach lining 3. Inhibits the proton pump to reduce acid production 4. Increases gastric motility Answer: 3. Inhibits the proton pump to reduce acid production 33. Question: A client with cirrhosis is experiencing ascites. What is the most appropriate nursing intervention?

1. Encourage a low-protein diet 2. Administer diuretics as prescribed 3. Monitor for signs of infection 4. Restrict fluid intake Answer: 2. Administer diuretics as prescribed 34. Question: A client with leukemia is receiving chemotherapy. What is the nurse’s priority assessment?

1. Monitoring for signs of infection 2. Encouraging high fluid intake 3. Administering anti-nausea medication 4. Providing a low-fiber diet Answer: 1. Monitoring for signs of infection 35. Question: A client with a history of seizures is prescribed phenytoin (Dilantin). What should the nurse monitor for as a potential side effect?

1. Hyperglycemia 2. Gingival hyperplasia 3. Hypertension 4. Weight gain Answer: 2. Gingival hyperplasia 36. Question: A client with multiple sclerosis is experiencing muscle spasticity. What is the most appropriate nursing intervention?

1. Apply cold packs to the affected muscles 2. Encourage the client to perform range-of-motion exercises 3. Administer muscle relaxants as prescribed 4. Provide a high-protein diet Answer: 3. Administer muscle relaxants as prescribed 37. Question: A client with hyperparathyroidism is at risk for developing which complication?

1. Hypocalcemia 2. Hypercalcemia

3. Hyponatremia 4. Hyperkalemia Answer: 2. Hypercalcemia 38. Question: A client with diabetic ketoacidosis (DKA) is receiving insulin therapy. What is the primary nursing intervention?

1. Monitor blood glucose levels hourly 2. Administer potassium supplements 3. Encourage oral fluid intake 4. Provide a high-carbohydrate diet Answer: 1. Monitor blood glucose levels hourly 39. Question: A client with a urinary tract infection (UTI) is prescribed phenazopyridine (Pyridium).

What is an expected side effect of this medication?

1. Blue-green urine 2. Orange-red urine 3. Dark brown urine 4. Clear urine Answer: 2. Orange-red urine 40. Question: A client with myasthenia gravis is experiencing difficulty swallowing. What is the most appropriate nursing intervention?

1. Offer thin liquids to make swallowing easier 2. Instruct the client to tilt their head back when swallowing 3. Provide small, frequent meals 4. Encourage the client to eat quickly Answer: 3. Provide small, frequent meals 41. Question: A client with acute pancreatitis is receiving nothing by mouth (NPO) status. What is the primary nursing intervention?

1. Administer intravenous fluids as prescribed 2. Encourage the client to sip water 3. Provide ice chips for comfort 4. Monitor for signs of dehydration Answer: 1. Administer intravenous fluids as prescribed 42. Question: A client with deep vein thrombosis (DVT) is receiving anticoagulant therapy. What is the primary nursing intervention?

1. Monitor for signs of bleeding 2. Encourage ambulation

3. Apply compression stockings 4. Provide a high-fiber diet Answer: 1. Monitor for signs of bleeding 43. Question: A client with cirrhosis is at risk for developing hepatic encephalopathy. What is the most appropriate nursing intervention?

1. Administer lactulose as prescribed 2. Encourage a high-protein diet 3. Monitor for signs of infection 4. Restrict fluid intake Answer: 1. Administer lactulose as prescribed 44. Question: A client with anemia is prescribed ferrous sulfate. What is an important teaching point for the nurse to include?

1. Take the medication with milk 2. Expect dark stools 3. Avoid vitamin C supplements 4. Take the medication at bedtime Answer: 2. Expect dark stools 45. Question: A client with a myocardial infarction is receiving thrombolytic therapy. What is the primary nursing intervention?

1. Monitor for signs of bleeding 2. Administer oxygen as prescribed 3. Provide a low-sodium diet 4. Encourage ambulation Answer: 1. Monitor for signs of bleeding 46. Question: A client with asthma is experiencing an acute exacerbation. What is the most appropriate nursing intervention?

1. Administer a bronchodilator as prescribed 2. Encourage the client to drink fluids 3. Provide a high-calorie diet 4. Monitor for signs of infection Answer: 1. Administer a bronchodilator as prescribed 47. Question: A client with a history of hypertension is prescribed a diuretic. What is an important nursing consideration?

