NCLEX-RN Exam Free Review By NCLEX Masters

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1. Which of these actions is the first priority in the prevention of infections, whether in the hospital or home setting?

Explanation

The correct answer is A: Handwashing. Handwashing remains the most effective way to avoid spreading infection. However, too often nurses do not practice good handwashing techniques and do not teach families to do so. Nurses need to wash their hands before and after touching the client. Note that all of the options are correct actions to prevent infection. However the most effective nurse action to prvent further infection is handwashing.

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About This Quiz
NCLEX-RN Exam Free Review By NCLEX Masters - Quiz

This NCLEX-RN Exam Review by Nclex Masters tests essential nursing skills and knowledge, covering topics like client communication, insulin management, and surgical preparations.

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2. 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?

Explanation

The correct answer is B: "Would you please clarify what you have written so I am sure I am reading it correctly?".

Assertive communication respects the rights and responsibilities of both parties. This statement is an honest expression of concern for safe practice and a request for clarification without self-depreciation. It reflects the right of the professional to give and receive information. Test-taking Tips: As you carefully read each answer option, compare them for the subjectivity or objectivity of the content. Ask yourself: Does the comment contain emotion, negative correction or belittling? If yes, then it is not an objective comment which would state the situation and the need.

Submit
3. A 14 years child goes into seizures. Which nursing action is a priority for a client during a seizure

Explanation

The correct answer is A: Protect the client from injury.

The priority during a seizure is to protect the client. Then, it is a priority to note, and then record, what movements are seen during a seizure. The diagnosis and subsequent treatment often rests on the seizure description. Suctioning may be done after seizure activity, as well as loosening clothing.

Submit
4. Which of these actions is the first priority in the prevention of infections, whether in the hospital or home setting?

Explanation

The correct answer is A: Handwashing. Handwashing remains the most effective way to avoid spreading infection. However, too often nurses do not practice good handwashing techniques and do not teach families to do so. Nurses need to wash their hands before and after touching the client. Note that all of the options are correct actions to prevent infection. However the most effective nurse action to prvent further infection is handwashing.

Submit
5. A 14 years child goes into seizures. Which nursing action is a priority for a client during a seizure

Explanation

The correct answer is A: Protect the client from injury.

The priority during a seizure is to protect the client. Then, it is a priority to note, and then record, what movements are seen during a seizure. The diagnosis and subsequent treatment often rests on the seizure description. Suctioning may be done after seizure activity, as well as loosening clothing.

Submit
6. 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? 　

Explanation

The correct answer is A: Solid foods are introduced one at a time beginning with cereal. Between four and six months, solid foods should be added one at a time to detect allergies or intolerance. If the infant is able to tolerate the food, another may be added in a week. Iron fortified cereal is the recommended first food.

Submit
7. 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?

Explanation

The correct answer is C: Eggs. The MMR antigens are derived from embryonic chicken eggs. Individuals with anaphylactic reactions to eggs, neomycin, or gelatin should not receive this vaccine.


Refer to www.nclex-masters.net/RNs_info for additional signals/symptoms information

Submit
8. 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:

Explanation

The correct answer is D: December 23. Naegele's rule: add seven days and subtract three months from the first day of the last regular menstrual period to calculate the estimated date of delivery.

Submit
9. 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:

Explanation

The correct answer is D: December 23. Naegele's rule: add seven days and subtract three months from the first day of the last regular menstrual period to calculate the estimated date of delivery.

Submit
10. A client states, "People think I'm no good, you know what I mean?" Which nursing response would be most therapeutic for this client?

Explanation

The correct answer is C: "I'm not sure what you mean. Tell me a bit more about that.". Therapeutic communication technique that elicits more information is delivered in an open non-judgmental fashion.

Submit
11. In taking the history of a pregnant woman, which factor would the nurse recognize as the primary contraindication for breast feeding?

Explanation

The correct answer is D: Uses cocaine on weekends.

Binge use of cocaine can be just as harmful to the breast fed newborn as regular daily use of cocaine.

Test-taking Tips:

The key words in this question are "primary factor which should be a contraindication for breast-feeding." As you read each option, ask yourself: Which of these would lead to the worst outcome for the infant receiving the feeding? This leads you to option 4.

Submit
12. 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? 　

Explanation

The correct answer is A: Solid foods are introduced one at a time beginning with cereal. Between four and six months, solid foods should be added one at a time to detect allergies or intolerance. If the infant is able to tolerate the food, another may be added in a week. Iron fortified cereal is the recommended first food.

Submit
13. 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: 　 　

Explanation

The best answer is C; helping the mother understand the child behavior is normal ressures her and help her deal with the child crying.

Submit
14. The nurse is observing a client with an obsessive-compulsive disorder in an inpatient setting. Which behavior is consistent with this diagnosis?

Explanation

The correct answer is A: Repeatedly checking that the door is locked. Behaviors that are repeated are symptomatic of obsessive-compulsive disorders. These behaviors often interfere with normal function and employment and are based in anxiety.

Submit
15. 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?

Explanation

The correct answer is B: "Would you please clarify what you have written so I am sure I am reading it correctly?".

Assertive communication respects the rights and responsibilities of both parties. This statement is an honest expression of concern for safe practice and a request for clarification without self-depreciation. It reflects the right of the professional to give and receive information. Test-taking Tips: As you carefully read each answer option, compare them for the subjectivity or objectivity of the content. Ask yourself: Does the comment contain emotion, negative correction or belittling? If yes, then it is not an objective comment which would state the situation and the need.

Submit
16. Privacy and confidentiality of client information is legally protected. In which of these situations would the nurse make an exception to this practice?

Explanation

The correct answer is B: The client threatens self-harm and/or harm to others. Privacy and confidentiality of all client information is protected with the exception of the client who threatens self harm or endangering the staff or the public.

Submit
17. Privacy and confidentiality of client information is legally protected. In which of these situations would the nurse make an exception to this practice?

Explanation

The correct answer is B: The client threatens self-harm and/or harm to others. Privacy and confidentiality of all client information is protected with the exception of the client who threatens self harm or endangering the staff or the public.

Submit
18. 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?

Explanation

The correct answer is C: Check the airway and breathing effort.Like any other intervention the first intervention is to assess breathing by checking airway. The first step in treatment of a toxic exposure or ingestion is to assess the airway and breathing. Circulation is secondary since the critical adverse effect of this drug class is respiratory depression. The other nursing actions would follow - options 4, then 2 then 1. .

Test-taking Tips:

The key words in this question are "nurse's first action" and a "three-year-old who ingested one ounce of a narcotic." Notice that options 1, 2, and 4 are interventions and option 3 is data collection. Remember, "first action" is "data collection." In addition, associate "narcotics with "depressed respirations." This line of thinking will lead you to option 3.

Submit
19. 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?

Explanation

The correct answer is B: Documentation of nursing actions on the client's record. Documentation is key for a nurse to be protected legally. Documentation should include all pertinent data with times, dosages and sites of actions, collected data, the nurse''s response to any change in a client's condition, specific actions taken, if and when other health care team members were notified and what the responses were.

Submit
20. 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:

Explanation

The correct answer is B: The client has a right to know about any prescribed or over-the-counter medications. Clients have a right to refuse treatment and to informed consent, including medication use and side effects.

Submit
21. 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

Explanation

The correct answer is C: The children are not to share hats and scarves. Head lice live only on human beings and can be spread easily by sharing hats, combs, scarves, coats and other items of clothing that touch the hair.

Submit
22. 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?

Explanation

The correct answer is A: Immunosuppression caused by the HIV infection.

The decreased immunity leads to frequent secondary infections. Herpes simplex virus 1 is an opportunistic infection.

Test-taking Tips:

If guessing, narrow your options down to the two that are similar but dissimilar. Here it would be options 1 and 2 in that they both focus on situations "caused by chronic disease." Associate HIV with the word "immunosuppression " in option 1. Think about what the option is saying in relation to the question. If you select option 2 it means that the cause of the herpes virus is emotional stress. This is unlikely since no data are in the stem to suggest stress.

Submit
23. In taking the history of a pregnant woman, which factor would the nurse recognize as the primary contraindication for breast feeding?

Explanation

The correct answer is D: Uses cocaine on weekends.

Binge use of cocaine can be just as harmful to the breast fed newborn as regular daily use of cocaine.

Test-taking Tips:

The key words in this question are "primary factor which should be a contraindication for breast-feeding." As you read each option, ask yourself: Which of these would lead to the worst outcome for the infant receiving the feeding? This leads you to option 4.

Submit
24. 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

Explanation

The correct answer is D: Protect the child from self injury. All of the options are correct since it is asking for the priority action. The child must be protected from injury during a seizure. Place a pillow, folded blanket or your hands under the child's head to prevent harm.

Submit
25. 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

Explanation

The correct answer is C. The patient's airway must be maintained. Therefore it is essential to remove anything, such as dentures, that may obstruct the airway.

Nursing process: planning.

Client need: safe, effective care environment.

Submit
26. 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

Explanation

The correct answer is C. A high Fowler's position allows maximal chest expansion and decreases hypoxia.

Submit
27. 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

Explanation

The correct answer is D. Handwashing should occur before donning the nonsterile gloves, when changing from nonsterile to sterile gloves, and after the procedure. This prevents the spread of microorganisms.

Submit
28. A client states, "People think I'm no good, you know what I mean?" Which nursing response would be most therapeutic for this client?

Explanation

The correct answer is C: "I'm not sure what you mean. Tell me a bit more about that.". Therapeutic communication technique that elicits more information is delivered in an open non-judgmental fashion.

Submit
29. 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:
　 　

Explanation

The best answer is C; helping the mother understand the child behavior is normal ressures her and help her deal with the child crying.

Submit
30. 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?

Explanation

The correct answer is A: Hold the tube feeding and notify the provider. A pH of less than four indicates that the tube is appropriately placed in the stomach, a highly acidic environment. A higher than 4 or more alkaline pH indicates intestinal placement which is incorrect.

Submit
31. 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?

Explanation

The correct answer is A: "Have the client sit on the side of the bed before starting to walk in the room.". Give clear information to the UAP about what is expected for client safety. The rule of specific delegation of outcomes applies in this case.

