NCLEX-rn Exam Free Review By NCLEX Masters

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1.  The nurse would anticipate that an eight month-old would be able to  do one or more of the following:
A.
B.
C.
D.
2.  The nurse would anticipate that an eight month-old would be able to  do one or more of the following:
A.
B.
C.
D.
3.  A client states, "People think I'm no good,you know what I mean? " Which nursing response would be most therapeutic for this client?
A.
B.
C.
D.
4.  A client states, " People think I 'm no good, you know what I mean?" Which nursing response would be most therapeutic for this client?
A.
B.
C.
D.
5.  A client calls the evening health clinic to state "I know I have a severely low sugar since the Lantus insulin was given three hours ago and it peaks in two hours." What should be the nurse 's initial response to the client?
A.
B.
C.
D.
6.  A client calls the evening health clinic to state "I know I have a severely low sugar since the Lantus insulin was given three hours ago and it peaks in two hours." What should be the nurse' s initial response to the client?
A.
B.
C.
D.
7.  A 64 year-old client scheduled for surgery with a general anesthetic refuses to remove her dentures prior to leaving the unit for the operating room. The most appropriate intervention by the nurse is:
A.
B.
C.
D.
8.  A 64 year-old client scheduled for surgery with a general anesthetic refuses to remove her dentures prior to leaving the unit for the operating room. The most appropriate intervention by the nurse is:
A.
B.
C.
D.
9.  The mother of a two year-old hospitalized child asks the nurse 's advice about the child' s screaming every time the mother gets ready to leave the hospital room. The best response of the nurse would be to:    
A.
B.
C.
D.
10.  Which of these actions best describes the application of time management strategies for the role of the PN charge nurse?
A.
B.
C.
D.
11.  Which of these actions best describes the application of time management strategies for the role of the PN charge nurse?
A.
B.
C.
D.
12.  A client with paranoid delusions stares at the nurse over a period of several days. The client suddenly walks up to the nurse and shouts "You think you're so perfect and pure and good. " The appropriate response for the nurse is:  
A.
B.
C.
D.
13.  A client with paranoid delusions stares at the nurse over a period of several days. The client suddenly walks up to the nurse and shouts " You think you 're so perfect and pure and good." The appropriate response for the nurse is:  
A.
B.
C.
D.
Discuss this Question
14.  The health care provider order reads "aspirate nasogastric feeding (NG) tube every four hours and check pH of aspirate". The pH of the aspirate is 10. Which action should the nurse take?
A.
B.
C.
D.
15.  The health care provider order reads "aspirate nasogastric feeding (NG) tube every four hours and check pH of aspirate". The pH of the aspirate is 10. Which action should the nurse take?
A.
B.
C.
D.
16.  The nurse is reviewing a handout on infant feeding to be distributed to families visiting the clinic. Which information should be included in the teaching materials?  
A.
B.
C.
D.
17.  The nurse is reviewing a handout on infant feeding to be distributed to families visiting the clinic. Which information should be included in the teaching materials?  
A.
B.
C.
D.
18.  A female client is admitted for a breast biopsy. She says, tearfully to the nurse, "If this turns out to be cancer and I have to have my breast removed, my companion will never come near me." The nurse's best response would be "Are you:
A.
B.
C.
D.
19.  A female client is admitted for a breast biopsy. She says, tearfully to the nurse, " If this turns out to be cancer and I have to have my breast removed,my companion will never come near me. " The nurse's best response would be " Are you:
A.
B.
C.
D.
20.  A client was just taken off the ventilator following surgery and has a nasogastric tube draining bile colored liquids. Which nursing measure will provide the most comfort to the client?
A.
B.
C.
D.
21.  A client was just taken off the ventilator following surgery and has a nasogastric tube draining bile colored liquids. Which nursing measure will provide the most comfort to the client?
A.
B.
C.
D.
22.  The parents of a four year-old hospitalized child tell the nurse they will leave for a time and return at 6 PM. When the child asks when the parents will come again, the nurse can best respond by saying:
A.
B.
C.
D.
23.  The parents of a four year-old hospitalized child tell the nurse they will leave for a time and return at 6 PM. When the child asks when the parents will come again, the nurse can best respond by saying:
A.
