NCLEX Quiz 2

A 25-year-old client is about to undergo a unilateral orchiectomy for treatment of testicular cancer.  The client says to the nurse, “I’m so worried that my future spouse is going to call off our engagement.”  What is the best response by the nurse?

A client is admitted to the hospital for chemotherapy complications.  Laboratory results show an absolute neutrophil count of 450 cells/mm³ (0.45 ×10⁹/L).  What information contained in the admission history of this client will need to be addressed during discharge education?

A client on hospice home care is taking sips of water but refusing food.  Family members appear distressed and insist that the personal care worker “force feed” the client.  What is the priority nursing action?

The nurse teaches safety precautions of home oxygen use to a client with emphysema being discharged with a nasal cannula and portable oxygen tank.  Which client statement indicates the need for further teaching?  Select all that apply.

The unit educator is performing skill validations with unit staff.  Which of the following actions by the staff nurses demonstrate a correct understanding of parenteral medication administration?  Select all that apply.

The pediatric nurse is reinforcing education about medication administration to the parents of a 4-year-old client.  Which statements made by the parents demonstrate correct understanding?  Select all that apply.

The male client had a hemicolectomy.  The client is refusing to wear the prescribed sequential compression devices (SCDs).  What is most important for the nurse to communicate to the client?

A nurse is making a home visit when a fire starts in the client’s kitchen trash can.  The client has a fire extinguisher.  The nurse should take which actions to properly operate the fire extinguisher?  Select all that apply.

A client who was placed in restraints appears in the hallway an hour later and states, “I’m Houdini.…  I can get out of anything.  There could be trouble now.”  Which of the following is the best response to this client?

The same-day surgery nurse performs the preoperative assessment for a client with a history of coronary artery disease scheduled for an elective laparoscopic cholecystectomy.  Which statement made by the client is critical to report to the health care provider (HCP) before the surgery?

The caregiver of a toddler calls the clinic because the child has accidentally ingested one capsule of amitriptyline found in the medicine cabinet.  The caregiver states that the child appears to be acting normally.  Which response by the nurse is appropriate?

The nurse is caring for a client with bacterial meningitis, identified as Neisseria meningitidis who has a stage 4 pressure injury.  What personal protective equipment is most appropriate for the nurse to wear when performing a dressing change?  Select all that apply.

The nurse performs tracheostomy care for a client with a disposable inner cannula and tracheostomy dressing.  Place the steps in the correct order.  All options must be used.

The occupational health nurse administers an intradermal tuberculin skin test (TST) to a health care worker (HCW).  The site must be assessed for a reaction afterward.  The nurse instructs the HCW to return in how many hours?

The student nurse verbalizes the procedure for obtaining a wound culture to the nurse preceptor.  Which of the following statements by the student indicate a correct understanding?  Select all that apply.

The graduate nurse (GN) is inserting an oropharyngeal airway into a client emerging from general anesthesia.  Which action by the GN causes the nurse preceptor to intervene?

The nurse is to administer an albuterol nebulizer treatment to a client with acute bronchospasm.  The prescribed dosage is 5 mg every 4 hours.  The available solution is albuterol (0.083%) inhaled, 2.5 mg/3 mL.  How many milliliters (mL) should the nurse administer with each dose?  Record your answer as a whole number.

An infant is experiencing respiratory depression immediately after a vaginal delivery using epidural analgesia with morphine.  The health care provider prescribes 0.1 mg/kg naloxone IM to be given STAT once.  The client weighs 3600 grams and naloxone 0.4 mg/mL is available.  How many milliliters will the nurse administer?  Record your answer using one decimal place.

Ten minutes after an infusion of packed red blood cells (PRBCs) is initiated through a central venous catheter (CVC), the client has shortness of breath and slight chest tightness.  What initial actions would be appropriate for the nurse to complete?  Select all that apply.

A postoperative client with obesity and diabetes mellitus has an abdominal incision and is at risk for poor wound healing.  Which interventions should the nurse include in the plan of care to promote wound healing and prevent dehiscence?  Select all that apply.

The nurse is caring for a client with partial hearing loss.  Which interventions would be appropriate to promote effective communication?  Select all that apply.