Submit
32. Which of the followwing entries in the progress notes of a client is the most complete?

Explanation

The correct answer is C: Dark green drainage of 100 ml from nasogastric tube in the last four hours.

Entries in clients' records need to be complete, accurate and factual. Records can only be used by third party payers for reimbursement if they are accurate, reliable and valid.

Test-taking Tips:

Remember that the "most complete" charting is the "most specific and detailed". Options 1, 2, and 4 are too "general" using the following words: "severe abdominal pain" without the location of the injection or specific site of the pain; "seems anxious" without specific behaviors; and "adequate" without specific numbers. This leaves you with option 3 as the only specific detailed answer. It is the most measurable. Specificity of actions by the patient and nursing intervention as critical part of documentation. Look for specific parameters.

Submit
33. 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:

Explanation

The correct answer is B: The client has a right to know about any prescribed or over-the-counter medications. Clients have a right to refuse treatment and to informed consent, including medication use and side effects.

Submit
34. 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?

Explanation

The correct answer is C: Check the airway and breathing effort.Like any other intervention the first intervention is to assess breathing by checking airway. The first step in treatment of a toxic exposure or ingestion is to assess the airway and breathing. Circulation is secondary since the critical adverse effect of this drug class is respiratory depression. The other nursing actions would follow - options 4, then 2 then 1. .

Test-taking Tips:

The key words in this question are "nurse's first action" and a "three-year-old who ingested one ounce of a narcotic." Notice that options 1, 2, and 4 are interventions and option 3 is data collection. Remember, "first action" is "data collection." In addition, associate "narcotics with "depressed respirations." This line of thinking will lead you to option 3.

Submit
35. 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

Explanation

The correct answer is D: Protect the child from self injury. All of the options are correct since it is asking for the priority action. The child must be protected from injury during a seizure. Place a pillow, folded blanket or your hands under the child's head to prevent harm.

Submit
36. 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?

Explanation

The correct answer is A: Immunosuppression caused by the HIV infection.

The decreased immunity leads to frequent secondary infections. Herpes simplex virus 1 is an opportunistic infection.

Test-taking Tips:

If guessing, narrow your options down to the two that are similar but dissimilar. Here it would be options 1 and 2 in that they both focus on situations "caused by chronic disease." Associate HIV with the word "immunosuppression " in option 1. Think about what the option is saying in relation to the question. If you select option 2 it means that the cause of the herpes virus is emotional stress. This is unlikely since no data are in the stem to suggest stress.

Submit
37. 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?
                                                                                      

Explanation

The correct answer is D: Preadolescent. Idiopathic scoliosis is seldom apparent before 10 years of age and is most noticeable at the beginning of the preadolescent growth spurt.

Submit
38. 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?

Explanation

The correct answer is D: Observe a return demonstration. Since this is a psychomotor skill, this is the best way to know if the client has learned the proper technique.

Submit
39. The nurse is caring for a post-operative client who develops an abdominal wound evisceration. The first nursing intervention should be to

Explanation

The correct answer is C: Cover the wound with sterile saline dressing. When evisceration occurs, the wound should FIRST be quickly covered with sterile dressings wet with sterile saline by sterile technique. Next would be to minimize tension on the site, option 4. Then pain is treated with the notification of the family last.

Submit
40. The nurse is observing a client with an obsessive-compulsive disorder in an inpatient setting. Which behavior is consistent with this diagnosis?

Explanation

The correct answer is A: Repeatedly checking that the door is locked. Behaviors that are repeated are symptomatic of obsessive-compulsive disorders. These behaviors often interfere with normal function and employment and are based in anxiety.

Submit
41. 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?

Explanation

The correct answer is A: "Have the client sit on the side of the bed before starting to walk in the room.". Give clear information to the UAP about what is expected for client safety. The rule of specific delegation of outcomes applies in this case.

Submit
42. Which of the followwing entries in the progress notes of a client is the most complete?

Explanation

The correct answer is C: Dark green drainage of 100 ml from nasogastric tube in the last four hours.

Entries in clients' records need to be complete, accurate and factual. Records can only be used by third party payers for reimbursement if they are accurate, reliable and valid.

Test-taking Tips:

Remember that the "most complete" charting is the "most specific and detailed". Options 1, 2, and 4 are too "general" using the following words: "severe abdominal pain" without the location of the injection or specific site of the pain; "seems anxious" without specific behaviors; and "adequate" without specific numbers. This leaves you with option 3 as the only specific detailed answer. It is the most measurable. Specificity of actions by the patient and nursing intervention as critical part of documentation. Look for specific parameters.

Submit
43. 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?

Explanation

The correct answer is A: Burning mouth and throat pain. Local irritation of tissues is most closely associated with a corrosive poisoning.Symptoms from swallowing hydrochloric acid may include:

Abdominal pain - severe
Breathing difficulty due to swelling of throat Chest pain - severe Drooling Fever Mouth pain - severe Rapid drop in blood pressure Throat pain - severe Vomiting blood

Submit
44. 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

Explanation

The correct answer is C: The children are not to share hats and scarves. Head lice live only on human beings and can be spread easily by sharing hats, combs, scarves, coats and other items of clothing that touch the hair.

Submit
45. 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?

Explanation

The correct answer is C: Four year-old with bilateral inguinal hernia repair.

The nurse must know that children with nephrotic syndrome have a higher risk for the development of infections as a result of the steroid therapy which has an immunosuppressant effect. Therefore, these children must be protected from sources of possible infection.

Test-taking Tips:

Notice that options 1 and 2 have "infectious situations" which would eliminate them as "most appropriate" roommates for a child with "nephrotic syndrome." Notice the age of the child in the stem of the question (three-year old). Ask yourself: Would it be better to place this child with a four-year old or a six-year old? If safety is not an issue, then roommates are better matched by age.

Submit
46. 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?

Explanation

The correct answer is D: Observe a return demonstration. Since this is a psychomotor skill, this is the best way to know if the client has learned the proper technique.

Submit
47. 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

Explanation

The correct answer is A. The fact that Ms. P. is chair-bound has the greatest impact on her developing pressure ulcers.

Submit
48. 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?

Explanation

The correct answer is A: Burning mouth and throat pain. Local irritation of tissues is most closely associated with a corrosive poisoning.Symptoms from swallowing hydrochloric acid may include:

Abdominal pain - severe
Breathing difficulty due to swelling of throat Chest pain - severe Drooling Fever Mouth pain - severe Rapid drop in blood pressure Throat pain - severe Vomiting blood

Submit
49. 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?
                                                                                      

Explanation

The correct answer is D: Preadolescent. Idiopathic scoliosis is seldom apparent before 10 years of age and is most noticeable at the beginning of the preadolescent growth spurt.

Submit
50. The nurse will administer liquid medicine to a nine month-old child. Which method is appropriate?

Explanation

The correct answer is B: Administer the medication with a syringe next to the tongue. Using a needleless syringe to give liquid medicine to an infant is often the safest and most effective method. If the nurse directs the medicine toward the side or the back of the mouth, gagging will be reduced while the syringe ensures the right dosis delivery.

Test-taking Tips:

Associate the words "administer liquid medicine" in the stem of the question with the words "administer" and "syringe" in option 2. Also, as you read all of the options, ask yourself: Is this appropriate for a "nine-month-old? Would this assure the baby would get all of the medication?

Submit
51. 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?

Explanation

The correct answer is C: Contact precautions. The resistant bacteria remain alive for up to three days post death. Therefore, contact precautions must still be implemented. Also, the body needs to be labeled so that the funeral home staff can protect themselves as well. Gown and gloves are required.MRSA stands for methicillin-resistant Staphylococcus aureus. It causes an infection that is resistant to several common antibiotics. There are two types of infection. Hospital-associated MRSA happens to people in healthcare settings. Community-associated MRSA happens to people who have close skin-to-skin contact with others, such as athletes involved in football and wrestling.

Submit
52. 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?

Explanation

The correct answer is C: Contact precautions. The resistant bacteria remain alive for up to three days post death. Therefore, contact precautions must still be implemented. Also, the body needs to be labeled so that the funeral home staff can protect themselves as well. Gown and gloves are required.MRSA stands for methicillin-resistant Staphylococcus aureus. It causes an infection that is resistant to several common antibiotics. There are two types of infection. Hospital-associated MRSA happens to people in healthcare settings. Community-associated MRSA happens to people who have close skin-to-skin contact with others, such as athletes involved in football and wrestling.

Submit
53. What is the primary nursing intervention to limit transmission of organisms for a client with a salmonella infection?

Explanation

The correct answer is A: Wash hands thoroughly before and after any client contact. Gram-negative bacilli cause Salmonella infections. Two million new cases appear each year. Lack of sanitation is the primary means of contamination. Thorough handwashing can prevent the spread of salmonella. Note that the question asks for the primary action. Thus, all of the options are correct and the task is to select the priority intervention. Also note that it does not state a location. The location could be in the home or in the hospital.

Submit
54. 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

Explanation

Tardive dyskinesia is a neurological syndrome caused by the long-term use of neuroleptic drugs. Neuroleptic drugs are generally prescribed for psychiatric disorders, as well as for some gastrointestinal and neurological disorders. Tardive dyskinesia is characterized by repetitive, involuntary, purposeless movements. Features of the disorder may include grimacing, tongue protrusion, lip smacking, puckering and pursing, and rapid eye blinking. Rapid movements of the arms, legs, and trunk may also occur. Involuntary movements of the fingers may appear as though the patient is playing an invisible guitar or piano.
Refer to www.nclex-masters.net/RNs_info for additional signals/symptoms information

Submit
55. 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)?

Explanation

The correct answer is A: Test blood sugar every 2 hours. The UAP can do standard, unchanging procedures with predictable outcomes and measurable results.

Submit
56. 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?

Explanation

The correct answer is C: Four year-old with bilateral inguinal hernia repair.

The nurse must know that children with nephrotic syndrome have a higher risk for the development of infections as a result of the steroid therapy which has an immunosuppressant effect. Therefore, these children must be protected from sources of possible infection.