B.
C.
D.
24.  The nurse is reinforcing teaching to a 24 year-old woman receiving acyclovir (Zovirax) for a Herpes Simplex Virus type 2 infection. The nurse should be sure to include which information?
A.
B.
C.
D.
25.  The nurse is reinforcing teaching to a 24 year-old woman receiving acyclovir (Zovirax) for a Herpes Simplex Virus type 2 infection. The nurse should be sure to include which information?
A.
B.
C.
D.
26.  A client is admitted to the emergency room following an acute asthma attack. Which of the following findings would be most important to report?
A.
B.
C.
D.
27.  A client is admitted to the emergency room following an acute asthma attack. Which of the following findings would be most important to report?
A.
B.
C.
D.
28.  In the last 48 hours of life, a hospice client may complain of dry mouth from a poor fluid intake. The nurse should only offer to moisten the mouth because:
A.
B.
C.
D.
Discuss this Question
29.  In the last 48 hours of life, a hospice client may complain of dry mouth from a poor fluid intake. The nurse should only offer to moisten the mouth because:
A.
B.
C.
D.
30.  A child, injured on the school playground, appears to have a fractured leg. The first action the school nurse should take is
A.
B.
C.
D.
31.  A child, injured on the school playground, appears to have a fractured leg. The first action the school nurse should take is
A.
B.
C.
D.
32.  An important goal in the development of a therapeutic inpatient milieu is providing a A) businesslike atmosphere where clients can work on individual goals forum in which clients deB) group cide on unit rules, regulations, and policies
A.
B.
C.
D.
33.  An important goal in the development of a therapeutic inpatient milieu is providing a A) businesslike atmosphere where clients can work on individual goals forum in which clients deB) group cide on unit rules, regulations, and policies
A.
B.
C.
D.
34.  The nurse is collecting data on a client with a stage 2 skin ulcer. Which treatment is considered most effective to promote healing?
A.
B.
C.
D.
35.  The nurse is collecting data on a client with a stage 2 skin ulcer. Which treatment is considered most effective to promote healing?
A.
B.
C.
D.
36.  The nurse is caring for a four year-old two hours after tonsillectomy and adenoidectomy. Which observation must be reported immediately?
A.
B.
C.
D.
37.  The nurse is caring for a four year-old two hours after tonsillectomy and adenoidectomy. Which observation must be reported immediately?
A.
B.
C.
D.
38.  The nurse is assisting with a pre-kindergarten physical on a five year-old. The last MMR vaccine will be administered. Allergy to which item might be a contraindication to giving the vaccine?
A.
B.
C.
D.
39.  The nurse is assisting with a pre-kindergarten physical on a five year-old. The last MMR vaccine will be administered. Allergy to which item might be a contraindication to giving the vaccine?
A.
B.
C.
D.
40.  A client receiving chlorpromazine HCL (Thorazine) is in psychiatric home care. During a home visit the nurse observes the client smacking the lips alternately with grinding of the teeth. The nurse assesses this as
A.
B.
C.
D.
41.  A client receiving chlorpromazine HCL (Thorazine) is in psychiatric home care. During a home visit the nurse observes the client smacking the lips alternately with grinding of the teeth. The nurse assesses this as
A.
B.
C.
D.
42.  A 14 month-old child ingested half a bottle of aspirin tablets. Which finding would the nurse expect to see in the child?
A.
B.
C.
D.
43.  A 14 month-old child ingested half a bottle of aspirin tablets. Which finding would the nurse expect to see in the child?
A.
B.
C.
D.
44.  The nurse is reinforcing instructions for a client with asthma. Which item should be stressed for the client to monitor on a daily basis?
A.
B.
C.
D.
45.  The nurse is reinforcing instructions for a client with asthma. Which item should be stressed for the client to monitor on a daily basis?
A.
B.
C.
D.
46.  A client in a long term care facility complains of pain. The nurse collects data about the client's pain. The first step in pain assessment is for the nurse to
A.
B.
C.
D.
47.  A client in a long term care facility complains of pain. The nurse collects data about the client's pain. The first step in pain assessment is for the nurse to
A.
B.
C.
D.
