NCLEX-rn Exam Free Review By NCLEX Masters

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1.  The nurse should begin considering discharge concerns for a hospitalized client considering one fo of the following:
A.
B.
C.
D.
2.  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.
3.  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.
4.  Ms. W. has a draining pressure ulcer on her sacrum and is to be discharged to her daughter's care. The nurse has taught Ms. W.'s daughter to perform dressing changes. Which observation by the nurse indicates the daughter's technique is done correctly? The daughter
A.
B.
C.
D.
5.  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.
6.  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.
7.  The nurse is to open a sterile package from central supply. Which is the correct direction to open the first flap?
A.
B.
C.
D.
8.  The nurse would reinforce the need to take alendronate (Fosamax) as prescribed by the physician,
A.
B.
C.
D.
9.  The nurse in the delivery room is caringfor the newborn. Which action is the most important and most immediate action for the nurse to take?
A.
B.
C.
D.
10.  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.
11.  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.
12.  Postoperative nursing care for an infant who has had a pyloromyotomy would include which of these items?
A.
B.
C.
D.
13.  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.
14.  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.
15.  The nurse would anticipate that an eight month-old would be able to  do one or more of the following:
A.
B.
C.
D.
16.  A 14 years child goes into seizures. Which nursing action is a priority for a client during a seizure
A.
B.
C.
D.
17.  Which of the followwing entries in the progress notes of a client is the most complete?
A.
B.
C.
D.
18.  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.
19.  A young adult is involuntarily admitted to the psychiatric unit in a manic state. Upon arrival on the unit he is unable to sit, and it is very difficult to follow what he is saying because of the rate and content of speech. He is very provocative and refuses to eat or drink. The area of disturbance that poses the greatest physical danger to this client is
A.
B.
C.
D.
20.  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.
21.  After a client has an intestinal feeding tube inserted, the most accurate method for verification of placement is
A.
B.
C.
D.
22.  Which of the followwing entries in the progress notes of a client is the most complete?
A.
B.
C.
D.
23.  Which of these actions best describes the application of time management strategies for the role of the PN charge nurse?
A.
B.
C.
D.
24.  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.
25.  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.
26.  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.
27.  Mr. D. has a disorder of the hypothalamus and is on a hypothermia blanket. The nurse should make which of the following assessments?
A.
B.
C.
D.
28.  The nurse recognizes that the client with posttraumatic stress disorder (PTSD), is improving when he
A.
B.
C.
D.
29.  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.
30.  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.
31.  Ms. L. is to go home with her family. The nurse is evaluating that the family members can correctly move Ms. L. from the bed to a chair. Which of the following should be seen?
A.
B.
C.
D.
32.  Ms. F. suffered a stroke and has right-sided hemiparesis. The nurse is going to transfer her from bed to wheelchair. Which of the following is the best method?
A.
B.
C.
D.
33.  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.
34.  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.
35.  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.
36.  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.
37.  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.
38.  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.
39.  Mrs. F. has remained close to the nurse all day. When the nurse talked with other clients during dinner, Mrs. F. tried to regain the nurse's attention and then began to shout "You're just like my mother. You pay attention to everyone but me!" The best interpretation of this behavior is that
A.
B.
C.
D.
40.  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.
41.  A client with heart failure has a prescription for digoxin. The nurse is aware that sufficient potassium should be included in the diet because hypokalemia in combination with this medication
A.
B.
C.
D.
42.  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.
43.  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.
44.  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.
45.  The physician's orders for Mr. C. include warm compresses to the left leg three times a day for treatment of an open wound. The nurse should
A.
B.
C.
D.
46.  When a client is diagnosed with tuberculosis, the public health department is to be notified for what reason?
A.
B.
C.
D.
47.  Miss Peters is found wandering on campus after a fraternity party. She is disheveled and does not know who she is. She has no recollection of the evening. She is diagnosed with dissociative amnesia subsequent to a rape. The most appropriate nursing diagnosis for the nurse to formulate is :
A.
B.
C.
D.
48.  What is the primary nursing intervention to limit transmission of organisms for a client with a salmonella infection?
A.
B.
C.
D.
49.  For which procedure would the nurse use aseptic technique and which would require the nurse to use sterile technique?
A.
B.
C.
D.
50.  Mr. T. is a C4 quadriplegic in a nursing home. Which of the following techniques would the nurse use to transfer him from bed to wheelchair?
A.
B.
C.
D.
51.  Randy, age 8, is admitted with rheumatic fever. Which clinical finding indicates to the nurse that Randy needs to continue taking the salicylates he had received at home?
A.
B.
C.
D.
52.  The nurse is to apply a dressing to a stage II pressure ulcer. Which of the following dressings is best?
A.