The nurse is conducting a home visit to assess an elderly client with advanced heart failure who lives alone.  When the nurse asks about sodium intake, the client becomes angry and says, “I’m so tired of people telling me what to do!  I’m going to eat what I want, so leave me alone!”  Which of the following is the most appropriate response by the nurse?

Which client is at the greatest risk for development of hospital-acquired pressure injuries?

The nurse is caring for 4 clients requiring IV fluid therapy.  For which client should the nurse anticipate the need for isotonic crystalloid administration?

The clinic nurse is assessing the client’s understanding of tiotropium, which has been prescribed for chronic obstructive pulmonary disease (COPD).  Which statement indicates that the client has a correct understanding of this medication?

A client with a tracheostomy is alert and oriented and able to tolerate oral intake.  Which action would be appropriate to reduce the client’s risk of aspiration pneumonia?

The nurse is caring for a client with HIV.  The nurse understands that which of the following are true regarding transmission-based precautions?  Select all that apply.

The nurse accidentally sticks him/herself in the finger with a client’s contaminated needle.  The client has HIV infection.  Place in order the steps the nurse should take.  All options must be used.

The nurse is caring for an agitated client with dementia who is pulling at the oxygen and IV tubing.  Wrist restraints are applied after less-restrictive safety measures have been ineffective.  Which actions are appropriate to protect the client from injury?  Select all that apply.

The emergency department nurse receives report on 4 clients.  Which client will the nurse prioritize for placement in an isolation room?

During a home visit, the community health nurse observes bruises in various stages of healing on the extremities and torso of an elderly client.  The client explains that the bruises are from bumping into furniture and the wall in the wheelchair.  What is the priority nursing action?

The orthopedic health care provider instructs a client with a fractured right femur, who has been non-weight bearing for the past 5 weeks, to progress to full weight bearing on the right leg.  Which advanced crutch gait that most closely resembles normal walking should the office nurse teach the client?

The spouse of a client calls the nurse at the clinic and reports that the client is not feeling well and is concerned that something is seriously wrong.  How should the nurse respond initially?

The nurse is preparing a client for a magnetic resonance cholangiopancreatography.  Which statements by the client would require the nurse to obtain further assessment data?  Select all that apply.

The nurse is reinforcing education about ascending stairs using a modified 3-point gait to a client prescribed crutches after a left ankle sprain.  Place the instructions for ascending the stairs in the correct order.  All options must be used.

A client with a nasogastric tube is prescribed intermittent bolus enteral feedings with routine gastric residual checks.  Which of the following actions by the nurse are appropriate?  Select all that apply.

A nurse is assisting with the care of a newborn during circumcision.  Which is an appropriate intervention?

The nurse working in an intensive care unit receives a prescription from the primary health care provider to discontinue a triple-lumen subclavian central venous catheter.  Which interventions will help prevent air embolism on removal?  Select all that apply.

A client is being discharged after having a coronary artery bypass grafting (CABG) x 5.  The client asks questions about the care of chest and leg incisions.  Which instructions should the registered nurse include?  Select all that apply.

As the nurse begins to assist with ambulation of a 9-year-old who is one day post appendectomy, the child cries out, “It hurts too much.  I can’t do it.”  What is the first action by the nurse?

A home health nurse visits a client with Alzheimer disease.  The caregiver appears frustrated and reports that the client has been persistently restless and agitated.  Which nursing action is the priority currently?

The nurse initiates prescribed intravenous (IV) therapy on an 86-year-old hospitalized client.  Which life span concept(s) should be considered when initiating IV therapy and caring for an older adult receiving IV therapy?  Select all that apply.

A nurse in a pediatric clinic is preparing to administer ear drops to a 5-year-old.  Which is an appropriate action by the nurse?

A new graduate nurse is preparing to administer the following analgesics to clients with postoperative pain.  Which situation would require intervention by the precepting nurse?

A student nurse assesses and obtains a urine specimen from a client with methicillin-resistant Staphylococcus aureus (MRSA) who is on contact precautions.  The registered nurse intervenes when the student performs which action?

The health care provider writes a prescription for hydromorphone 10 mg intravenous push every 2 hours prn for the post-operative client.  The usual recommended dose is 0.2-1 mg every 2-3 hours prn.  What action should the nurse initially take?

The nurse is caring for a client who performs frequent urinary self-catheterizations.  Which of the following client assessments would indicate a potential for a latex allergy?  Select all that apply.