48.  The nurse is observing a client with an obsessive-compulsive disorder in an inpatient setting. Which behavior is consistent with this diagnosis?
A.
B.
C.
D.
49.  The nurse is observing a client with an obsessive-compulsive disorder in an inpatient setting. Which behavior is consistent with this diagnosis?
A.
B.
C.
D.
Discuss this Question
50.  Which one of these tasks could be assigned to the certified nursing assistant (cna)? 
A.
B.
C.
D.
51.  Which one of these tasks could be assigned to the certified nursing assistant (cna)? 
A.
B.
C.
D.
52.  A client refuses to take the medication prescribed because the client prefers to take an herbal preparation. What is the first action the nurse should take?
A.
B.
C.
D.
Discuss this Question
53.  A client refuses to take the medication prescribed because the client prefers to take an herbal preparation. What is the first action the nurse should take?
A.
B.
C.
D.
54.  Which statement by the nurse is appropriate when asking an unlicensed assistive personnel (UAP) to assist a 69 year-old surgical client to ambulate for the first time?
A.
B.
C.
D.
55.  Which statement by the nurse is appropriate when asking an unlicensed assistive personnel (UAP) to assist a 69 year-old surgical client to ambulate for the first time?
A.
B.
C.
D.
56.  If a nurse is uncertain about whether he or she is licensed to perform certain tasks, they should first check information in which of these resources?
A.
B.
C.
D.
57.  If a nurse is uncertain about whether he or she is licensed to perform certain tasks, they should first check information in which of these resources?
A.
B.
C.
D.
58.  A nurse who works at an extended care facility has just reviewed a new medication order which is not legible. Which statement best reflects assertive communication to the health care provider who wrote the order?
A.
B.
C.
D.
59.  A nurse who works at an extended care facility has just reviewed a new medication order which is not legible. Which statement best reflects assertive communication to the health care provider who wrote the order?
A.
B.
C.
D.
60.  A client with a diagnosis of bipolar disorder has been referred to a local boarding home to be considered for placement. The social worker telephoned the hospital unit for information about the client's mental status and adjustment. The nurse should know that the most acceptable is : 
A.
B.
C.
D.
61.  A client with a diagnosis of bipolar disorder has been referred to a local boarding home to be considered for placement. The social worker telephoned the hospital unit for information about the client's mental status and adjustment. The nurse should know that the most acceptable is : 
A.
B.
C.
D.
62.  A client who has just joined a health maintenance organization (HMO) asks for information about the payment obligations with this plan. The most accurate description of health care costs is that the client will be charged
A.
B.
C.
D.
63.  A client who has just joined a health maintenance organization (HMO) asks for information about the payment obligations with this plan. The most accurate description of health care costs is that the client will be charged
A.
B.
C.
D.
64.  A nurse arranges for an interpreter to assist with communication between the health care team and a non-English speaking client. To promote therapeutic communication when working with an interpreter, the utmost thing for the nurse to remember is to :
A.
B.
C.
D.
65.  A nurse arranges for an interpreter to assist with communication between the health care team and a non-English speaking client. To promote therapeutic communication when working with an interpreter, the utmost thing for the nurse to remember is to :
A.
B.
C.
D.
66.  Which of the followwing entries in the progress notes of a client is the most complete?
A.
B.
C.
D.
67.  Which of the followwing entries in the progress notes of a client is the most complete?
A.
B.
C.
D.
68.  Privacy and confidentiality of client information is legally protected. In which of these situations would the nurse make an exception to this practice?
A.
B.
C.
D.
69.  Privacy and confidentiality of client information is legally protected. In which of these situations would the nurse make an exception to this practice?
A.
B.
C.
D.
70.  The nurse should be informed about cultural issues related to the client's background because one of the following:
A.
B.
C.
D.
71.  The nurse should be informed about cultural issues related to the client's background because one of the following:
A.
B.
C.
D.
72.  A client frequently compliments the nurse and invites the nurse to go to a movie and dinner. The nurse should take which approach?
A.
B.
C.
D.
73.  A client frequently compliments the nurse and invites the nurse to go to a movie and dinner. The nurse should take which approach?
A.
B.
C.
D.