Test-taking Tips:

Notice that options 1 and 2 have "infectious situations" which would eliminate them as "most appropriate" roommates for a child with "nephrotic syndrome." Notice the age of the child in the stem of the question (three-year old). Ask yourself: Would it be better to place this child with a four-year old or a six-year old? If safety is not an issue, then roommates are better matched by age.

Submit
57. 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:

Explanation

The correct answer is D: "Show me what you have learned about emptying your pouch.". Most adult learners obtain skills by participating in the activities. Anxiety about discharge can be causing the client to forget that they have mastered the skill of emptying the pouch. The client should show the nurse how they empty the pouch.

Submit
58. The nurse will administer liquid medicine to a nine month-old child. Which method is appropriate?

Explanation

The correct answer is B: Administer the medication with a syringe next to the tongue. Using a needleless syringe to give liquid medicine to an infant is often the safest and most effective method. If the nurse directs the medicine toward the side or the back of the mouth, gagging will be reduced while the syringe ensures the right dosis delivery.

Test-taking Tips:

Associate the words "administer liquid medicine" in the stem of the question with the words "administer" and "syringe" in option 2. Also, as you read all of the options, ask yourself: Is this appropriate for a "nine-month-old? Would this assure the baby would get all of the medication?

Submit
59. While giving nursing care to a hospitalized adolescent, the nurse should be aware that the major threat felt by the hospitalized adolescent is :

Explanation

The correct answer is C: Altered body image. The hospitalized adolescent may see each of these as a threat. However, the major threat that they feel when hospitalized is the fear of altered body image, because of the emphasis on physical appearance.

Submit
60.

The nurse would anticipate that an eight month-old would be able to  do one or more of the following:

Explanation

The correct answer is C: Sit without support. The age at which the normal child develops the ability to sit steadily without support is from seven to eight months.

Submit
61. 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)?

Explanation

The correct answer is A: Test blood sugar every 2 hours. The UAP can do standard, unchanging procedures with predictable outcomes and measurable results.

Submit
62. 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?

Explanation

The correct answer is B: A positive purified protein derivative (PPD) test with an abnormal chest x-ray. The client who must be placed in airborne precautions is the client with a positive PPD and an abnormal chest film which could be suspicious tuberculin lesions.
The reaction will take 48 - 72 hours to develop. You must return to your health care provider within that time to have the area checked. This will determine whether you have had a significant reaction to the PPD test. A reaction is measured in millimeters of hard swelling (induration) at the site.
The test site (usually the forearm) is cleansed. The PPD extract is then injected under the top layer of skin, causing a blister to form on the skin.

Submit
63. What is the primary nursing intervention to limit transmission of organisms for a client with a salmonella infection?

Explanation

The correct answer is A: Wash hands thoroughly before and after any client contact. Gram-negative bacilli cause Salmonella infections. Two million new cases appear each year. Lack of sanitation is the primary means of contamination. Thorough handwashing can prevent the spread of salmonella. Note that the question asks for the primary action. Thus, all of the options are correct and the task is to select the priority intervention. Also note that it does not state a location. The location could be in the home or in the hospital.

Submit
64. 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

Explanation

The correct Answer is B. Absence of the blinking reflex is due to neurologic impairment. Tear formation will return when the cerebral blood flow improves.

Nursing process: collecting data.

Client need: safe, effective care environment.

Submit
65. The client is receiving an intravenous piggyback infusion of penicillin. Which client statement would require the nurse's immediate attention?

Explanation

The correct answer is C: "I am itching all over.".

Complaints of itching, feeling hot all over and/or the appearance of raised, red welts on the skin are findings of an allergic reaction to the penicillin infusion. Therefore, the RN needs immediate notification and the drug administration should be stopped immediately.

Test Taking Tip:

Notice that option 3 focuses on the entire body. "All over" indicates a drug reaction as opposed to a side effect. The other options are more specific areas and less likely to be of an `immediate' concern.

Submit
66. 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?

Explanation

The correct answer is C: Perform frequent oral care with a toothsponge. Frequent cleansing and stimulation of the mucous membrane is important for a client with a nasogastric tube to prevent development of lesions and to promote comfort. Ice chips or mints could be contraindicated, and do not stimulate the tissue. Glycerin swabs do not cleanse since they only moisturize.

Submit
67. 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:

Explanation

The correct answer is A: "They will be back right after supper.". Time is not completely understood by a four year-old. The child interprets time with his own frame of reference. Thus, it is best to explain time in relationship to routine events such as a meal.

Submit
68. 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?

Explanation

The correct answer is A: The nurse practice act of the state in which they practice. The state nurse practice act is the governing document.Each State Nursing Board regulates the practice limitations of RNs.

Submit
69. 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

Explanation

The correct answer is A: Urine and saliva will be radioactive for 24 hours. The client''s urine and saliva are radioactive for 24 hours after ingestion. Vomitus is radioactive for six to eight hours. The client should double flush the commode after use, use disposable utensils, and avoid close contact with children and pregnant women for at least 48 to 72 hours after ingestion.

Submit
70. 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

Explanation

The correct answer is A: Urine and saliva will be radioactive for 24 hours. The client''s urine and saliva are radioactive for 24 hours after ingestion. Vomitus is radioactive for six to eight hours. The client should double flush the commode after use, use disposable utensils, and avoid close contact with children and pregnant women for at least 48 to 72 hours after ingestion.

Submit
71. While giving nursing care to a hospitalized adolescent, the nurse should be aware that the major threat felt by the hospitalized adolescent is :

Explanation

The correct answer is C: Altered body image. The hospitalized adolescent may see each of these as a threat. However, the major threat that they feel when hospitalized is the fear of altered body image, because of the emphasis on physical appearance.

Submit
72. 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?

Explanation

The correct answer is B: "Right after the period, when your breasts are less tender.". The best time for a breast self exam (BSE) is at the end of a menstral cycle, when the breasts are no longer swollen and tender from hormone elevation. BSE is to be avoided the first two (2) days of the menses.

Submit
73. 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

Explanation

The correct answer is D: Interview the client without the partner to determine the origin of the injuries. It would be wrong to assume domestic violence without further assessment. Separate the suspected victims from their partner until battering has been ruled out.

Submit
74. 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

Explanation

The correct answer is C: Can predispose to dysrhythmias. The nurse should be aware of a decrease in the client's potassium levels because low potassium can enhance the effects of digoxin and predispose the client to dysrhythmias . The other options are seen in hyperkalemia. Muscle weakness occurs in both hyperkalemia and hypokalemia.

Submit
75. The nurse is caring for a four year-old two hours after tonsillectomy and adenoidectomy. Which observation must be reported immediately?

Explanation

The correct answer is D: Increased restlessness. Restlessness and increased respiratory and heart rates are often early signs of hemorrhage.

Refer to www.nclex-masters.net/RNs_info for additional signals/symptoms information

Submit
76. A 14 month-old child ingested half a bottle of aspirin tablets. Which finding would the nurse expect to see in the child?

Explanation

Blood thinners such as Coumadin or aspirin may cause or worsen nosebleeds Refer to www.nclex-masters.net/RNs_info for additional signals/symptoms information

Submit
77. 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?

Explanation

The correct answer is B: A positive purified protein derivative (PPD) test with an abnormal chest x-ray. The client who must be placed in airborne precautions is the client with a positive PPD and an abnormal chest film which could be suspicious tuberculin lesions.
The reaction will take 48 - 72 hours to develop. You must return to your health care provider within that time to have the area checked. This will determine whether you have had a significant reaction to the PPD test. A reaction is measured in millimeters of hard swelling (induration) at the site.
The test site (usually the forearm) is cleansed. The PPD extract is then injected under the top layer of skin, causing a blister to form on the skin.

Submit
78. 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?

Explanation

The correct answer is D: Use gloves when handling the client's bedpan or urinal. The specific measure to prevent the spread of hepatitis A is careful handling and protection while handling fecal material.The correct answer is D: Use gloves when handling the client's bedpan or urinal. The specific measure to prevent the spread of hepatitis A is careful handling and protection while handling fecal material.

Submit
79. 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?

Explanation

The correct answer is B: "Right after the period, when your breasts are less tender.". The best time for a breast self exam (BSE) is at the end of a menstral cycle, when the breasts are no longer swollen and tender from hormone elevation. BSE is to be avoided the first two (2) days of the menses.

Submit
80. When reinforcing teaching to a depressed client about a new prescription for nortriptyline (Pamelor), the nurse must emphasize

Explanation

The correct answer is B: Alcohol use is to be avoided. Alcohol potentiates the action of tricyclic as well as other antidepressants.Nortriptyline is used to treat depression. Nortriptyline is in a group of medications called tricyclic antidepressants. It works by increasing the amounts of certain natural substances in the brain that are needed to maintain mental balance.

Submit
81. 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

Explanation

Tardive dyskinesia is a neurological syndrome caused by the long-term use of neuroleptic drugs. Neuroleptic drugs are generally prescribed for psychiatric disorders, as well as for some gastrointestinal and neurological disorders. Tardive dyskinesia is characterized by repetitive, involuntary, purposeless movements. Features of the disorder may include grimacing, tongue protrusion, lip smacking, puckering and pursing, and rapid eye blinking. Rapid movements of the arms, legs, and trunk may also occur. Involuntary movements of the fingers may appear as though the patient is playing an invisible guitar or piano.
Refer to www.nclex-masters.net/RNs_info for additional signals/symptoms information

Submit
82. 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?

Explanation

The correct answer is A: The nurse practice act of the state in which they practice. The state nurse practice act is the governing document.Each State Nursing Board regulates the practice limitations of RNs.

Submit
83. 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 :

Explanation

The correct answer is A: Focus on the client's verbal and nonverbal exchange.

The nurse should communicate with the client not with the interpreter. Culturally appropriate eye contact, gestures, and body language toward the client and family are important factors to enhance rapport and understanding. The nurse should elicit feedback and read nonverbal cues of the client.

Test-taking Tips:

Although all options might be considered, you are being asked for the "first" thing to remember. Relate "therapeutic communication" in the stem of the question with "verbal and non-verbal exchange" in option 1 which is the most comprehensive answer.