1. Monitor blood pressure 2. Encourage a high-sodium diet

3. Administer with food 4. Provide a high-calcium diet Answer: 1. Monitor blood pressure 48. Question: A client with chronic kidney disease is receiving erythropoietin injections. What is the desired outcome of this treatment?

1. Increase urine output 2. Decrease serum creatinine levels 3. Increase hemoglobin and hematocrit levels 4. Decrease potassium levels Answer: 3. Increase hemoglobin and hematocrit levels 49. Question: A client with a spinal cord injury is at risk for autonomic dysreflexia. What is the most appropriate nursing intervention to prevent this condition?

1. Keep the client in a supine position 2. Ensure the client’s bladder is emptied regularly 3. Administer antihypertensive medication prophylactically 4. Provide a high-fiber diet to prevent constipation Answer: 2. Ensure the client’s bladder is emptied regularly 50. Question: A client with anxiety disorder is prescribed lorazepam (Ativan). What is an important teaching point for the nurse to include?

1. Avoid alcohol while taking this medication 2. Take the medication on an empty stomach 3. Discontinue the medication if dizziness occurs 4. Limit fluid intake Answer: 1. Avoid alcohol while taking this medication 51. Question: A client with heart failure is experiencing fluid overload. Which of the following assessment findings should the nurse expect? (Select all that apply.)

•

Weight gain

•

Crackles in the lungs

•

Hypotension

•

Decreased urine output

•

Jugular vein distention Answers:

•

Weight gain

•

Crackles in the lungs

•

Jugular vein distention

52. Question: A client with chronic obstructive pulmonary disease (COPD) is prescribed oxygen therapy. Which of the following instructions should the nurse include? (Select all that apply.)

•

Use oxygen continuously

•

Adjust oxygen flow rate as needed

•

Check the oxygen equipment daily

•

Avoid smoking while using oxygen

•

Limit fluid intake Answers:

•

Use oxygen continuously

•

Check the oxygen equipment daily

•

Avoid smoking while using oxygen

53. Question: A client with type 2 diabetes is experiencing peripheral neuropathy. Which of the following instructions should the nurse include in the client’s teaching plan? (Select all that apply.)

•

Check feet daily for injuries

•

Wear well-fitting shoes

•

Apply lotion between toes

•

Use heating pads to keep feet warm

•

Avoid walking barefoot

•

Answers:

•

Check feet daily for injuries

•

Wear well-fitting shoes

•

Avoid walking barefoot

54. Question: A client with a newly inserted chest tube is at risk for complications. Which of the following should the nurse monitor for? (Select all that apply.)

•

Continuous bubbling in the water seal chamber

•

Sudden increase in chest tube drainage

•

Subcutaneous emphysema

•

Decrease in breath sounds on the affected side

•

Client reports of burning sensation at the site

Answers: •

Continuous bubbling in the water seal chamber

•

Sudden increase in chest tube drainage

•

Subcutaneous emphysema

•

Decrease in breath sounds on the affected side

55. Question: A client with end-stage renal disease (ESRD) is receiving hemodialysis. Which of the following are expected findings? (Select all that apply.)

•

Decreased serum creatinine

•

Hyperkalemia

•

Hypertension

•

Anemia

•

Hypocalcemia Answers:

•

Decreased serum creatinine

•

Hyperkalemia

•

Anemia

•

Hypocalcemia

56. SATA Question: A client with a new diagnosis of hypertension is being educated on lifestyle changes. Which of the following recommendations should the nurse include? (Select all that apply.)

•

Reduce sodium intake

•

Increase physical activity

•

Limit alcohol consumption

•

Avoid smoking

•

Follow a low-protein diet Answers:

•

Reduce sodium intake

•

Increase physical activity

•

Limit alcohol consumption

•

Avoid smoking

57. Question: A client with gastroesophageal reflux disease (GERD) is receiving education on dietary modifications. Which of the following foods should the nurse instruct the client to avoid? (Select all that apply.)

•

Chocolate

•

Citrus fruits

•

Peppermint

•

High-fat foods

•

Whole grains Answers:

•

Chocolate

•

Citrus fruits

•

Peppermint

•

High-fat foods

58. Question: A client with peripheral arterial disease (PAD) is experiencing intermittent claudication.

What are some important nursing interventions? (Select all that apply.)