74.  After working with a very demanding client, an unlicensed assistive personnel (UAP) tells the nurse, "I have had it with that client. I just can't do anything that pleases him. I'm not going in there again." The nurse's appropriate response should be
A.
B.
C.
D.
75.  After working with a very demanding client, an unlicensed assistive personnel (UAP) tells the nurse, "I have had it with that client. I just can't do anything that pleases him. I'm not going in there again." The nurse's appropriate response should be
A.
B.
C.
D.
76.  A nurse has been named in a lawsuit. The best evidence a nurse can use for self- protection in a court of law is which of these items?
A.
B.
C.
D.
77.  A nurse has been named in a lawsuit. The best evidence a nurse can use for self- protection in a court of law is which of these items?
A.
B.
C.
D.
78.  Which one of these tasks for a 69 year-old client with a diagnosis of hyperglycemia could the nurse assign to the unlicensed assistive personnel (UAP)?
A.
B.
C.
D.
79.  Which one of these tasks for a 69 year-old client with a diagnosis of hyperglycemia could the nurse assign to the unlicensed assistive personnel (UAP)?
A.
B.
C.
D.
80.  A client is admitted with a diagnosis of schizophrenia. The client states "I don't need medication. It makes me sleepy." The client insists that the nurse explain the use and side effects of the medication. The nurse should understand that the best intervention is:
A.
B.
C.
D.
81.  A client is admitted with a diagnosis of schizophrenia. The client states "I don't need medication. It makes me sleepy." The client insists that the nurse explain the use and side effects of the medication. The nurse should understand that the best intervention is:
A.
B.
C.
D.
82.  A client tells the nurse, "I have something very important to tell you if you promise not to tell anyone." The appropriate response by the nurse would be
A.
B.
C.
D.
83.  A client tells the nurse, "I have something very important to tell you if you promise not to tell anyone." The appropriate response by the nurse would be
A.
B.
C.
D.
84.  Which newly admitted client would be most appropriate to assign to the unlicensed assistive personnel (UAP)?
A.
B.
C.
D.
85.  The nurse should begin considering discharge concerns for a hospitalized client considering one fo of the following:
A.
B.
C.
D.
86.  Which newly admitted client would be most appropriate to assign to the unlicensed assistive personnel (UAP)?
A.
B.
C.
D.
87.  When a client is diagnosed with tuberculosis, the public health department is to be notified for what reason?
A.
B.
C.
D.
88.  The nurse should begin considering discharge concerns for a hospitalized client considering one fo of the following:
A.
B.
C.
D.
89.  A 5 years old child has been admitted to the pediatric unit after swallowing a household cleaner. Which of these findings is more commonly associated with the fact that the poison was a corrosive?
A.
B.
C.
D.
90.  When a client is diagnosed with tuberculosis, the public health department is to be notified for what reason?
A.
B.
C.
D.
91.  Which of these actions is the first priority in the prevention of infections, whether in the hospital or home setting?
A.
B.
C.
D.
92.  A 14 years child goes into seizures. Which nursing action is a priority for a client during a seizure
A.
B.
C.
D.
93.  X-RN A client with a diagnosis of methicillin resistant staphylococcus aureus (MRSA) has died. Which type of transmission-based precautions is the appropriate type to use when performing postmortem care?
A.
B.
C.
D.
94.  Several clients are admitted to an adult medical unit. The nurse would expect airborne precautions for a client with which of the following medical conditions?
A.
B.
C.
D.
95.  A 5 years old child has been admitted to the pediatric unit after swallowing a household cleaner. Which of these findings is more commonly associated with the fact that the poison was a corrosive?
A.
B.
C.
D.
96.  A three year-old child is treated in the emergency room after ingestion of an ounce from a liquid narcotic bottle. What action should the nurse take first?
A.
B.
C.
D.
97.  Which of these actions is the first priority in the prevention of infections, whether in the hospital or home setting?
A.
B.
C.
D.
98.  A school nurse plans to reinforce information about the most effective methods to prevent the spread of head lice in school age children at a teacher's conference . The most appropriate information to give would be that
A.
B.
C.
D.
99.  A 14 years child goes into seizures. Which nursing action is a priority for a client during a seizure
A.
B.
C.
D.