Submit
84. 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 :

Explanation

The correct answer is A: Focus on the client's verbal and nonverbal exchange.

The nurse should communicate with the client not with the interpreter. Culturally appropriate eye contact, gestures, and body language toward the client and family are important factors to enhance rapport and understanding. The nurse should elicit feedback and read nonverbal cues of the client.

Test-taking Tips:

Although all options might be considered, you are being asked for the "first" thing to remember. Relate "therapeutic communication" in the stem of the question with "verbal and non-verbal exchange" in option 1 which is the most comprehensive answer.

Submit
85. 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:

Explanation

The correct answer is D: "Show me what you have learned about emptying your pouch.". Most adult learners obtain skills by participating in the activities. Anxiety about discharge can be causing the client to forget that they have mastered the skill of emptying the pouch. The client should show the nurse how they empty the pouch.

Submit
86. 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

Explanation

The correct answer is D: Flight of ideas. Flight of ideas is characterized by over productivity of talk and verbal skipping from one idea to another.

Submit
87. 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?

Explanation

The correct answer is C: Perform frequent oral care with a toothsponge. Frequent cleansing and stimulation of the mucous membrane is important for a client with a nasogastric tube to prevent development of lesions and to promote comfort. Ice chips or mints could be contraindicated, and do not stimulate the tissue. Glycerin swabs do not cleanse since they only moisturize.

Submit
88. 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:

Explanation

The correct answer is A: "They will be back right after supper.". Time is not completely understood by a four year-old. The child interprets time with his own frame of reference. Thus, it is best to explain time in relationship to routine events such as a meal.

Submit
89. A 14 month-old child ingested half a bottle of aspirin tablets. Which finding would the nurse expect to see in the child?

Explanation

Blood thinners such as Coumadin or aspirin may cause or worsen nosebleeds Refer to www.nclex-masters.net/RNs_info for additional signals/symptoms information

Submit
90. 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?

Explanation

Explain the importance of the medication to the client
Explain the importance of the medication to the client and obtain addtional information regarding the medication preferred by the patient.

Submit
91. The nurse should be informed about cultural issues related to the client's background because one of the following:

Explanation

The correct answer is A: Normal patterns of behavior may be labeled as deviant, immoral, or insane. Culture is an important variable in the assessment of clients. To work effectively with clients, the nurse must be aware of culturally distinctive qualities.

Submit
92. 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?

Explanation

The correct answer is D: Use gloves when handling the client's bedpan or urinal. The specific measure to prevent the spread of hepatitis A is careful handling and protection while handling fecal material.The correct answer is D: Use gloves when handling the client's bedpan or urinal. The specific measure to prevent the spread of hepatitis A is careful handling and protection while handling fecal material.

Submit
93. A 52 year-old post menopausal woman asks the nurse how frequently she should have a mammogram. The nurse's best response is:

Explanation

The correct answer is C: "Once a woman reaches 50, she should have a mammogram yearly.". In this question, the only option choice that follows either of the guidelines is option 3. Timing of mammograms is controversial between the National Cancer Institute (NCI) and the American Cancer Society. The NCI recommends (2002):

1) Women in their 40s should be screened every one to two years with mammography.

2) Women aged 50 and older should be screened every one to two years.

3) Women who are at higher than average risk of breast cancer should seek expert medical advice about whether they should begin screening before age 40 and the frequency of screening.http://www.ahcpr.gov/clinic/3rduspstf/breastcancer/brcanrr.htm

Submit
94. During the focused assessment of a client with major depression, the nurse may ask which of the following questions?

Explanation

Correct answer is C: patients suffering major clinical depression are high risk for suicide; the best nursing assessment with such patient is to evaluate the rsik potential for suicidal behavior.

Submit
95. 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

Explanation

The correct answer is C: A pre-determined fee for all services.

An HMO plan is a plan that provides for all services based on a flat rate. During the specified period of enrollment, all health care services are provided with no additional charges.

Test-taking Tips:

If guessing, narrow the options to the two that are similar/dissimilar-options 2 and 3 are this way in that they both focus on "health care costs" with different ways to charge. Think and ask yourself: Which seems more realistic `a flat rate for each service' or `a predetermined rate for all services'? Notice that option 3 is more encompassing since it includes `all services.' Associate "HMO" with "pre-determined fee" in option 3.

Submit
96. 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

Explanation

The correct answer is C: "He is scared and taking it out on you. Let''s try to figure out what to do.". This response explains the client''s behavior without belittling the UAP's feelings. The UAP is encouraged to help solve the problem with the nurse.

Submit
97. The nurse should begin considering discharge concerns for a hospitalized client considering one fo of the following:

Explanation

The correct answer is C: During the admission process in the emergency room or on the assigned unit. Thoughts about discharge concerns for the plan of care are incorporated after the admission process and during the initial care of the client discussion.

Test-taking Tips:

If guessing, you can group or cluster options 1, 2, and 4 under the theme of `to wait after admission' Select option 3 as the odd option out that has the timeframe of ''during the admission process. After initial assessment, an estimation of how long the care plan may take can be discussed. Timeframes for discharge may adjust to the patient actual recovery as it occurs.

Submit
98. A 52 year-old post menopausal woman asks the nurse how frequently she should have a mammogram. The nurse's best response is:

Explanation

The correct answer is C: "Once a woman reaches 50, she should have a mammogram yearly.". In this question, the only option choice that follows either of the guidelines is option 3. Timing of mammograms is controversial between the National Cancer Institute (NCI) and the American Cancer Society. The NCI recommends (2002):

1) Women in their 40s should be screened every one to two years with mammography.

2) Women aged 50 and older should be screened every one to two years.

3) Women who are at higher than average risk of breast cancer should seek expert medical advice about whether they should begin screening before age 40 and the frequency of screening.http://www.ahcpr.gov/clinic/3rduspstf/breastcancer/brcanrr.htm

Submit
99. 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?

Explanation

The correct answer is A: Utilize bilateral elbow restraints at all times.

The major efforts in the post operative period are directed toward protecting the operative site. Elbow restraints should be used and only one arm released at a time with close supervision by the nurse and/or parents. Usually diluted peroxide solutions are used for suture cleansing.

Test-taking Tips:

The key words or clues in this question are: "two-month-old, cleft lip repair, immediate post-op, and priority nursing action". Although there is an absolute word in option 1 (all), when you ask yourself "is this true?" consider why it may be correct. The natural response of this age child would be to touch the operative site. Ask yourself: What problems could this cause in relation to ABCs? It is not an ABC priority but a safety issue - a safety hazard to the operative site.

Submit
100. 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?

Explanation

The correct answer is C: "I will need to take the medication for at least two weeks before I can see any benefit.". Theraputic drug effects may not be noticed for at least two weeks. Therapy is usually prolonged and individual and family counseling are helpful in identifying and addressing issues such as self-esteem.Eating disorders are serious behavior problems. They include

Anorexia nervosa, in which you become too thin, but you don't eat enough because you think you are fat
Bulimia nervosa, involving periods of overeating followed by purging, sometimes through self-induced vomiting or using laxatives
Binge-eating, which is out-of-control eating
Women are more likely than men to have eating disorders. They usually start in the teenage years and often occur along with depression, anxiety disorders and substance abuse.
Hospital Based Care (including inpatient, partial hospitalization, intensive outpatient and/or residential care in an eating disorders specialty unit or facility) is necessary when an eating disorder has led to physical problems that may be life-threatening, or when it is associated with severe psychological or behavioral problems.

Submit
101. 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?

Explanation

Correct answer is B: Polyarthritis is characterized by swollen, painful, hot joints that respond to salicylates .

Submit
102. The nurse should be informed about cultural issues related to the client's background because one of the following:

Explanation

The correct answer is A: Normal patterns of behavior may be labeled as deviant, immoral, or insane. Culture is an important variable in the assessment of clients. To work effectively with clients, the nurse must be aware of culturally distinctive qualities.

Submit
103. 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

Explanation

The correct answer is C: "I can't make such a promise.". Secrets are inappropriate in therapeutic relationships and are counter productive to the therapeutic efforts of the interdisciplinary team. Secrets may be related to risk for harm to self or others. The nurse should honor and help clients understand the rights, limitations, and boundaries about confidentiality.

The correct answer is B: "I can't make such a promise.". Secrets are inappropriate in therapeutic relationships and are counter productive to the therapeutic efforts of the interdisciplinary team. Secrets may be related to risk for harm to self or others. The nurse should honor and help clients understand the rights, limitations, and boundaries about confidentiality.

Submit
104. The nurse should begin considering discharge concerns for a hospitalized client considering one fo of the following:

Explanation

The correct answer is C: During the admission process in the emergency room or on the assigned unit. Thoughts about discharge concerns for the plan of care are incorporated after the admission process and during the initial care of the client discussion.

Test-taking Tips:

If guessing, you can group or cluster options 1, 2, and 4 under the theme of `to wait after admission' Select option 3 as the odd option out that has the timeframe of ''during the admission process. After initial assessment, an estimation of how long the care plan may take can be discussed. Timeframes for discharge may adjust to the patient actual recovery as it occurs.

Submit
105. 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?

Explanation

The correct answer is D: Turn her to her left side. The weight of the uterus can put pressure on the vena cava and aorta when a pregnant woman is flat on her back causing supine hypotension. Action is needed to relieve the pressure on the vena cava and aorta. Turning the woman to the side reduces this pressure and relieves postural hypotension.

Submit
106. Mr. D. has a disorder of the hypothalamus and is on a hypothermia blanket. The nurse should make which of the following assessments?

Explanation

The correct answer is D. Baseline vital sign assessment is necessary to document against those taken during and after the treatment.

Submit
107. 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

Explanation

Correct answer is C: tranference is the unconcious transferring of traits or behavior associated with other people and transferred to the nurse by the patient.

Submit
108. 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?

Explanation

B is the most correct action by the nurse; determining what the patient may be feeling at the moment help the RN assessing the patient current state.

Submit
109. 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?

Explanation

Explain the importance of the medication to the client
Explain the importance of the medication to the client and obtain addtional information regarding the medication preferred by the patient.

Submit
110. A client frequently compliments the nurse and invites the nurse to go to a movie and dinner. The nurse should take which approach?