A client newly returned to the unit after knee surgery asks the nurse for assistance to a chair.  What action should the nurse implement first?

A graduate nurse is caring for a client with a triple-lumen peripherally inserted central catheter in the right arm.  Which actions by the graduate nurse indicate that more education is needed?  Select all that apply.

The nurse cares for a client admitted to the hospital following a motor vehicle accident caused by the client’s newly diagnosed seizure disorder.  The health care provider prescribes seizure precautions for the client.  The nurse prepares to initiate which interventions?  Select all that apply.

A nurse prepares to administer an intermittent enteral feeding via nasogastric tube to a client with a prescription for gastric residual checks before each feeding.  The nurse obtains a gastric residual volume of 80 mL.  Which action should the nurse perform next?

The nurse is assisting with procedural moderate sedation (conscious sedation) at a client’s bedside.  The unlicensed assistive personnel (UAP) come to the door and indicates that the client in the next room needs the nurse right now.  How should the nurse respond?

The nurse is assessing urine dipstick results in a client with right flank area pain for the past 24 hours.  According to the dipstick results, what is the nurse’s best action? See the exhibit button for additional information.

The nurse prepares to insert a large-bore nasogastric tube for gastric decompression.  After obtaining equipment, the nurse identifies the client, performs hand hygiene, applies clean gloves, assesses nares, and selects a naris.  Place the remaining steps in the correct order.  All options must be used.

The nurse is preparing to administer a unit of packed red blood cells to a 16-year-old with blood loss anemia.  The client currently has D5W infusing through a 20-gauge IV catheter.  What action should the nurse take?

The health care provider prescribes a continuous IV infusion of regular insulin at 5 units/hr.  The infusion bag contains 50 units of regular insulin in 100 mL of normal saline solution.  At what rate in milliliters per hour (mL/hr) does the nurse set the IV pump?  Record your answer using a whole number.

A nurse is caring for a 3-month-old client with a new tracheostomy.  Which findings would indicate a need for suctioning?  Select all that apply.

A 55-year-old client on a medical-surgical unit has just received a diagnosis of pancreatic cancer.  The client says to the nurse, “Is this disease going to kill me?”  What is the best response by the nurse?

The nurse is providing discharge instructions to a 70-year-old client newly diagnosed with heart failure who has a low literacy level.  What are some teaching strategies that the nurse can use for this client?  Select all that apply.

The educator on a rehabilitation unit is teaching a graduate nurse (GN) about caring for clients who have had a stroke.  Which of the following statements by the GN indicate correct understanding of the teaching?  Select all that apply.

The nurse is caring for a client newly prescribed crutches.  Which finding indicates the need for further teaching?

The nurse precepts a nursing student caring for a client with glaucoma and observes the student administer timolol maleate, an ophthalmic medication.  Which student action indicates that further instruction is needed?

A client with terminal cancer is prescribed fentanyl patches for pain management while receiving hospice care at home.  Which instructions related to this medication should the nurse provide?  Select all that apply.

A client with suspected foot osteomyelitis is scheduled for an MRI.  Which findings should the nurse notify the health care provider about before the test?  Select all that apply.

The nurse cares for a child with bed bug bites.  Which parent statement indicates that further teaching is required?

The nurse in the intensive care unit (ICU) is giving unlicensed assistive personnel (UAP) directions for bathing a client who has a surgical incision infected with methicillin-resistant Staphylococcus aureus (MRSA).  Which instructions would be most effective for reducing infection?

A client on fall precautions is found on the floor by the bed when the unlicensed assistive personnel make hourly rounds.  Place the actions the registered nurse should take in the appropriate order.  All options must be used.

The nurse prepares to exit the room of a client on airborne and contact isolation precautions.  Place the following nursing actions in the correct order.  All options must be used.

The charge nurse is notified that a client is being admitted with a diagnosis of active shingles with a disseminated rash.  Which room assignment is most appropriate for this client?

The nurse is caring for a client who has deep venous thrombosis and is prescribed a continuous IV infusion of heparin 25,000 units in 500 mL of D₅W at 1300 units/hr.  After 6 hours of the heparin infusion, the client’s PTT is 44 seconds.  The nurse must adjust the infusion rate according to the heparin drip protocol (shown in the exhibit).  According to the protocol, at what rate in milliliters per hour (mL/hr) should the nurse set the IV infusion pump?  See the exhibit button for additional information.  Record your answer using a whole number.