100.  Which of these protocols would be essential for the nurse to implement during the care of a client with active tuberculosis?
A.
B.
C.
D.
101.  X-RN A client with a diagnosis of methicillin resistant staphylococcus aureus (MRSA) has died. Which type of transmission-based precautions is the appropriate type to use when performing postmortem care?
A.
B.
C.
D.
102.  The mother of an infant who is being treated for pesticide poisoning asks why activated charcoal is the treatment. What is the nurse's best response?
A.
B.
C.
D.
103.  Several clients are admitted to an adult medical unit. The nurse would expect airborne precautions for a client with which of the following medical conditions?
A.
B.
C.
D.
104.  Which nursing diagnosis would indicate that an 86 year-old client is at greatest risk for falls?
A.
B.
C.
D.
105.  A three year-old child is treated in the emergency room after ingestion of an ounce from a liquid narcotic bottle. What action should the nurse take first?
A.
B.
C.
D.
106.  In addition to handwashing, an appropriate infection control intervention during the care of a newly admitted adult client with a diagnosis of Hepatitis A would be which action?
A.
B.
C.
D.
107.  A school nurse plans to reinforce information about the most effective methods to prevent the spread of head lice in school age children at a teacher's conference . The most appropriate information to give would be that
A.
B.
C.
D.
108.  The nurse is assigned to a client with HIV infection. The client also has a secondary herpes simplex 1 (HSV 1) infection. The nurse knows that the most likely cause of the HSV 1 infection is which of these items?
A.
B.
C.
D.
109.  A child is admitted to the pediatric unit with a diagnosis of suspected meningococcal meningitis. Which of these nursing actions should the nurse expect to do first?
A.
B.
C.
D.
110.  A nurse is reinforcing teaching with a client about compromised host precautions. The client is receiving filgrastim (Neupogen) for neutropenia. The selection of which lunch suggests the client has learned about necessary dietary changes?
A.
B.
C.
D.
111.  The nurse is responsible for assisting in the decisions about client room assignments. Which of these possible roommates would be most appropriate for a three year-old child with minimal change nephrotic syndrome?
A.
B.
C.
D.
112.  A ten year-old child has a history of tonic-clonic seizures. The school nurse should instruct the classroom teacher that if the child experiences a seizure in the classroom, the most important action during the seizure activity would be to
A.
B.
C.
D.
113.  Which of these protocols would be essential for the nurse to implement during the care of a client with active tuberculosis?
A.
B.
C.
D.
114.  An outpatient client is scheduled to receive an oral solution of radioactive iodine. In order to reduce hazards, the nurse should reinforce to the client that
A.
B.
C.
D.
115.  The mother of an infant who is being treated for pesticide poisoning asks why activated charcoal is the treatment. What is the nurse's best response?
A.
B.
C.
D.
116.  What is the primary nursing intervention to limit transmission of organisms for a client with a salmonella infection?
A.
B.
C.
D.
117.  Which nursing diagnosis would indicate that an 86 year-old client is at greatest risk for falls?
A.
B.
C.
D.
118.  A two 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 of these nursing actions should be the priority?
A.
B.
C.
D.
119.  In addition to handwashing, an appropriate infection control intervention during the care of a newly admitted adult client with a diagnosis of Hepatitis A would be which action?
A.
B.
C.
D.
120.  Scoliosis a C S curvature of the spine; it cna a temporary or permanent condidtion. At what time would the nurse expect early findings of scoliosis to appear?                                                                                      
A.
B.
C.
D.
121.  The nurse is assigned to a client with HIV infection. The client also has a secondary herpes simplex 1 (HSV 1) infection. The nurse knows that the most likely cause of the HSV 1 infection is which of these items?
A.
B.
C.
D.
122.  The nurse is gathering data from a client who states her last menstrual period was March 16, and she has missed one period. She reports episodes of nausea and vomiting. After confirming pregnancy, the nurse calculates the estimated date of delivery (EDD) to be about:
A.
B.
C.
D.
123.  A child is admitted to the pediatric unit with a diagnosis of suspected meningococcal meningitis. Which of these nursing actions should the nurse expect to do first?
A.
B.
C.
D.
124.  In taking the history of a pregnant woman, which factor would the nurse recognize as the primary contraindication for breast feeding?
