1) The nurse notes blanching, coolness, and edema at the peripheral intravenous (IV) site.On the basis findings, the nurse would implement which action ? a) Remove the peripheral intravenous b) Apply a warm compress. c) Check for a blood return. d) Measure the area of inltration. 2) The nurse has received the client assignment for the day. Which client would the nurse assess first? a) The client who has a nasogastric tube attached to intermittent suction b) The client who needs to receive subcutaneous insulin before breakfast c) The client who is 2 days postoperative and is complaining of incisional pain   d) The client who has a blood glucose level of 50 mg/dL (2.8 mmol/L) and complains of blurred vision  3) The nurse prepares to care for a client on contact precautions who has a hospital-acquired infection caused by methicillin-resistant Staphylococcus aureus (MRSA). The client has an abdominal wound that requires irrigation and has a tracheostomy attached to a mechanical ventilator, which requires frequent suctioning. The nurse would assemble which necessary protective items before entering the client’s room?   a) Gloves and gown b) Gloves and face shield c) Gloves, gown, and face shield d) Gloves, gown, and shoe protectors 4) The nurse is choosing age-appropriate toys for a toddler. Which toy is the best choice for this age? a) Puzzle b) Toy soldiers c) Large stacking blocks d) A card game with large pictures 5) A client with end-stage chronic obstructive pulmonary disease has selected guided imagery to help cope with psychological stress.Which client statement indicates the best understanding of this stress-reduction measure? a) “This will help only if I play music at the same time.” b) “This will work for me if I am alone in a quiet area.” c) “I need to do this when I lie down in case I fall asleep.” d) “The best thing about this is that I can use it anywhere,anytime.” 6) A client with Parkinson’s disease develops akinesia while ambulating, increasing the risk for falls. Which suggestion would the nurse provide to the client to alleviate this problem? a) Use a wheelchair to move around. b) Stand erect and use a cane to ambulate. c) Keep the feet close together while ambulating and use a walker d) Consciously think about walking over imaginary lines on the floor 7) The nurse monitors a client receiving digoxin for which early manifestation of digoxin toxicity? a) Anorexia b) Facial pain c) Photophobia d) Yellow color perception 8) A magnetic resonance imaging (MRI) study is prescribed for a client with a suspected brain tumor. The nurse would implement which action to prepare the client for this test? a) Shave the groin for insertion of a femoral catheter. b) Remove all metal-containing objects from the client c) Keep the client NPO (nothing by mouth) for 6 hours before the test. d) Instruct the client in inhalation techniques for the administration of a radioisotope. 9) A client with renal insufficiency has a magnesium level of 3.5mEq/L (1.44 mmol/L). On the basis of this laboratory result, the nurse interprets which sign as significant? a) Hyperpnea b) Drowsiness c) Hypertension d) Physical hyperactivity 10) A client is scheduled for angioplasty. The client says to the nurse, “I’m so afraid that it will hurt and will make me worse off than I am.” Which response by the nurse is therapeutic? a) “Can you tell me what you understand about the procedure?” b) “Your fears are a sign that you really should have this procedure.” c) “Those are very normal fears, but please be assured that everything will be okay.” d) “Try not to worry. This is a well-known and easy procedure for the cardiologist.” 11) The emergency department nurse is caring for a child suspected of acute epiglottitis. Which interventions apply in the care of the child? a) Obtain a throat culture and Maintain the child in a supine position. b) Auscultate lung sounds, Obtain a pediatric-size tracheostomy tray, Place the child on an oxygen saturation monitor and Prepare the child for a lateral neck and chest x-ray. 12) A 30-year-old client visits the clinic and requests a prescription for oral contraceptives. The nurse performs an assessment on the client and reviews the history and physical examination documented in the medical record from the client’s previous visit. The nurse determines that oral contraceptives are contraindicated because of which documented items? a) Hypertension, Coronary artery disease, Complete blood cell count results and Past medical history of deep vein thrombosis with associated thrombophlebitis b) Prediabetes and Renal ultrasound results c) Takes multivitamin orally daily d) Takes lisinopril 40 mg orally daily e) Takes atorvastatin 10 mg orally daily f) Takes metformin 500 mg orally twice daily 13) A client who experienced a myocardial infarction is being monitored via cardiac