•

Encourage regular walking exercises

•

Advise the client to rest when pain occurs

•

Apply heating pads to the extremities

•

Elevate the legs above heart level

•

Administer antiplatelet medications as prescribed Answers:

•

Encourage regular walking exercises

•

Advise the client to rest when pain occurs

•

Administer antiplatelet medications as prescribed

59. SATA Question: A client with cirrhosis is experiencing hepatic encephalopathy. Which of the following interventions should the nurse implement? (Select all that apply.)

•

Administer lactulose as prescribed

•

Monitor ammonia levels

•

Provide a low-protein diet

•

Encourage fluid restriction

•

Assess for asterixis Answers:

•

Administer lactulose as prescribed

•

Monitor ammonia levels

•

Assess for asterixis

60. Question: A client with hypothyroidism is prescribed levothyroxine. What are some important instructions for the nurse to provide? (Select all that apply.)

•

Take the medication in the morning on an empty stomach

•

Avoid consuming soy products

•

Monitor for signs of hyperthyroidism

•

Expect an immediate effect after starting the medication

•

Take the medication at the same time every day Answers:

•

Take the medication in the morning on an empty stomach

•

Avoid consuming soy products

•

Monitor for signs of hyperthyroidism

•

Take the medication at the same time every day

61. Question: A client with acute kidney injury (AKI) is experiencing hyperkalemia. What is the most appropriate nursing intervention?

1. Administer calcium gluconate 2. Administer sodium bicarbonate 3. Administer insulin and glucose 4. Administer furosemide Answer: 3. Administer insulin and glucose 62. Question: A client with pneumonia is experiencing pleuritic chest pain. What is the most appropriate nursing intervention?

1. Administer prescribed analgesics 2. Encourage deep breathing and coughing exercises 3. Apply a cold pack to the chest 4. Provide a high-protein diet Answer: 1. Administer prescribed analgesics

63. Question: A client with hyperthyroidism is prescribed methimazole. What is the mechanism of action of this medication?

1. Increases thyroid hormone production 2. Inhibits thyroid hormone synthesis 3. Stimulates thyroid hormone release 4. Blocks the conversion of T4 to T3 Answer: 2. Inhibits thyroid hormone synthesis 64. Question: A client with chronic heart failure is experiencing orthopnea. What is the most appropriate nursing intervention?

1. Administer diuretics as prescribed 2. Encourage the client to lie flat 3. Provide a low-sodium diet 4. Elevate the head of the bed Answer: 4. Elevate the head of the bed 65. Question: A client with a colostomy is concerned about odor. What is the best nursing response?

1. "You should change your colostomy bag once a day."

2. "Avoid foods that cause gas and odor."

3. "Use a deodorizing spray in the room."

4. "Clean the stoma with alcohol." Answer: 2. "Avoid foods that cause gas and odor."

66. Question: A client with tuberculosis is prescribed isoniazid (INH). What is an important teaching point for the nurse to include?

1. Take the medication with antacids 2. Avoid alcohol while taking this medication 3. Expect orange discoloration of urine 4. Limit intake of dairy products Answer: 2. Avoid alcohol while taking this medication 67. Question: A client with Alzheimer’s disease is prescribed donepezil (Aricept). What is the desired outcome of this medication?

1. Cure the disease 2. Improve cognitive function 3. Decrease agitation 4. Increase appetite Answer: 2. Improve cognitive function

68. Question: A client with a history of deep vein thrombosis (DVT) is prescribed warfarin (Coumadin).

What is the nurse’s priority teaching?

1. Monitor for signs of bleeding 2. Increase intake of green leafy vegetables 3. Avoid exercise 4. Take the medication with milk Answer: 1. Monitor for signs of bleeding 69. Question: A client with chronic kidney disease (CKD) is prescribed erythropoietin. What is the primary goal of this medication?

1. Increase urine output 2. Decrease blood pressure 3. Increase red blood cell production 4. Decrease potassium levels Answer: 3. Increase red blood cell production 70. Question: A client with osteoporosis is concerned about the risk of fractures. What is the most appropriate nursing intervention?

1. Encourage a high-calcium diet 2. Recommend weight-bearing exercises 3. Administer vitamin D supplements 4. Provide a low-sodium diet Answer: 2. Recommend weight-bearing exercises 71. Question: A client with heart failure is experiencing pulmonary edema. What is the most appropriate nursing intervention?

1. Administer diuretics as prescribed 2. Provide a high-protein diet 3. Encourage fluid intake 4. Administer antitussive medication Answer: 1. Administer diuretics as prescribed 72. Question: A client with a seizure disorder is prescribed carbamazepine (Tegretol). What is an important nursing consideration?