A.
B.
C.
D.
125.  A nurse is reinforcing teaching with a client about compromised host precautions. The client is receiving filgrastim (Neupogen) for neutropenia. The selection of which lunch suggests the client has learned about necessary dietary changes?
A.
B.
C.
D.
126.  While caring for a client, the nurse notes a pulsating mass in the client's periumbilical area. Which of the following actions is appropriate for the nurse to perform?
A.
B.
C.
D.
127.  The nurse is responsible for assisting in the decisions about client room assignments. Which of these possible roommates would be most appropriate for a three year-old child with minimal change nephrotic syndrome?
A.
B.
C.
D.
128.  A ten year-old child has a history of tonic-clonic seizures. The school nurse should instruct the classroom teacher that if the child experiences a seizure in the classroom, the most important action during the seizure activity would be to
A.
B.
C.
D.
129.  The nurse will administer liquid medicine to a nine month-old child. Which method is appropriate?
A.
B.
C.
D.
130.  An outpatient client is scheduled to receive an oral solution of radioactive iodine. In order to reduce hazards, the nurse should reinforce to the client that
A.
B.
C.
D.
131.  A 52 year-old post menopausal woman asks the nurse how frequently she should have a mammogram. The nurse's best response is:
A.
B.
C.
D.
132.  What is the primary nursing intervention to limit transmission of organisms for a client with a salmonella infection?
A.
B.
C.
D.
133.  The hospice nurse is visiting a 75 year-old client with end-stage cancer. For chronic malignant pain management in this client the nurse understands that:
A.
B.
C.
D.
134.  A two 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 of these nursing actions should be the priority?
A.
B.
C.
D.
135.  The nurse is assisting with teaching a group of college students about breast self-examination. A woman asks when to perform the monthly exam. The appropriate reply by the nurse would be which of these?
A.
B.
C.
D.
136.  Scoliosis a C S curvature of the spine; it cna a temporary or permanent condidtion. At what time would the nurse expect early findings of scoliosis to appear?                                                                                      
A.
B.
C.
D.
137.  The nurse observes a newborn whose Apgar score was 8 and 9. This score would be most closely associated with which of these areas?
A.
B.
C.
D.
138.  The nurse is gathering data from a client who states her last menstrual period was March 16, and she has missed one period. She reports episodes of nausea and vomiting. After confirming pregnancy, the nurse calculates the estimated date of delivery (EDD) to be about:
A.
B.
C.
D.
139.  Which action would be the best strategy for the nurse to use when reinforcing insulin injection techniques to a newly diagnosed adult client with diabetes mellitus?
A.
B.
C.
D.
140.  In taking the history of a pregnant woman, which factor would the nurse recognize as the primary contraindication for breast feeding?
A.
B.
C.
D.
141.  The nurse is caring for a client who is four days post-op for a transverse colostomy. The client is ready for discharge and asks the nurse to empty the colostomy pouch. The nurse's best response to the client is:
A.
B.
C.
D.
142.  While caring for a client, the nurse notes a pulsating mass in the client's periumbilical area. Which of the following actions is appropriate for the nurse to perform?
A.
B.
C.
D.
143.  While giving nursing care to a hospitalized adolescent, the nurse should be aware that the major threat felt by the hospitalized adolescent is :
A.
B.
C.
D.
144.  The nurse will administer liquid medicine to a nine month-old child. Which method is appropriate?
A.
B.
C.
D.
145.  A 52 year-old post menopausal woman asks the nurse how frequently she should have a mammogram. The nurse's best response is:
A.
B.
C.
D.
146.  The hospice nurse is visiting a 75 year-old client with end-stage cancer. For chronic malignant pain management in this client the nurse understands that:
A.
B.
C.
D.
147.  The nurse is assisting with teaching a group of college students about breast self-examination. A woman asks when to perform the monthly exam. The appropriate reply by the nurse would be which of these?
A.
B.
C.
D.
148.  The nurse observes a newborn whose Apgar score was 8 and 9. This score would be most closely associated with which of these areas?
A.
B.
C.
D.
Discuss this Question
149.  Which action would be the best strategy for the nurse to use when reinforcing insulin injection techniques to a newly diagnosed adult client with diabetes mellitus?