telemetry. The nurse notes the sudden onset of this cardiac rhythm on the monitor (refer to figure) and immediately takes which action? a) Takes the client’s blood pressure b) Initiates cardiopulmonary resuscitation (CPR) c) Places a nitroglycerin tablet under the client’s tongue d) Continues to monitor the client and then contacts the cardiologist 14) The nurse would place the client in which position to administer an enema? (Refer to the figures in 1 to 4.) a) prone position b) sim's position c) fowler's position d) supine position 15) The nurse is caring for a hospitalized client with a diagnosis of heart failure who suddenly complains of shortness of breath and dyspnea during activity. After assisting the client to bed and placing the client in high-Fowler’s position, the nurse would take which immediate action? a) Administer high-ow oxygen to the client. b) Call the consulting cardiologist to report the ndings. c) Prepare to administer an additional dose of furosemide d) Obtain a set of vital signs and perform focused respiratory and cardiovascular assessments 16) The nurse is caring for a client with terminal cancer.The nurse would consider which factor when planning pain relief? a) Not all pain is real. b) Opioid analgesics are highly addictive c) Opioid analgesics can cause tachycardia. d) Around-the-clock dosing gives better pain relief than as needed dosing 17) The nurse is caring for a client who just returned from the recovery room after undergoing abdominal surgery. The nurse would monitor for which early sign of hypovolemic shock? a) Sleepiness b) Increased pulse rate c) Increased depth of respiration d) Increased orientation to surroundings 18) The nurse is teaching a client in skeletal leg traction about measures to increase bed mobility. Which item would be most helpful for this client? a) Television b) Fracture bedpan c) Overhead trapeze d) Reading materials 19) The nurse provides medication instructions to a client about digoxin. Which statement by the client indicates an understanding of its adverse effects? a) “Blurred vision is expected.” b) “If my pulse rate drops below 60 beats per minute, I should let my cardiologist know.” c) “If I am nauseated or vomiting, I should stay on liquids and take some liquid antacids.” d) “This medication may cause headache and weakness, but that is nothing to worry about.” 20) The nurse has provided discharge instructions to a client who has undergone a right mastectomy with axillary lymph node dissection. Which statement by the client indicates a need for further teaching regarding home care measures? a) “I should use a straight razor to shave under my arms.” b) “I should inform all of my other doctors that I have had this surgical procedure." c) “I need to be sure that I do not have blood pressures or blood draw from my right arm." d) “I need to be sure to wear thick mitt hand covers or use thick pot holders when I am cooking and touching hot pans.” 21) A client with a diagnosis of cancer is receiving morphine sulfate for pain. The nurse would plan to employ which priority action in the care of the client? a) Monitor stools. b) Monitor urine output. c) Encourage fluid intake d) Encourage the client to cough and deep-breathe. 22) The nurse planning care for a client experiencing dystocia determines that the priority is which action? a) Position changes and providing comfort measures b) Explanations to the client about what is happening c) Monitoring for changes in the condition of the birthing parent and fetus d) Encouraging the use of breathing techniques learned in childbirth preparatory classes 23) A client who had an application of a right arm cast complains of pain at the wrist when the arm is passively moved. Based on the assessment findings, the nurse recognizes cues that indicate the need to take which action first? a) Elevate the arm. b) Document the findings c) Medicate with an additional dose of an opioid. d) Check for paresthesias and paralysis of the right arm. 24) The nurse reviews the arterial blood gas results of a client and notes the following: pH 7.45, Pco2 30 mmHg, and HCO3 22 mEq/L (22 mmol/L). The nurse analyzes these results as indicating which condition? a) Metabolic acidosis, compensated b) Respiratory alkalosis, compensated c) Metabolic alkalosis, uncompensated d) Respiratory acidosis, uncompensated 25) The home care nurse visits a client who has cataracts. The nurse identifies which problem as the priority for this client? a) Concern about the loss of eyesight b) Altered vision due to opacity of the ocular lens c) Difculty moving around because of the need for glasses d) Loneliness because of decreased community immersion 26) The nurse is caring for a client who is receiving total parenteral nutrition through a central venous catheter. Which action would the nurse plan to decrease the risk of infection in this client? a) Track the client’s oral temperature. b) Administer antibiotics intravenously c) Check the differential of the leukocytes. d) Use sterile technique for dressing changes. 