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Nclex-rn Exam Free Review By Nclex Masters

265 Questions  I  By Rneducator
Nclex-RN Exam FREE Review by Nclex Masters
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1.  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.
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.  Dorreen an adolescent female is newly diagnosed with bulimia. The nurse is reinforcing instructions to the client and her parents about the theraputic benefits of Tofranil. Which statement demonstrates an understanding by the client?
A.
B.
C.
D.
4.  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.
5.  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.
6.  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.
7.  Which of the followwing entries in the progress notes of a client is the most complete?
A.
B.
C.
D.
8.  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.
9.  The nurse is reinforcing teaching about the use of nonsteroidal anti-inflammatory (NSAIDs) drugs to a group of arthritic clients. To minimize the side effects, the nurse should emphasize
A.
B.
C.
D.
10.  Mr. Lowell is brought in after a motor vehicle accident. He has suffered a head injury and possible spinal injury. When moving him from the stretcher to the bed, the nurse should do the following
A.
B.
C.
D.
11.  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.
12.  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.
13.  Which nursing diagnosis would indicate that an 86 year-old client is at greatest risk for falls?
A.
B.
C.
D.
14.  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.
15.  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.
16.  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.
17.  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.
18.  Which of these points should be reinforced during the discharge instructions to a client who is prescribed warfarin sodium (Coumadin) for the next six months?
A.
B.
C.
D.
19.  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.
20.  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.
21.  A client with chronic obstructive pulmonary disease (COPD) and a history of coronary artery disease is receiving Aminophylline, 25mg/hour. Which finding by the nurse would require immediate intervention?
A.
B.
C.
D.
22.  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.
23.  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.
24.  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.
25.  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.
26.  7.    Bumping into a crib, the nurse notices that the newborn infant demonstrates the Moro (startle) reflex. This is seen as the following:
A.
B.
C.
D.
27.  Which of the following is least likely to influence the potential for patient to comply with lithium therapy after discharge?
A.
B.
C.
D.
28.  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.
29.  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.
30.  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.
31.  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.
32.  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.
33.  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.
34.  The nurse will administer liquid medicine to a nine month-old child. Which method is appropriate?
A.
B.
C.
D.
35.  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.
36.  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.
37.  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.
38.  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.
39.  The best action to establish correct placement of a gastric tube is for the nurse to
A.
B.
C.
D.
40.  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.
41.  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.
42.     Mr. Manor's family brought him into the hospital because of his many somatic complaints. He has been seen by many medical specialists in     the past without discovery of organic pathology  .The nurse assesses that Mr. Manor is experiencing which of the following problems?            
A.
B.
C.
D.
43.  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.
44.  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.
45.  When reinforcing teaching to a depressed client about a new prescription for nortriptyline (Pamelor), the nurse must emphasize
A.
B.
C.
D.
46.  Mr. Warren, a client with paranoid schizophrenia, has a delusion of persecution. He tells the nurse, "They are out to get me. They're spying on me." The nurse's best initial response is :
A.
B.
C.
D.
47.  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.
48.  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.
49.  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.
50.  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.
51.  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.
52.  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.
53.  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.
54.  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.
55.  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.
56.  Which one of the following statements best describes the effects of immobility in children?
A.
B.
C.
D.
57.   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.
58.  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.
59.  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.
60.  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.
61.  A client has been taking Procardia for Raynaud's disease and hypertension. Which finding would indicate that the client may be having a side effect of the medication?
A.
B.
C.
D.
62.  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.
63.  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.
64.  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.
65.  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.
66.  Postoperative nursing care for an infant who has had a pyloromyotomy would include which of these items?
A.
B.
C.
D.
67.  Mr. C. has just been admitted for acute asthma exacerbation and placed in a high Fowler's position. The nurse knows this position is best because it
A.
B.
C.
D.
68.  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.
69.  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.
70.  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.
71.  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.
72.  Mrs. Wyatt is hospitalized for treatment of a conversion disorder. She complained of paralysis of her right side after her husband threatened to leave her and their children. She seems unconcerned about her paralysis. An appropriate long-term goal for the nurse to formulate is that Mrs. Waytt. will
A.
B.
C.
D.
73.  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.
74.  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.
75.  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.
76.  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.
77.  A 14 years child goes into seizures. Which nursing action is a priority for a client during a seizure
A.
B.
C.
D.
78.  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.
79.  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.
80.  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.
81.  The nurse should be informed about cultural issues related to the client's background because one of the following:
A.
B.
C.
D.
82.  During the focused assessment of a client with major depression, the nurse may ask which of the following questions?
A.
B.
C.
D.
83.  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.
84.  What is the primary nursing intervention to limit transmission of organisms for a client with a salmonella infection?
A.
B.
C.
D.
85.  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.
86.  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.
87.  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.
88.  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.
89.  For which procedure would the nurse use aseptic technique and which would require the nurse to use sterile technique?
A.
B.
C.
D.
90.  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.
91.  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.
92.  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.
93.  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.
94.  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.
95.  The client is receiving an intravenous piggyback infusion of penicillin. Which client statement would require the nurse's immediate attention?
A.
B.
C.
D.
96.  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.
97.  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.
98.  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.
99.  The nurse would reinforce the need to take alendronate (Fosamax) as prescribed by the physician,
A.