Explanation

The correct answer is D: Talk about the boundaries of the relationship with the client. The nurse-client relationship is one with professional not social boundaries. Consistent adherence to the limits of the professional relationship builds trust.

Submit
111. 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

Explanation

The correct answer is C: "I can't make such a promise.". Secrets are inappropriate in therapeutic relationships and are counter productive to the therapeutic efforts of the interdisciplinary team. Secrets may be related to risk for harm to self or others. The nurse should honor and help clients understand the rights, limitations, and boundaries about confidentiality.

The correct answer is B: "I can't make such a promise.". Secrets are inappropriate in therapeutic relationships and are counter productive to the therapeutic efforts of the interdisciplinary team. Secrets may be related to risk for harm to self or others. The nurse should honor and help clients understand the rights, limitations, and boundaries about confidentiality.

Submit
112. Which newly admitted client would be most appropriate to assign to the unlicensed assistive personnel (UAP)?

Explanation

The correct answer is c: A client with chronic peripheral vascular disease. The UAP can be assigned to care for a client with a chronic condition after an initial assessment is done by the nurse. This client has the most predictable outcome based on a treatment plan.

Submit
113. When a client is diagnosed with tuberculosis, the public health department is to be notified for what reason?

Explanation

The correct answer is B: Contacts need to be traced and screened. Tuberculosis is a reportable disease because persons who had contact with the client must be traced, evaluated for the disease and possibly treated prophalactally. A patient's family members must be screened and follow up per healthcare authority mandates to prevent further contamination and spread of disease.

Submit
114. When a client is diagnosed with tuberculosis, the public health department is to be notified for what reason?

Explanation

The correct answer is B: Contacts need to be traced and screened. Tuberculosis is a reportable disease because persons who had contact with the client must be traced, evaluated for the disease and possibly treated prophalactally. A patient's family members must be screened and follow up per healthcare authority mandates to prevent further contamination and spread of disease.

Submit
115. 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?

Explanation

The correct answer is B: Auscultate the mass. Auscultation of the abdomen and finding a bruit will confirm the presence of an abdominal aneurysm and will form the basis of information given to the health care provider. This should be the first action of the nurse. The other actions would be contraindicated and have the risk of causing a rupture of the aneurysm.

Submit
116. 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?

Explanation

The correct answer is B: Auscultate the mass. Auscultation of the abdomen and finding a bruit will confirm the presence of an abdominal aneurysm and will form the basis of information given to the health care provider. This should be the first action of the nurse. The other actions would be contraindicated and have the risk of causing a rupture of the aneurysm.

Submit
117. 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?

Explanation

The correct answer is A: Link the caregiver with a support group. Assist caregivers to locate and join support groups. This is most helpful. Families share feelings and learn about services such as respite care. Health education is also available through local and national Alzheimer''s chapters.

Submit
118. The nurse is to open a sterile package from central supply. Which is the correct direction to open the first flap?

Explanation

The correct answer is A. This allows for the least possible potential for contamination while opening the package.

Submit
119. 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

Explanation

Correct answer is B : Reading the name on the client's ID bracelet is the most accurate way to confirm identity.

Submit
120. 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?

Explanation

B is the most correct action by the nurse; determining what the patient may be feeling at the moment help the RN assessing the patient current state.

Submit
121. A client is admitted to the emergency room following an acute asthma attack. Which of the following findings would be most important to report?



Explanation

The correct answer is A: Diffuse, inspiratory wheezing. In asthma, the airways are narrowed - creating difficulty getting air in which produces a wheezing sound. Note that all of the findings are associated with an acute asthma attack. Inspiratory wheezing indicates a potential for airwary closure. Refer to www.nclex-masters.net/RNs_info for additional signals/symptoms information.

Submit
122. A child, injured on the school playground, appears to have a fractured leg. The first action the school nurse should take is



Explanation

The correct answer is C: Assess the child and the extent of the injury. When applying the nursing process, assessment is the first step in providing care. The 5 "Ps" of vascular impairment can be used as a guide (pain, pulse, pallor, paresthesia, paralysis).
Refer to www.nclex-masters.net/RNs_info for additional signals/symptoms information

Submit
123. 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?

Explanation

The correct answer is A: Utilize bilateral elbow restraints at all times.

The major efforts in the post operative period are directed toward protecting the operative site. Elbow restraints should be used and only one arm released at a time with close supervision by the nurse and/or parents. Usually diluted peroxide solutions are used for suture cleansing.

Test-taking Tips:

The key words or clues in this question are: "two-month-old, cleft lip repair, immediate post-op, and priority nursing action". Although there is an absolute word in option 1 (all), when you ask yourself "is this true?" consider why it may be correct. The natural response of this age child would be to touch the operative site. Ask yourself: What problems could this cause in relation to ABCs? It is not an ABC priority but a safety issue - a safety hazard to the operative site.

Submit
124. The nurse observes a newborn whose Apgar score was 8 and 9. This score would be most closely associated with which of these areas?

Explanation

Answer D is correct;a score between 8 and 9 is related to skin color. Although the Apgar score was developed in 1952 by an anesthesiologist named Virginia Apgar, you may have also heard it referred to as an acronym for: Activity, Pulse, Grimace, Appearance, and Respiration - APGAR

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125. The nurse is caring for a two month-old infant with a congenital heart defect. Which of the following is a priority nursing action?

Explanation

The correct answer is A: Provide small feedings every three hours. Infants with congenital heart defects are at increased risk to develop heart failure. Infants with heart failure have an increased metabolic rate and require additional calories to grow. However, at the same time, rest and conservation of energy for feedings is important. Feedings should be smaller and every 3 hours rather than the usual 4 hour schedule.The goal for feeding an infant with congenital heart disease is consistent weight gain. Most babies gain 1/2 to 1 ounce of weight per day. However, babies with heart disease tend to gain weight at a much slower rate. The pediatrician and cardiologist will assess a child's weight at each visit and make recommendations regarding the feedings at that time.They also tend to require more calories to grow than the average infant. Each ounce of formula or breast milk usually contains 20 calories.

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126. When Mr. C. is placed on a hypothermia blanket, which of the following should be included in the nursing care plan?

Explanation

The correct answer is B. Frequent vital signs and skin assessments are necessary to ensure that the treatment is working and there are no adverse effects.

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127. A client is admitted to the emergency room following an acute asthma attack. Which of the following findings would be most important to report?



Explanation

The correct answer is A: Diffuse, inspiratory wheezing. In asthma, the airways are narrowed - creating difficulty getting air in which produces a wheezing sound. Note that all of the findings are associated with an acute asthma attack. Inspiratory wheezing indicates a potential for airwary closure. Refer to www.nclex-masters.net/RNs_info for additional signals/symptoms information.

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128. The nurse is reinforcing instructions for a client with asthma. Which item should be stressed for the client to monitor on a daily basis?

Explanation

The correct answer is B: Peak air flow volumes. The peak airflow volume decreases about 24 hours before clinical findings of acute asthma attacks. Refer to www.nclex-masters.net/RNs_info for additional signals/symptoms information

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129. 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

Explanation

The correct answer is C: "He is scared and taking it out on you. Let''s try to figure out what to do.". This response explains the client''s behavior without belittling the UAP's feelings. The UAP is encouraged to help solve the problem with the nurse.

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130. Which newly admitted client would be most appropriate to assign to the unlicensed assistive personnel (UAP)?

Explanation

The correct answer is c: A client with chronic peripheral vascular disease. The UAP can be assigned to care for a client with a chronic condition after an initial assessment is done by the nurse. This client has the most predictable outcome based on a treatment plan.

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131. 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?

Explanation

Correct answeer id D: giving the patient factual information enhances recollection of event through neural networking activity.

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132. 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?

Explanation

The correct answer is D. CVA is a neurologic disorder due to a pathologic process in a blood vessel, causing damage to the brain. All of the listed symptoms may occur, depending on what area of the brain is affected.

Nursing process: collecting data

Client need: safe, effective care environment

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133. 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?

Explanation

The correct answer is C. A mechanical lifting device (Hoya, Hoyer) helps to transfer clients and prevents back injury to the nurses.

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134. Which of these actions best describes the application of time management strategies for the role of the PN charge nurse?

Explanation

The correct answer is C: Set daily goals to prioritize the workload of self and others. Time management strategies must include setting priorities and meeting goals on a daily and long-term basis

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135. The nurse is caring for a four year-old two hours after tonsillectomy and adenoidectomy. Which observation must be reported immediately?

Explanation

The correct answer is D: Increased restlessness. Restlessness and increased respiratory and heart rates are often early signs of hemorrhage.

Refer to www.nclex-masters.net/RNs_info for additional signals/symptoms information

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136. 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

Explanation

The correct answer is C: A pre-determined fee for all services.

An HMO plan is a plan that provides for all services based on a flat rate. During the specified period of enrollment, all health care services are provided with no additional charges.

Test-taking Tips:

If guessing, narrow the options to the two that are similar/dissimilar-options 2 and 3 are this way in that they both focus on "health care costs" with different ways to charge. Think and ask yourself: Which seems more realistic `a flat rate for each service' or `a predetermined rate for all services'? Notice that option 3 is more encompassing since it includes `all services.' Associate "HMO" with "pre-determined fee" in option 3.

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137. A client frequently compliments the nurse and invites the nurse to go to a movie and dinner. The nurse should take which approach?

Explanation

The correct answer is D: Talk about the boundaries of the relationship with the client. The nurse-client relationship is one with professional not social boundaries. Consistent adherence to the limits of the professional relationship builds trust.

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138. The nurse observes a newborn whose Apgar score was 8 and 9. This score would be most closely associated with which of these areas?

Explanation

Answer D is correct;a score between 8 and 9 is related to skin color. Although the Apgar score was developed in 1952 by an anesthesiologist named Virginia Apgar, you may have also heard it referred to as an acronym for: Activity, Pulse, Grimace, Appearance, and Respiration - APGAR

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139. Which one of these tasks could be assigned to the certified nursing assistant (cna)? 

Explanation

The correct answer is B: Giving enemas until clear to a middle-aged man scheduled for a colonoscopy. The certified nursing assistant can be assigned tasks which have predictable outcomes.