1. Monitor liver function tests 2. Administer with food 3. Encourage a high-fiber diet 4. Monitor for signs of infection Answer: 1. Monitor liver function tests

73. Question: A client with asthma is prescribed a leukotriene receptor antagonist. What is the desired outcome of this medication?

1. Reduce airway inflammation 2. Dilate the bronchioles 3. Suppress the immune response 4. Decrease mucus production Answer: 1. Reduce airway inflammation 74. Question: A client with a urinary tract infection (UTI) is prescribed trimethoprim-sulfamethoxazole (Bactrim). What is an important teaching point for the nurse to include?

1. Take the medication with milk 2. Avoid direct sunlight 3. Expect a reddish-brown discoloration of urine 4. Limit fluid intake Answer: 2. Avoid direct sunlight 75. Question: A client with hypothyroidism is experiencing constipation. What is the most appropriate nursing intervention?

1. Encourage a high-fiber diet 2. Administer a laxative daily 3. Provide a low-residue diet 4. Encourage the client to lie down after meals Answer: 1. Encourage a high-fiber diet 76. Question: A client with a history of alcoholism is prescribed disulfiram (Antabuse). What is the primary goal of this medication?

1. Reduce withdrawal symptoms 2. Prevent relapse by causing adverse effects when alcohol is consumed 3. Treat alcohol-induced liver damage 4. Decrease cravings for alcohol Answer: 2. Prevent relapse by causing adverse effects when alcohol is consumed 77. Question: A client with a history of venous insufficiency is experiencing edema in the lower extremities. What is the most appropriate nursing intervention?

1. Apply compression stockings 2. Encourage fluid restriction 3. Administer diuretics as prescribed 4. Elevate the legs above heart level Answer: 1. Apply compression stockings

78. Question: A client with chronic obstructive pulmonary disease (COPD) is prescribed a mucolytic agent. What is the desired outcome of this medication?

1. Reduce airway inflammation 2. Thin and loosen mucus 3. Suppress the cough reflex 4. Decrease bronchospasm Answer: 2. Thin and loosen mucus 79. Question: A client with chronic kidney disease (CKD) is experiencing pruritus. What is the most appropriate nursing intervention?

1. Administer antihistamines as prescribed 2. Encourage frequent bathing with hot water 3. Apply lotion to dry skin 4. Provide a high-protein diet Answer: 1. Administer antihistamines as prescribed 80. Question: A client with a history of gout is prescribed allopurinol. What is the mechanism of action of this medication?

1. Increases excretion of uric acid 2. Decreases production of uric acid 3. Increases renal reabsorption of uric acid 4. Decreases renal excretion of uric acid Answer: 2. Decreases production of uric acid 81. Question: A client with a new colostomy is concerned about the appearance of the stoma. What is the best nursing response?

1. "The stoma will shrink and become less noticeable over time."

2. "It’s normal to feel this way, and you’ll get used to it."

3. "Let’s talk about your feelings regarding the stoma."

4. "You can wear clothing that will hide the stoma." Answer: 1. "The stoma will shrink and become less noticeable over time."

82. Question: A client with chronic kidney disease (CKD) is prescribed a phosphate binder. What is the desired outcome of this medication?

1. Increase serum calcium levels 2. Decrease serum phosphate levels 3. Increase urine output 4. Decrease blood pressure Answer: 2. Decrease serum phosphate levels

83. Question: A client with a history of myocardial infarction (MI) is prescribed a beta-blocker. What is the desired outcome of this medication?

1. Increase heart rate 2. Decrease blood pressure 3. Increase cardiac output 4. Decrease oxygen demand on the heart Answer: 4. Decrease oxygen demand on the heart 84. Question: A client with chronic obstructive pulmonary disease (COPD) is experiencing weight loss.

What is the most appropriate nursing intervention?

1. Provide a high-calorie, high-protein diet 2. Encourage fluid restriction 3. Administer appetite stimulants as prescribed 4. Encourage the client to eat quickly Answer: 1. Provide a high-calorie, high-protein diet 85. Question: A client with a history of renal calculi is experiencing severe flank pain. What is the most appropriate nursing intervention?

1. Encourage fluid intake 2. Administer analgesics as prescribed 3. Provide a high-calcium diet 4. Apply a cold pack to the flank area Answer: 2. Administer analgesics as prescribed