A.
B.
C.
D.
150.  The nurse is caring for a client who is four days post-op for a transverse colostomy. The client is ready for discharge and asks the nurse to empty the colostomy pouch. The nurse's best response to the client is:
A.
B.
C.
D.
151.  While giving nursing care to a hospitalized adolescent, the nurse should be aware that the major threat felt by the hospitalized adolescent is :
A.
B.
C.
D.
152.  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 check for
A.
B.
C.
D.
153.  A client is admitted to the hospital with a history of confusion. The client has difficulty remembering recent events and beccomes lost when she leaves home. Which statement would provide the best reality orientation for this client?
A.
B.
C.
D.
154.  A client says, "It's raining outside and it's raining in my heart. Did you know that St. Patrick drove the snakes out of Ireland? I've never been to Ireland." The nurse reviews this data and determines that this client is experiencing a speech pattern commonly seen in manic episodes called
A.
B.
C.
D.
155.  The parents of a child who has suddenly been hospitalized for an acute illness state that they should have taken the child to the pediatrician earlier. Which approach by the nurse is appropriate?
A.
B.
C.
D.
156.  Mr. Reynolds, 69 years of age, is found unconscious by his wife at 7:00 a.m. An ambulance is summoned by the physician, and Mr. Reynolds is admitted to the medical unit, where you work as a practical nurse, with a diagnosis of cerebral vascular accident (CVA). As you assist the team leader with the admission process, you note a previous history of hypertension. His wife has also revealed that Mr. Reynolds complained of a headache before retiring the night before. In addition to the headache and hypertension, which of the following symptoms would you expect Mr. Reynolds to exhibit?
A.
B.
C.
D.
157.  Mr. Reynolds, 69 years of age, is found unconscious by his wife at 7:00 a.m. An ambulance is summoned by the physician, and Mr. Reynolds is admitted to the medical unit, where you work as a practical nurse, with a diagnosis of cerebral vascular accident (CVA). As you assist the team leader with the admission process, you note a previous history of hypertension. His wife has also revealed that Mr. Reynolds complained of a headache before retiring the night before. The team leader instructs you to remove Mr. Reynolds's dentures. You do so because
A.
B.
C.
D.
158.  Mr. Reynolds, 69 years of age, is found unconscious by his wife at 7:00 a.m. An ambulance is summoned by the physician, and Mr. Reynolds is admitted to the medical unit, where you work as a practical nurse, with a diagnosis of cerebral vascular accident (CVA). As you assist the team leader with the admission process, you note a previous history of hypertension. His wife has also revealed that Mr. Reynolds complained of a headache before retiring the night before. Unresponsive patients like Mr. Reynolds may develop a drying of the cornea, which is usually caused by
A.
B.
C.
D.
159.  Marty Cole, 7 years old, is admitted to the pediatric service with a diagnosis of juvenile diabetes mellitus. He has not been under treatment previously. As a practical nurse, you would expect Marty to exhibit all of the following symptoms EXCEPT
A.
B.
C.
D.
160.  Marty Cole, 7 years old, is admitted to the pediatric service with a diagnosis of juvenile diabetes mellitus. He has not been under treatment previously. Because Marty is so young and because his mother works, it is decided to start him on
A.
B.
C.
D.
161.  Marty Cole, 7 years old, is admitted to the pediatric service with a diagnosis of juvenile diabetes mellitus. He has not been under treatment previously. When counseling Marty about his diabetes and its treatment, you would advise against eating
A.
B.
C.
D.
162.  Which one of the following statements best describes the effects of immobility in children?
A.
B.
C.
D.
163.  A client with heart failure has been instructed by the RN about proper nutrition. The selection of which lunch indicates the client has learned about sodium restriction?
A.
B.
C.
D.
164.  After a client has an intestinal feeding tube inserted, the most accurate method for verification of placement is
A.
B.
C.
D.
165.  Which of the following agents should be avoided by clients on methotrexate therapy?
A.
B.
C.
D.
166.  The visiting nurse makes a postpartum home visit to a married female client. Upon arrival, the nurse observes that the client has a black eye and numerous bruises on her arms and legs. The next nursing intervention would be to
A.