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140. 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:    

Explanation

The correct answer is D: "You are angry right now.". The nurse recognizes the underlying emotion with matter of fact attitude.

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141. The nurse is collecting data on a client with a stage 2 skin ulcer. Which treatment is considered most effective to promote healing?

Explanation

The correct answer is D: Applying a transparent film cover. For this type of ulcer, the most effective treatment is a transparent cover.Refer to www.nclex-masters.net/RNs_info for additional signals/symptoms information

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142. Which one of these tasks could be assigned to the certified nursing assistant (cna)? 

Explanation

The correct answer is B: Giving enemas until clear to a middle-aged man scheduled for a colonoscopy. The certified nursing assistant can be assigned tasks which have predictable outcomes.

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143. Mr. S. is to have a tepid sponge bath to lower his fever. What temperature should the nurse make the water?

Explanation

The correct answer is B. Unlike a cooling sponge bath where the temperature begins at this point and gradually is lowered to 65° F (18° C) at the end, this is the temperature that the water begins and ends at for a tepid sponge bath.

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144. 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?

Explanation

Correct answer is C : This behavior indicates a delay in language and speech development. The child may not be able to hear. The child should have a vocabulary of about 900 words and use complete sentences of three to four words.

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145. 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:

Explanation

The correct answer is D: Ask the client if it would be preferred to remove the dentures in the operating room receiving area. Clients anticipating surgery may experience a variety of fears. This choice allows the client control over the situation and fosters the client''s sense of self-esteem and self-concept. Additionally,reduces any self harmingo to the patint's. moth/tonge, etc

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146. Which of these actions best describes the application of time management strategies for the role of the PN charge nurse?

Explanation

The correct answer is C: Set daily goals to prioritize the workload of self and others. Time management strategies must include setting priorities and meeting goals on a daily and long-term basis

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147. 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:    

Explanation

The correct answer is D: "You are angry right now.". The nurse recognizes the underlying emotion with matter of fact attitude.

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148. 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:

Explanation

The correct answer is D: worried that the surgery will change you?". This is a response that encourages further discussion without focusing on an area that the nurse feels is a problem.

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149. 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 : 

Explanation

The correct answer is D: The nurse will need to check for or get the client's written consent before the release of any information. In order to release information about a client there must be a signed consent form unless the client is a threat of harm to self or others by the Nursing Practice Act to protect the confidentiality of patient intervention and rights.

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150. 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?

Explanation

The correct answer is B: roast beef, mashed potatoes, and green beans. The client has correctly selected an appropriate lunch and appears to have knowledge of restrictions. Low granulocyte counts and susceptibility to infection are expected. Compromised host precautions require that foods are either cooked or canned. Options 1, 3 and 4 do not demonstrate learning, as raw fruits, vegetables, and milk are to be avoided.The correct answer is B: roast beef, mashed potatoes, and green beans.

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151. 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?

Explanation

The correct answer is B: roast beef, mashed potatoes, and green beans. The client has correctly selected an appropriate lunch and appears to have knowledge of restrictions. Low granulocyte counts and susceptibility to infection are expected. Compromised host precautions require that foods are either cooked or canned. Options 1, 3 and 4 do not demonstrate learning, as raw fruits, vegetables, and milk are to be avoided.The correct answer is B: roast beef, mashed potatoes, and green beans.

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152. 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

Explanation

The correct answer is B. For a child this age, the diet is kept as normal as possible except for the elimination of concentrated sweets such as ice cream.

Nursing process: planning.

Client need: physiological integrity.

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153. 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?

Explanation

Correct answer is A: Lithium reduces the intensity, duration and frequency of manic-depressive episodes;blood levels must monitored in acute phases and during treatment.

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154. 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:

Explanation

The correct answer is D: worried that the surgery will change you?". This is a response that encourages further discussion without focusing on an area that the nurse feels is a problem.

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155. The nurse is collecting data on a client with a stage 2 skin ulcer. Which treatment is considered most effective to promote healing?

Explanation

The correct answer is D: Applying a transparent film cover. For this type of ulcer, the most effective treatment is a transparent cover.Refer to www.nclex-masters.net/RNs_info for additional signals/symptoms information

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156. The nurse is reinforcing instructions for a client with asthma. Which item should be stressed for the client to monitor on a daily basis?

Explanation

The correct answer is B: Peak air flow volumes. The peak airflow volume decreases about 24 hours before clinical findings of acute asthma attacks. Refer to www.nclex-masters.net/RNs_info for additional signals/symptoms information

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157. 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 : 

Explanation

The correct answer is D: The nurse will need to check for or get the client's written consent before the release of any information. In order to release information about a client there must be a signed consent form unless the client is a threat of harm to self or others by the Nursing Practice Act to protect the confidentiality of patient intervention and rights.

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158. Which of these protocols would be essential for the nurse to implement during the care of a client with active tuberculosis?

Explanation

The correct answer is D: With the client in a negative pressure room use customized respirators. A client with active tuberculosis should be hospitalized in a negative pressure room to prevent respiratory droplets from leaving the room when the door is opened. The door is to be closed at all times except for entry and exiting. Personal protective equipment such as a HEPA-filtered respirator are required.The correct answer is D: With the client in a negative pressure room use customized respirators. A client with active tuberculosis should be hospitalized in a negative pressure room to prevent respiratory droplets from leaving the room when the door is opened. The door is to be closed at all times except for entry and exiting. Personal protective equipment such as a HEPA-filtered respirator are required.The correct answer is D: With the client in a negative pressure room use customized respirators. A client with active tuberculosis should be hospitalized in a negative pressure room to prevent respiratory droplets from leaving the room when the door is opened. The door is to be closed at all times except for entry and exiting. Personal protective equipment such as a HEPA-filtered respirator are required.

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159. 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?

Explanation

Correct answer is C: Place on airborne precautions to avoid further contamination of other patients.

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160. 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

Explanation

The correct answer is C: Rounded swelling above the pubis. Swelling above the pubis is representative of a distended bladder in the male client.

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161. 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?

Explanation

Correct asnwer is A: The child has great curiosity and has the mobility to explore. Toddlers need to be supervised in play areas. Play areas with soft ground cover and safe equipment need to be selected.

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162. A child, injured on the school playground, appears to have a fractured leg. The first action the school nurse should take is



Explanation

The correct answer is C: Assess the child and the extent of the injury. When applying the nursing process, assessment is the first step in providing care. The 5 "Ps" of vascular impairment can be used as a guide (pain, pulse, pallor, paresthesia, paralysis).
Refer to www.nclex-masters.net/RNs_info for additional signals/symptoms information

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163. Which of these protocols would be essential for the nurse to implement during the care of a client with active tuberculosis?

Explanation

The correct answer is D: With the client in a negative pressure room use customized respirators. A client with active tuberculosis should be hospitalized in a negative pressure room to prevent respiratory droplets from leaving the room when the door is opened. The door is to be closed at all times except for entry and exiting. Personal protective equipment such as a HEPA-filtered respirator are required.The correct answer is D: With the client in a negative pressure room use customized respirators. A client with active tuberculosis should be hospitalized in a negative pressure room to prevent respiratory droplets from leaving the room when the door is opened. The door is to be closed at all times except for entry and exiting. Personal protective equipment such as a HEPA-filtered respirator are required.The correct answer is D: With the client in a negative pressure room use customized respirators. A client with active tuberculosis should be hospitalized in a negative pressure room to prevent respiratory droplets from leaving the room when the door is opened. The door is to be closed at all times except for entry and exiting. Personal protective equipment such as a HEPA-filtered respirator are required.

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164. 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?

Explanation

The appropriate approach by the nurse is to accept the parents' feelings without judgment. This response validates the parents' emotions and allows them to express their concerns without feeling criticized or blamed. It creates a supportive and non-judgmental environment, which can help the parents feel more comfortable and open to discussing their child's needs and recovery. By accepting their feelings, the nurse can build trust and rapport with the parents, facilitating effective communication and collaboration in the child's care.

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165. 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

Explanation

The correct answer is B. A stage II pressure ulcer may look like a blister, abrasion, or shallow crater and only involve a partial thickness skin loss of the epidermis and/or dermis.

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166. 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?

Explanation

Excess output of the thyroid hormones increases the metabolic rate and increases sympathetic (adrenergic) activity, resulting in
nervousness, hyperexcitability, palpitations, and a pulse that is abnormally elevated even at rest. The client usually demonstrates a fine tremor of the hands and intolerance to heat.

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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:

Explanation

The correct answer is B: increased hydration can prolong discomfort. Increased hydration can make the dying process more uncomfortable and prolonged. In option 1 aspiration is likely only if the gag reflex is reduced or the client is comatose. There is no evidence that renal shutdown has occurred without more information.

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168. 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?

Explanation

Correct answer is C: Place on airborne precautions to avoid further contamination of other patients.

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169. 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

Explanation

The correct answer is C: Administer oxygen therapy. Early findings of shock reveal hypoxia with rapid heart rate and respirations. Oxygen therapy is the most critical and the initial intervention. The other interventions are secondary to oxygen therapy and would occur in a sequence of options 4,2, and 1.

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170. 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:

Explanation

The correct answer is A: Evaluate SaO2 levels frequently. The best method to evaluate a client''s oxygenation is to evaluate the SaO2. This is just as effective as an arterial blood gas to evaluate the oxygenation, and is less traumatic and expensive.Normal Oxygen saturation (SaO2) - 94 - 100% can be compared against PaO2 levels.

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171. 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:

Explanation

The correct answer is B: increased hydration can prolong discomfort. Increased hydration can make the dying process more uncomfortable and prolonged. In option 1 aspiration is likely only if the gag reflex is reduced or the client is comatose. There is no evidence that renal shutdown has occurred without more information.