27) The nurse is caring for a hospitalized client with coronary artery disease who begins to experience chest pain. The nurse administers a nitroglycerin tablet sublingually as prescribed, but the pain is unrelieved. The nurse would take which action next? a) Reposition the client. b) Call the client’s family. c) Contact the cardiologist. d) Administer another nitroglycerin tablet. 28) The nurse is evaluating the client’s response to treatment of a pleural effusion with a chest tube. The nurse notes a respiratory rate of 20 breaths per minute, fluctuation of the fluid level in the water seal chamber, and a decrease in the amount of drainage by 30 mL since the previous shift. On evaluation, which interpretation would the nurse make? a) The client is responding well to treatment. b) Suction should be decreased to the system. c) The system should be assessed for an air leak. d) Water should be added to the water seal chamber. 29) The nurse is caring for a client who is taking digoxin and is complaining of nausea. The nurse gathers additional assessment data and checks the most recent laboratory results. Which laboratory value requires the need for follow-up by the nurse? a) Sodium 138 mEq/L (138 mmol/L) b) Potassium 3.3 mEq/L (3.3 mmol/L) c) Phosphorus 3.1 mg/dL (1.0 mmol/L) d) Magnesium 1.8 mg/dL (0.9 mmol/L) 30) The nurse is providing discharge instructions to a client with diabetes mellitus. The client’s glycosylated hemoglobin (HbA1c) level is 10%. The nurse would make which statement to the client? a) “Increase the amount of vegetables and water intake in your diet regimen.” b) “Change the time of day you exercise because it may cause hypoglycemia.” c) “Continue with the same diet and exercise regimen you are currently using.” d) “Start a high-intensity exercise regimen and decrease carbohydrate consumption.” 31) A client scheduled for surgery states to the nurse, “I’m not sure if I should have this surgery.” Which response by the nurse is appropriate? a) “It’s your decision.” b) “Don’t worry. Everything will be fine.” c) “Why don’t you want to have this surgery?” d) “Tell me what concerns you have about the surgery.” 32) The nurse is caring for a group of clients. On review of the clients’ medical records, the nurse determines that which client is at risk for excess fluid volume? a) The client taking diuretics b) The client with an ileostomy c) The client with kidney disease d) The client undergoing gastrointestinal suctioning 33) A client is to undergo a computed tomography (CT) scan of the abdomen with oral contrast, and the nurse provides pre procedure instructions. The nurse instructs the client to take which action in the pre procedure period? a) Avoid eating or drinking for at least 3 hours before the test. b) Limit self to only two cigarettes on the morning of the test. c) Have a clear liquid breakfast only on the morning of the test. d) Take all routine medications with a glass of water on the morning of the test 34) A client admitted to the hospital is diagnosed with a pressure injury on the coccyx and has a wound vac. The wound culture results indicate that methicillin-resistant Staphylococcus aureus is present. The wound dressing and wound vac foam are due to be changed. The nurse would employ which protective precautions to prevent contraction of the infection during care? a) Gloves and a mask b) Contact precautions c) Airborne precautions d) Face shield and gloves 35) The nurse in charge of a long-term care facility is planning the client assignments for the day. Which client would the nurse assign to the assistive personnel (AP)? a) A client on strict bed rest b) A client with dyspnea who is receiving oxygen therapy c) A client scheduled for transfer to the hospital for surgery d) A client with a gastrostomy tube who requires tube feedings every 4 hours 36) The nurse is called to a client’s room to assist the client who has a chest tube. The client states that it feels as if the tube has pulled out of the chest. The nurse assesses the client and finds that the tube has dislodged and is lying on the floor.What action would the nurse take next? a) Ask for a pair of sterile gloves. b) Contact the charge nurse for help. c) Cover the insertion site with a sterile dressing. d) Submerge the dislodged tube into sterile water. 37) Lisinopril is prescribed as adjunctive therapy in the treatment of heart failure. After administering the first dose, the nurse would monitor which item as the priority? a) Weight b) Urine output c) Lung sounds d) Blood pressure

Nclex test simulator

Trykke
Integrere

Rangliste

Visuel stil

Indstillinger

Skift skabelon

Gendan automatisk gemt: ?