B.
C.
D.
53.  Which of the following nursing diagnoses would be most appropriate for a client who is diagnosed as bipolar I disorder, single manic episode and is intrusive, argumentative, and severely critical of peers?
A.
B.
C.
D.
54.  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.
55.  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.
56.  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.
57.  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.
58.  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.
59.  The mother of a three-month-old infant asks the nurse when she can start feeding her baby solid food. Which of the following should the nurse include in teaching this mother about the nutritional needs of infants?
A.
B.
C.
D.
60.  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.
61.  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.
62.  The nurse knows which of the following is the proper technique for medical asepsis selecting:
A.
B.
C.
D.
63.  The nurse will administer liquid medicine to a nine month-old child. Which method is appropriate?
A.
B.
C.
D.
64.  The parent of a three-year-old child brings the child to the clinic for a well child checkup. Which of these assessment findings made by the nurse is an area of concern and requires further investigation?
A.
B.
C.
D.
65.  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.
66.  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.
67.  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.
68.  The nurse should begin considering discharge concerns for a hospitalized client considering one fo of the following:
A.
B.
C.
D.
69.  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.
70.  The best action to establish correct placement of a gastric tube is for the nurse to
A.
B.
C.
D.
71.  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.
72.  Before administering digoxin (Lanoxin) to a client, which nursing action is a priority?
A.
B.
C.
D.
73.  A client is recovering from a hip replacement and is taking Tylenol #3 every 3 hours for pain. In checking the client, which finding suggests a side effect of the analgesic?
A.
B.
C.
D.
74.  Which nursing diagnosis would indicate that an 86 year-old client is at greatest risk for falls?
A.
B.
C.
D.
75.  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.
76.  An adult is in an acute manic phase of bipolar disorder. He talks and paces incessantly, frequently shouting and threatening other clients. The nurse expects the client's care plan to include which of the following?
A.
B.
C.
D.
77.  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.
78.  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.
79.  The nurse is giving anticipatory guidance regarding safety and injury prevention to the parents of an 18-month-old toddler. Which of the following actions by the parents indicates understanding of the safety needs of a toddler?
A.
B.
C.
D.
80.  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.
81.  A young man was arrested by the police for indecent exposure, loitering, and disturbing the peace. He became hyperactive, stripped off his clothes, and terrorized people living in the area near the house. He was then admitted to the psychiatric unit. Upon admission he was speaking very rapidly, and moved quickly around the unit, never sitting. He refused to eat or drink. The nursing diagnosis that would most appropriately describe the behavior that is of greatest concern is :
A.
B.
C.
D.
82.  A client with a panic disorder has a new prescription for Xanax (alpazolam). When reinforcing teaching to the client about the drug's actions and side effects, which item should the nurse emphasize?
A.
B.
C.
D.
83.  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.
84.  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.
85.  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.
86.  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.
87.  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.
88.  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.
89.  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.
90.  Which nursing diagnosis would indicate that an 86 year-old client is at greatest risk for falls?
A.
B.
C.
D.
91.  The health care provider has written "Morphine sulfate 2 mgs IV every three-to-four hours prn for pain" on the chart of an elderly client in an extended care facility. The PN has no other licensed persons working that shift. The initial action by the PN should be to
A.
B.
C.
D.
92.  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.
93.  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.
94.  Ms. P. is transferred to a skilled nursing facility from the hospital because she is unable to ambulate due to a left femoral fracture. The nurse knows Ms. P.'s greatest risk factor for developing a pressure ulcer is that she
A.
B.
C.
D.
95.  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.
96.  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.
97.  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.
98.  When planning for the care of a client with a pressure ulcer on the sacrum, the nurse would include which of the following?
A.
B.
C.
D.
99.  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.
100.  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.
101.  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.
102.  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.
103.  Which of these actions is the first priority in the prevention of infections, whether in the hospital or home setting?
A.
B.
C.
D.
104.  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.
105.  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.
106.  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.
107.  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.
108.  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.
109.  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.
110.  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.
111.  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.
112.  The nurse realizes that the discharge instructions given to a woman with placenta previa are understood when the nurse overhears the client tell her husband,
A.
B.
C.
D.
113.  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.
114.  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.
115.  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.
116.  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.
117.  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.
118.  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.
119.  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.
120.  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.
121.  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.
122.  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.
123.  A 14 years child goes into seizures. Which nursing action is a priority for a client during a seizure
A.
B.
C.
D.
124.  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.
125.  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.
126.  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.
127.  12.    A young woman with a history of bipolar disorder is admitted to the psychiatric unit. She is talking excitedly and walking rapidly around the unit. During the initial period of hospitalization, the nurse would most likely encourage the client to participate in group and therapeutic activities.