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172. 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

Explanation

The correct answer is C: accept the client's report of pain. Although the information above is correct, the first and most important piece of information in this client's pain assessment is what the client is telling you about the pain --"the client's report". The correct answer is C: accept the client's report of pain. Although the information above is correct, the first and most important piece of information in this client's pain assessment is what the client is telling you about the pain --"the client's report". Refer to www.nclex-masters.net/RNs_info for additional signals/symptoms information

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173. 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:

Explanation

The correct answer is A: the pain threshold is higher in older adults. Pain is better tolerated in the elderly. Thus it can be said that their pain threshold is higher than younger adults. In option 2 the doses of analgesics will be decreased and be given at more frequent intervals since older adults with chronic pain have less relief from analgesics. Option 3 findings are not associated with chronic pain. Immediate relief is experienced with acute pain more often than with chronic pain.

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174. 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

Explanation

The correct answer is C: Taking the drug with food, milk, or antacids. Taking the medication with food, milk, or antacids decreases the irritation to the gastrointestinal (GI) tract.NSAID medicines can cause ulcers and bleeding in the stomach and intestines at any time during treatment.

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175. 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:

Explanation

The correct answer is A: the pain threshold is higher in older adults. Pain is better tolerated in the elderly. Thus it can be said that their pain threshold is higher than younger adults. In option 2 the doses of analgesics will be decreased and be given at more frequent intervals since older adults with chronic pain have less relief from analgesics. Option 3 findings are not associated with chronic pain. Immediate relief is experienced with acute pain more often than with chronic pain.

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176. The nurse is assisting in the assessment of a client's home in preparation for discharge. Which focus should be given priority consideration?

Explanation

The correct answer is A: Family's understanding of the client's needs. Communication patterns between family members are fundamental to meeting family needs and influencing relationships.

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177. 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

Explanation

Correct answer is D: log rolling minimizes further dislocation and pain.

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178. When planning for the care of a client with a pressure ulcer on the sacrum, the nurse would include which of the following?

Explanation

The correct answer is A. Any supportive device that protects bony prominences aids in relieving pressure. This can include egg crates, gel flotation devices, sheepskins, alternating pressure mattresses, and various air loss beds.

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179. 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 :

Explanation

Correct answer is B: 'la belle indiference' is an apparently concious unconcern for an otherwise worrying medical disorder to most people; it's indicative of psyhcological problems with the individual and possibly the real reason for the disorder.

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180. The nurse would reinforce the need to take alendronate (Fosamax) as prescribed by the physician,

Explanation

The correct answer is A: On an empty stomach. Fosamax should be taken first thing in the morning with water at least 30 minutes before other medication or food. Fosamax, a bone reabsorption inhibitor, is used for postmenopausal bone thinning osteoporosis, and to treat Paget''s disease.Alendronate comes as a tablet and a solution (liquid) to take by mouth. The solution is usually taken on an empty stomach once a week in the morning. The 5-mg and 10-mg tablets are usually taken on an empty stomach once a day in the morning, and the 35-mg and 70-mg tablets are usually taken on an empty stomach once a week in the morning. The 40-mg tablets are usually taken once a day in the morning for six months to treat Paget's disease of bone.

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181. 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?



Explanation

The correct answer is B: Begin treatment with acyclovir at the onset of findings of recurrence. When the client is aware of early findings, such as pain, itching or tingling, treatment is very effective.

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182. 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

Explanation

The correct answer is C: accept the client's report of pain. Although the information above is correct, the first and most important piece of information in this client's pain assessment is what the client is telling you about the pain --"the client's report". The correct answer is C: accept the client's report of pain. Although the information above is correct, the first and most important piece of information in this client's pain assessment is what the client is telling you about the pain --"the client's report". Refer to www.nclex-masters.net/RNs_info for additional signals/symptoms information

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183. Which nursing diagnosis would indicate that an 86 year-old client is at greatest risk for falls?

Explanation

The correct answer is D: Altered patterns of urinary elimination related to nocturia. Nocturia is especially problematic because many elderly clients fall when they rush to reach the bathroom at night. They may be confused or not fully alert. Inadequate lighting can increase their chances of stumbling and they often fall over furniture or carpets increasint the probabilities of falls.

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184. Which cognitive skill would the nurse expect a six-year-old child to be in the process of developing?

Explanation

Correct answer is A: children age 5 to 7 years old are at the preoperational and preconceptual developmental stage understanding basci rules only.

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185. 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

Explanation

The correct answer is B: Hold the medication and contact the health care provider. PNs do not give IV push medications unless they have attended special classes. The narcotic would have to be ordered by another route.

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186. 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?

Explanation

The correct answer is B: That was done correctly. Did you have any problems with the insertion?. Left side-lying position is the optimal position for the client receiving rectal medications. Due to the position of the descending colon, left side-lying allows the medication to be inserted and move along the natural curve of the intestine and facilitates retention of the medication. After a short time it will not hurt the client to turn in any manner. The suppository should be somewhat melted after 10 to 15 minutes. The other responses are incorrect since no data is in the stem to support such comments.

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187. 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 :

Explanation

Correct asnwer is B: Many characteristics of a client who is manic (Le., irritability, excitement, agitation, provocative behavior) contribute to the potential for violence. Maintaining the safety of the client and those around him is the greatest priority.

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188. 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?



Explanation

The correct answer is B: Begin treatment with acyclovir at the onset of findings of recurrence. When the client is aware of early findings, such as pain, itching or tingling, treatment is very effective.

Submit
189. Which nursing diagnosis would indicate that an 86 year-old client is at greatest risk for falls?

Explanation

The correct answer is D: Altered patterns of urinary elimination related to nocturia. Nocturia is especially problematic because many elderly clients fall when they rush to reach the bathroom at night. They may be confused or not fully alert. Inadequate lighting can increase their chances of stumbling and they often fall over furniture or carpets increasint the probabilities of falls.

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190. Mr. A. has sprained his ankle. The physician would order cold applied to the injured area to

Explanation

The correct answer is B. Cold will produce an anesthetic effect and help to reduce pain as well as control bleeding by constricting blood vessels.

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191. The nurse recognizes that the client with posttraumatic stress disorder (PTSD), is improving when he

Explanation

Correct answer is C: cognitive treatment of traumatic events such as PTSD includes redefining the event and finding meaning in the experience. Numbness, constricted and avoiding behavior, as well as, drinking show lack of improvement for the client and need for further psychological intervention/treatment. A posttraumatic syndrome is the mental state of an individual patient experiencing a sustained painfull response to traumatic past event of extremelly fearful consequences, like war, car/airplanes accidents and similar events that threatened the life of individuals.

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192. 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?

Explanation

The correct answer is C: Restlessness and palpitations. Side effects of Aminophylline include restlessness, palpitations and muscle twitching. Aminophylline is used to prevent and treat wheezing, shortness of breath, and difficulty breathing caused by asthma, chronic bronchitis, emphysema, and other lung diseases. It relaxes and opens air passages in the lungs, making it easier to breathe.Aminophylline may cause side effects. Tell your doctor if any of these symptoms are severe or do not go away.

upset stomach
stomach pain
diarrhea
headache
restlessness
insomnia
irritability

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193. 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

Explanation

Correct answer is A : The client's high activity level poses the most danger because it can lead to absence of food, fluid, and rest with resultant dehydration, electrolyte imbalance, and physical collapse .

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194. 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

Explanation

The correct answer is C: testing ground for new patterns of behavior for which the client takes responsibility. A therapeutic milieu is purposeful and planned to provide safety and a testing ground for new patterns of behavior. Refer to Psych Nursing for additional information.Refer to www.nclex-masters.net/RNs_info for additional signals/symptoms information

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195. 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?

Explanation

The correct answer is B: Sliced turkey sandwich and canned pineapple. Sliced turkey sandwich is appropriate since it is not a highly processed food and canned fruits are low in sodium. All other choices contain one or more high sodium foods.

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196. 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?

Explanation

Correct answer is B: a mental health patient who invades the space of other patients and is argumentative is at risk of being attaked by other patients. The nurse diagnose focuses on the reason for such behavior and potential consequences of same behavior intervening for the safety of the patient effectively assessing his/her behavior to prevent harm to the patient or any others.

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197.    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?            

Explanation

Correct answeer is D: excessive proccupation with one's health without organic pathology is due to hypochondriasis a mental disorder dealing with psycho-somatic conditions.

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198. 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

Explanation

Correct answer is A: the nurse's treatment plan must include a long term psychological interventions related to the patient ineffective way for dealing with complex unresolved familiy issues without recurring to self paralysis or conversion mechanisms.

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199. 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?

Explanation

The correct answer is D: No bowel movement for 3 days. With opioid analgesics observe for respiratory depression, sedation, and constipation. Bruising is not related to the analgesic, but could be the result of corticosteroids or previously used anticoagulants. Elevated heart rate could be the result of bronchodilators. Some antibiotics can lower platelet count.

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200. 7.    Bumping into a crib, the nurse notices that the newborn infant demonstrates the Moro (startle) reflex. This is seen as the following:

Explanation

The Moro (startle) reflex is demonstrated by abduction, extension, and adduction of arms to an embracing position .