B.
C.
D.
100.  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.
101.  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.
102.  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.
103.  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.
104.  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.
105.  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.
106.  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.
107.  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.
108.  A 14 years child goes into seizures. Which nursing action is a priority for a client during a seizure
A.
B.
C.
D.
109.  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.
110.  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.
111.  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.
112.  An adult woman is seen in the clinic for treatment of a minor burn. While assessing the woman the nurse obtains data suggesting that the client has developed hyperthyroidism. Which data are most suggestive of hyperthyroidism?
A.
B.
C.
D.
113.  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.
114.  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.
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.  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.
117.  When a client is diagnosed with tuberculosis, the public health department is to be notified for what reason?
A.
B.
C.
D.
118.  An elderly male client is transferred to a skilled nursing facility from the hospital because he is unable to ambulate due to a left femoral fracture. When doing a skin assessment, the nurse notices a 3-cm, round area partial thickness skin loss that looks like a blister on the client's sacrum. The nurse knows this is a
A.
B.
C.
D.
119.  Which of the following agents should be avoided by clients on methotrexate therapy?
A.
B.
C.
D.
120.  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.
121.  The community health nurse is making a newborn follow-up home visit. During the visit the two-year-old sibling has a temper tantrum. The parent asks the nurse for guidance in dealing with the toddler's temper tantrums. Which of the following is the most appropriate nursing action?
A.
B.
C.
D.
122.  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.
123.  When evaluating a client with a pressure ulcer, the nurse understands that the best response to treatment of the sacral pressure ulcer on a client with a hip fracture would be indicated by
A.
B.
C.
D.
124.  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.
125.  Which one of these tasks could be assigned to the certified nursing assistant (cna)? 
A.
B.
C.
D.
126.  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.
127.  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.
128.  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.
129.  While giving an adult a tepid sponge bath to reduce his temperature, the nurse notes that the client is shivering. The nurse correctly interprets this to mean  
A.
B.
C.
D.
130.  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.
131.  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.
132.  The nurse should be informed about cultural issues related to the client's background because one of the following:
A.
B.
C.
D.
133.  Mr. A. has sprained his ankle. The physician would order cold applied to the injured area to
A.
B.
C.
D.
134.  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.
135.  Which newly admitted client would be most appropriate to assign to the unlicensed assistive personnel (UAP)?
A.
B.
C.
D.
136.  Which of these actions is the first priority in the prevention of infections, whether in the hospital or home setting?
A.
B.
C.
D.
137.  After a client has an intestinal feeding tube inserted, the most accurate method for verification of placement is
A.
B.
C.
D.
138.  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.
139.  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.
140.  Which one of these tasks could be assigned to the certified nursing assistant (cna)? 
A.
B.
C.
D.
141.  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.
142.  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.
143.  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.
144.  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.
145.  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.
146.  Following change-of-shift report on an orthopedic unit, which client should the nurse see first?
A.
B.
C.
D.
147.  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.
148.  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.
149.  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.
150.  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.
151.  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.
152.  What is the primary nursing intervention to limit transmission of organisms for a client with a salmonella infection?
A.
B.
C.
D.
153.  Before administering digoxin (Lanoxin) to a client, which nursing action is a priority?
A.
B.
C.
D.
154.  A nurse observes a family member administer a rectal suppository by having the client lie on the left side for the administration. The family member pushed the suppository until the finger went up to the second knuckle. After 10 minutes the client was told by the family member to turn to the right side and the client did this. What is the appropriate comment for the nurse to make?
A.
B.
C.
D.
155.  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.
156.  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.
157.  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.
158.  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.
159.  The nurse uses a wide stance when moving a heavy box of supplies. Which of the following is the best reason the nurse would do this? Because it
A.
B.
C.
D.
160.  The nurse would anticipate that an eight month-old would be able to  do one or more of the following:
A.
B.
C.
D.
161.  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.
162.  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.
163.  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.
164.  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.
165.  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.
166.  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.
167.  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.
168.  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.
169.  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.
170.  The nurse should begin considering discharge concerns for a hospitalized client considering one fo of the following:
A.
B.
C.
D.
171.  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.
172.  19.    The nurse is caring for a 48-hour full-term infant whose mother abused cocaine and heroin throughout pregnancy. The mother does not wish to go into rehabilitation at this time. The nursing care plan should include which of the following?            
A.
B.
C.
D.
173.  The nurse is preparing to administer lithium (Eskalith) to a client with bipolar disorder. The client complains of nausea and muscle weakness, and his speech is slurred. His lithium level is 1.6 mEq/L. The best action for the nurse to take is to
A.
B.
C.
D.
174.  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.
175.  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.
176.  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.
177.  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.
178.  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.
179.  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.
180.  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.
181.  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.
182.  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.
183.  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.
184.  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.
185.  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.
186.  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.
187.  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.
188.  Which of these actions is the first priority in the prevention of infections, whether in the hospital or home setting?
A.
B.
C.
D.
189.  When a client is diagnosed with tuberculosis, the public health department is to be notified for what reason?
A.
B.
C.
D.
190.  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.
191.  A 14 month-old child ingested half a bottle of aspirin tablets. Which finding would the nurse expect to see in the child?
A.