B.
C.
D.
167.  A client is admitted with severe injuries from an auto accident. The client's vital signs are BP 120/50, pulse rate 110, and respiratory rate of 28. The initial nursing intervention would be to
A.
B.
C.
D.
168.  The client is receiving an intravenous piggyback infusion of penicillin. Which client statement would require the nurse's immediate attention?
A.
B.
C.
D.
169.  The nurse is caring for a client who is receiving TPA (altipase) For a cerebral vascular accident (CVA). Which of these nursing interventions should receive priority?
A.
B.
C.
D.
170.  Before administering digoxin (Lanoxin) to a client, which nursing action is a priority?
A.
B.
C.
D.
171.  When reinforcing teaching to a depressed client about a new prescription for nortriptyline (Pamelor), the nurse must emphasize
A.
B.
C.
D.
172.  The nurse checks a client with chronic obstructive pulmonary disease. The client has oxygen per mask for low PaO2 levels. A nursing priority would be to:
A.
B.
C.
D.
173.  The nurse is assisting in the assessment of a client's home in preparation for discharge. Which focus should be given priority consideration?
A.
B.
C.
D.
174.  The nurse is caring for a two month-old infant with a congenital heart defect. Which of the following is a priority nursing action?
A.
B.
C.
D.
175.  The best action to establish correct placement of a gastric tube is for the nurse to
A.
B.
C.
D.
Discuss this Question
176.  The nurse is working in a high risk antepartal clinic. A 40 year-old woman in the first trimester gives a thorough health history. Which of the following collected data should receive priority attention by the nurse?
A.
B.
C.
D.
177.  The nurse is checking a woman in early labor. While positioning for a vaginal exam, she complains of dizziness and nausea and appears pale. Her blood pressure has dropped slightly. What is the appropriate initial nursing action?
A.
B.
C.
D.
178.  The nurse is caring for a client several days following a cerebral vascular accident (CVA). Coumadin (warfarin) has been prescribed. Today's prothrombin level is abnormally elevated. Which item is a priority to check?
A.
B.
C.
D.
179.  The nurse is caring for a client who is receiving procainamide (Pronestyl) intravenously. What is a priority for the nurse to do for her client?
A.
B.
C.
D.
180.  A client is receiving a nitroglycerin (NTG) infusion for unstable angina. What would be a priority for monitoring the effects of this medication?
A.
B.
C.
D.
181.  The partner of a client with Alzheimer's disease expresses concern about the burden of caregiving. Which action by the nurse should be a priority?
A.
B.
C.
D.
182.  A nurse is to collect a sputum specimen for acid-fast bacillus (AFB) from a client. Which action should the nurse take first?
A.
B.
C.
D.
183.  Following change-of-shift report on an orthopedic unit, which client should the nurse see first?
A.
B.
C.
D.
184.  The nurse is caring for a post-operative client who develops an abdominal wound evisceration. The first nursing intervention should be to
A.
B.
C.
D.
185.  Postoperative nursing care for an infant who has had a pyloromyotomy would include which of these items?
A.
B.
C.
D.
186.  A client receives high doses of potassium over 30 minutes. Which is a priority to check prior to giving this medication?
A.
B.
C.
D.
187.  A nurse is to administer meperidine hydrochloride (Demerol) 100 mg, atropine sulfate (Atropisol) 0.4 mg, and promethizine hydrochloride (Phenergan) 50 mg IM to a pre-operative client. Which action should the nurse take first?
A.
B.
C.
D.
188.  A client calls the PN because of an onset of chest pain. Which of these statements would require the most immediate action?
A.
B.
C.
D.
189.  Ms. O'Brien is bedridden. The nurse is evaluating whether the family members understand how to position the client correctly. Which of the following should the nurse observe?
A.
B.
C.
D.
190.  A victim of a motor vehicle accident is brought to the emergency room via ambulance in hypovolemic shock. When placing the client in a modified Trendelenburg position, the nurse should place the client
A.
B.
C.
D.
191.  Ms. Jordan is bedridden and positioned on her right side. There is a pillow beneath her head. Her right arm is extended near her hip. Her left leg is extended and parallel with the right leg. Which of the following is correct?
A.
B.