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Which of these actions is the first priority in the prevention of...
A nurse who works at an extended care facility has just reviewed a new...
A 14 years child goes into seizures. Which nursing action is a...
Which of these actions is the first priority in the prevention of...
A 14 years child goes into seizures. Which nursing action is a...
The nurse is reviewing a handout on infant feeding to be distributed...
The nurse is assisting with a pre-kindergarten physical on a five...
The nurse is gathering data from a client who states her last...
The nurse is gathering data from a client who states her last...
A client states, "People think I'm no good, you know what I mean?"...
In taking the history of a pregnant woman, which factor would the...
The nurse is reviewing a handout on infant feeding to be distributed...
The mother of a two year-old hospitalized child asks the nurse's...
The nurse is observing a client with an obsessive-compulsive disorder...
A nurse who works at an extended care facility has just reviewed a new...
Privacy and confidentiality of client information is legally...
Privacy and confidentiality of client information is legally...
A three year-old child is treated in the emergency room after...
A nurse has been named in a lawsuit. The best evidence a nurse can use...
A client is admitted with a diagnosis of schizophrenia. The client...
A school nurse plans to reinforce information about the most effective...
The nurse is assigned to a client with HIV infection. The client also...
In taking the history of a pregnant woman, which factor would the...
A ten year-old child has a history of tonic-clonic seizures. The...
Mr. Reynolds, 69 years of age, is found unconscious by his wife at...
Mr. C. has just been admitted for acute asthma exacerbation and placed...
Ms. W. has a draining pressure ulcer on her sacrum and is to be...
A client states, "People think I'm no good, you know what I mean?"...
The mother of a two year-old hospitalized child asks the nurse's...
The health care provider order reads "aspirate nasogastric feeding...
Which statement by the nurse is appropriate when asking an unlicensed...
Which of the followwing entries in the progress notes of a client...
A client is admitted with a diagnosis of schizophrenia. The client...
A three year-old child is treated in the emergency room after...
A ten year-old child has a history of tonic-clonic seizures. The...
The nurse is assigned to a client with HIV infection. The client also...
Scoliosis a C S curvature of the spine; it cna a temporary or...
Which action would be the best strategy for the nurse to use when...
The nurse is caring for a post-operative client who develops an...
The nurse is observing a client with an obsessive-compulsive disorder...
Which statement by the nurse is appropriate when asking an unlicensed...
Which of the followwing entries in the progress notes of a client...
A 5 years old child has been admitted to the pediatric unit after...
A school nurse plans to reinforce information about the most effective...
The nurse is responsible for assisting in the decisions about client...
Which action would be the best strategy for the nurse to use when...
Ms. P. is transferred to a skilled nursing facility from the hospital...
A 5 years old child has been admitted to the pediatric unit after...
Scoliosis a C S curvature of the spine; it cna a temporary or...
The nurse will administer liquid medicine to a nine month-old child....
X-RN ...
X-RN ...
What is the primary nursing intervention to limit transmission of...
A client receiving chlorpromazine HCL (Thorazine) is in psychiatric...
Which one of these tasks for a 69 year-old client with a diagnosis of...
The nurse is responsible for assisting in the decisions about client...
The nurse is caring for a client who is four days post-op for a...
The nurse will administer liquid medicine to a nine month-old child....
While giving nursing care to a hospitalized adolescent, the nurse...
The nurse would anticipate that an eight month-old would be able...
Which one of these tasks for a 69 year-old client with a diagnosis of...
Several clients are admitted to an adult medical unit. The nurse would...
What is the primary nursing intervention to limit transmission of...
Mr. Reynolds, 69 years of age, is found unconscious by his wife at...
The client is receiving an intravenous piggyback infusion of...
A client was just taken off the ventilator following surgery and has a...
The parents of a four year-old hospitalized child tell the nurse they...
If a nurse is uncertain about whether he or she is licensed to perform...
An outpatient client is scheduled to receive an oral solution of...
An outpatient client is scheduled to receive an oral solution of...
While giving nursing care to a hospitalized adolescent, the nurse...
The nurse is assisting with teaching a group of college students about...
The visiting nurse makes a postpartum home visit to a married female...
A client with heart failure has a prescription for digoxin. The nurse...
The nurse is caring for a four year-old two hours after tonsillectomy...
A 14 month-old child ingested half a bottle of aspirin tablets. Which...
Several clients are admitted to an adult medical unit. The nurse would...
In addition to handwashing, an appropriate infection control...
The nurse is assisting with teaching a group of college students about...
When reinforcing teaching to a depressed client about a new...
A client receiving chlorpromazine HCL (Thorazine) is in psychiatric...
If a nurse is uncertain about whether he or she is licensed to perform...
A nurse arranges for an interpreter to assist with communication...
A nurse arranges for an interpreter to assist with communication...
The nurse is caring for a client who is four days post-op for a...
A client says, "It's raining outside and it's raining in my heart. Did...
A client was just taken off the ventilator following surgery and has a...
The parents of a four year-old hospitalized child tell the nurse they...
A 14 month-old child ingested half a bottle of aspirin tablets. Which...
A client refuses to take the medication prescribed because the client...
The nurse should be informed about cultural issues related to the...
In addition to handwashing, an appropriate infection control...
A 52 year-old post menopausal woman asks the nurse how frequently she...
During the focused assessment of a client with major depression, the...
A client who has just joined a health maintenance organization (HMO)...
After working with a very demanding client, an unlicensed assistive...
The nurse should begin considering discharge concerns for a...
A 52 year-old post menopausal woman asks the nurse how frequently she...
A two month-old infant has both a cleft lip and palate which will be...
Dorreen an adolescent female is newly diagnosed with bulimia. The...
Randy, age 8, is admitted with rheumatic fever. Which clinical finding...
The nurse should be informed about cultural issues related to the...
A client tells the nurse, "I have something very important to tell you...
The nurse should begin considering discharge concerns for a...
The nurse is checking a woman in early labor. While positioning for a...
Mr. D. has a disorder of the hypothalamus and is on a hypothermia...
Mrs. F. has remained close to the nurse all day. When the nurse talked...
A client calls the evening health clinic to state "I know I have a...
A client refuses to take the medication prescribed because the client...
A client frequently compliments the nurse and invites the nurse to go...
A client tells the nurse, "I have something very important to tell you...
Which newly admitted client would be most appropriate to assign to the...
When a client is diagnosed with tuberculosis, the public health...
When a client is diagnosed with tuberculosis, the public health...
While caring for a client, the nurse notes a pulsating mass in the...
While caring for a client, the nurse notes a pulsating mass in the...
The partner of a client with Alzheimer's disease expresses concern...
The nurse is to open a sterile package from central supply. Which is...
9.    Miss Rodriguez is an 88-year-old client at a...
A client calls the evening health clinic to state "I know I have a...
A client is admitted to the emergency room following an acute asthma...
A child, injured on the school playground, appears to have a fractured...
A two month-old infant has both a cleft lip and palate which will be...
The nurse observes a newborn whose Apgar score was 8 and 9. This score...
The nurse is caring for a two month-old infant with a congenital heart...
When Mr. C. is placed on a hypothermia blanket, which of the following...
A client is admitted to the emergency room following an acute asthma...
The nurse is reinforcing instructions for a client with asthma. Which...
After working with a very demanding client, an unlicensed assistive...
Which newly admitted client would be most appropriate to assign to the...
A client is admitted to the hospital with a history of confusion. The...
Mr. Reynolds, 69 years of age, is found unconscious by his wife at...
Mr. T. is a C4 quadriplegic in a nursing home. Which of the following...
Which of these actions best describes the application of time...
The nurse is caring for a four year-old two hours after tonsillectomy...
A client who has just joined a health maintenance organization (HMO)...
A client frequently compliments the nurse and invites the nurse to go...
The nurse observes a newborn whose Apgar score was 8 and 9. This score...
Which one of these tasks could be assigned to the certified nursing...
A client with paranoid delusions stares at the nurse over a period of...
The nurse is collecting data on a client with a stage 2 skin ulcer....
Which one of these tasks could be assigned to the certified nursing...
Mr. S. is to have a tepid sponge bath to lower his fever. What...
The parent of a three-year-old child brings the child to the clinic...
A 64 year-old client scheduled for surgery with a general anesthetic...
Which of these actions best describes the application of time...
A client with paranoid delusions stares at the nurse over a period of...
A female client is admitted for a breast biopsy. She says, tearfully...
A client with a diagnosis of bipolar disorder has been referred to a...
A nurse is reinforcing teaching with a client about compromised host...
A nurse is reinforcing teaching with a client about compromised host...
Marty Cole, 7 years old, is admitted to the pediatric service with a...
An adult is in an acute manic phase of bipolar disorder. He talks and...
A female client is admitted for a breast biopsy. She says, tearfully...
The nurse is collecting data on a client with a stage 2 skin ulcer....
The nurse is reinforcing instructions for a client with asthma. Which...
A client with a diagnosis of bipolar disorder has been referred to a...
Which of these protocols would be essential for the nurse to implement...
A child is admitted to the pediatric unit with a diagnosis of...
A 74 year-old male is admitted due to inability to void. He has a...
The nurse is giving anticipatory guidance regarding safety and injury...
A child, injured on the school playground, appears to have a fractured...
Which of these protocols would be essential for the nurse to implement...
The parents of a child who has suddenly been hospitalized for an acute...
An elderly male client is transferred to a skilled nursing facility...
An adult woman is seen in the clinic for treatment of a minor burn....
In the last 48 hours of life, a hospice client may complain of dry...
A child is admitted to the pediatric unit with a diagnosis of...
A client is admitted with severe injuries from an auto accident. The...
The nurse checks a client with chronic obstructive pulmonary disease....
In the last 48 hours of life, a hospice client may complain of dry...
A client in a long term care facility complains of pain. The nurse...
The hospice nurse is visiting a 75 year-old client with end-stage...
The nurse is reinforcing teaching about the use of nonsteroidal...
The hospice nurse is visiting a 75 year-old client with end-stage...
The nurse is assisting in the assessment of a client's home in...
Mr. Lowell is brought in after a motor vehicle accident. He has...
When planning for the care of a client with a pressure ulcer on the...
The nurse finds, during the initial assessment of the star player on...
The nurse would reinforce the need to take alendronate (Fosamax) as...
The nurse is reinforcing teaching to a 24 year-old woman receiving...
A client in a long term care facility complains of pain. The nurse...
Which nursing diagnosis would indicate that an 86 year-old client is...
Which cognitive skill would the nurse expect a six-year-old child to...
The health care provider has written "Morphine sulfate 2 mgs IV every...
A nurse observes a family member administer a rectal suppository by...
A young man was arrested by the police for indecent exposure,...
The nurse is reinforcing teaching to a 24 year-old woman receiving...
Which nursing diagnosis would indicate that an 86 year-old client is...
Mr. A. has sprained his ankle. The physician would order cold applied...
The nurse recognizes that the client with posttraumatic stress...
A client with chronic obstructive pulmonary disease (COPD) and a...
A young adult is involuntarily admitted to the psychiatric unit in a...
An important goal in the development of a therapeutic inpatient milieu...
A client with heart failure has been instructed by the RN about proper...
Which of the following nursing diagnoses would be most appropriate for...
  ...
Mrs. Wyatt is hospitalized for treatment of a conversion disorder. She...
A client is recovering from a hip replacement and is taking Tylenol #3...
7.    Bumping into a crib, the nurse notices that the...
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