A.
B.
C.
D.
128.  Which of the following is least likely to influence the potential for patient to comply with lithium therapy after discharge?
A.
B.
C.
D.
129.  Which newly admitted client would be most appropriate to assign to the unlicensed assistive personnel (UAP)?
A.
B.
C.
D.
130.  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.
131.  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.
132.  Which of these actions is the first priority in the prevention of infections, whether in the hospital or home setting?
A.
B.
C.
D.
133.  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.
134.  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.
135.  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.
136.  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.
137.  A client is admitted for Lithium (Lithane) toxicity. Which finding should the nurse report immediately to the health care provider?
A.
B.
C.
D.
138.  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.
139.  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.
140.  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.
141.  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.
142.  When a client is diagnosed with tuberculosis, the public health department is to be notified for what reason?
A.
B.
C.
D.
143.  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.
144.  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.
145.  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.
146.  The nurse should be informed about cultural issues related to the client's background because one of the following:
A.
B.
C.
D.
147.  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.
148.  Which of these actions best describes the application of time management strategies for the role of the PN charge nurse?
A.
B.
C.
D.
149.  The nurse is caring for a 30-week baby girl who is currently receiving 15 ml of breast milk via oral gastric tube every three hours. As part of the routine assessment the nurse should assess which of the following?
A.
B.
C.
D.
150.   The nurse is talking with a mother to assess her child. A positive response to which question would indicate the child is in the anal stage of psychosexual development as described by Freud?
A.
B.
C.
D.
151.  Four-year-old Amy has been blind since birth. She has been attending a nursery program for the visually impaired. To continue independence in her activities of daily living, when her lunch tray arrives, the nurse will
A.
B.
C.
D.
152.  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.
153.  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.
154.  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.
155.  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.
156.  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.
157.  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.
158.  Which one of these tasks could be assigned to the certified nursing assistant (cna)? 
A.
B.
C.
D.
159.  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.
160.  The nurse monitors a client after the treatment of bradycardia with intravenous atropine sulfate. Which of these findings should be reported to the health care provider immediately?
A.
B.
C.
D.
161.  The nurse is assessing a six-month-old infant during a well child visit. The nurse makes all of the following observations. Which of the following assessments made by the nurse is an area of concern indicating a need for further evaluation?
A.
B.
C.
D.
162.  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.
163.  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.
164.  A nurse is part of a community task force on teenage suicide. The task force is considering all of the following steps in an effort to reduce teen suicide. Which action represents primary prevention?
A.
B.
C.
D.
165.  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.
166.  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.
167.  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.
168.  Mr. S. is to have a tepid sponge bath to lower his fever. What temperature should the nurse make the water?
A.
B.
C.
D.
169.  PharmacologyAn antibiotic (intramuscular) IM injection for a two year-old child is ordered. The total volume of the injection equals 2.0 ml The correct action is to
A.
B.
C.
D.
170.  Following change-of-shift report on an orthopedic unit, which client should the nurse see first?
A.
B.
C.
D.
171.  Which cognitive skill would the nurse expect a six-year-old child to be in the process of developing?
A.
B.
C.
D.
172.  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.
173.  The nurse finds, during the initial assessment of the star player on the basketball team, that he is not concerned about the sudden paralysis of his "shooting arm." This behavior is known as :
A.
B.
C.
D.
174.  The client is receiving an intravenous piggyback infusion of penicillin. Which client statement would require the nurse's immediate attention?
A.
B.
C.
D.
175.  The nurse is caring for a client with advanced cancer of the breast. She complains of hypoguesia. The nurse should recommend
A.
B.
C.
D.
176.  9.    Miss Rodriguez is an 88-year-old client at a long-term care facility. Prior to administering any medication or treatment to this client the nurse must confirm identity by asking the client if she is Miss Rodriguez
A.
B.
C.
D.
177.  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.
178.  What is the primary nursing intervention to limit transmission of organisms for a client with a salmonella infection?
A.
B.
C.
D.
179.  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.
180.  The nurse is dangling Ms. S. prior to transferring her from the bed to a wheelchair. Which of the following assessments is essential for the nurse to make before moving the client?
A.
B.
C.
D.
181.  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.
182.  Which one of the following statements best describes the effects of immobility in children?
A.
B.
C.
D.
183.  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.
184.  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.
185.  When Mr. C. is placed on a hypothermia blanket, which of the following should be included in the nursing care plan?
A.
B.
C.
D.
186.  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.
187.  Mr. A. has sprained his ankle. The physician would order cold applied to the injured area to
A.
B.
C.
D.
188.  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.