A client is receiving a blood transfusion.  Fifteen minutes after the transfusion starts, the nurse notes a drop in blood pressure from 110/70 to 84/50 mm Hg.  The client reports “feeling a little cold.”  Based on this assessment, in what order should the nurse complete the following actions?  All options must be used.

A school nurse observes a 3-year-old begin to choke and turn blue while eating lunch.  What should be the nurse’s initial action?

The nurse is inserting an indwelling (Foley) urinary catheter into a male client.  After inserting the catheter about 6 in (15.2 cm), the nurse notes drops of urine in the tubing.  What action should the nurse take next?

An elderly client is brought to the emergency department with lethargy, chills, and sharp chest pain with deep breathing.  Pulse oximeter shows 93% on room air and respirations are 24/min.  What is the nurse’s initial action?

A client postoperative from a transurethral prostatectomy has a triple-lumen, indwelling urinary catheter and is receiving continuous bladder irrigation of sterile normal saline solution at 175 mL/hr.  The nurse empties the urine drainage bag for a total of 2300 mL at the end of the 8-hour shift.  How many milliliters (mL) should the nurse document as the net urine output for the shift?  Record your answer using a whole number.

The nurse is suctioning the artificial airway of a conscious client.  Which actions demonstrate correct technique?  Select all that apply.

A client with advanced multiple sclerosis (MS) has been a resident in a nursing home for the past 2 years.  One day, the client tells the nurse, “I want to get out of here and try living in my own home.”  What is the best response by the nurse?

A home health nurse is visiting a 72-year-old client who had coronary artery bypass graft surgery 2 weeks ago.  The client reports being forgetful and becoming teary easily.  How should the nurse respond?

Which interventions does the nurse perform to promote normal rest and sleep patterns for a critically ill client?  Select all that apply.

An unlicensed assistive personnel (UAP) is aiding a client recovering from a right-sided cerebrovascular accident with resulting mild oropharyngeal dysphagia.  The client has been placed on a dysphagia diet.  Which actions require intervention by the registered nurse?  Select all that apply.

A nurse is caring for 4 clients.  Which prescription by the health care provider would the nurse question and seek further clarification before administering?

The pediatric nurse is preparing to administer an acetaminophen suppository to an 11-month-old with pyrexia.  Which actions are appropriate?  Select all that apply.

A nurse is caring for a group of clients on a medical surgical unit.  Which client is most at risk for contracting a nosocomial infection?

The charge nurse is preparing for the admission of an elderly client with delirium and agitation associated with urinary tract infection.  To promote client safety, which intervention is most important for the charge nurse to implement?

A client who has been prescribed several medications asks, “Can I take over-the-counter (OTC) medications with my prescriptions?”  Which of the following statements by the nurse is appropriate?  Select all that apply.

The nurse removes personal protective equipment (PPE) after completing a wound dressing change for a client in airborne transmission-based precautions.  Which PPE should the nurse remove first?

A nurse is reviewing the most recent laboratory results of a client on the telemetry floor.  The client is currently asymptomatic, and the telemetry monitor indicates sinus rhythm.  Which of the following critical values is most likely due to laboratory error?

A client is seen in the clinic for the third time for a nonhealing, infected diabetic foot ulcer.  The client is able to verbalize the correct procedure for wound care but reports not adhering to the ordered routine at home.  What intervention does the nurse prioritize to promote proper self care?

The nurse is performing open endotracheal suctioning for a client with a tracheostomy tube.  Which of the following actions by the nurse are appropriate?  Select all that apply.

The nurse is caring for a client with newly prescribed hearing aids.  Which of the following actions by the client indicate proper use and care of hearing aids?  Select all that apply.

The nurse is preparing to administer an antibiotic to a child with pneumonia.  The prescription reads: 7.5 mg/kg every 24 hours divided into 2 doses, PO in liquid form.  The client weighs 78 lb.  The pharmacy has supplied the drug in 125 mg/5 mL.  How many milliliters (mL) should the client receive for each dose?  Record your answer using one decimal place.

The nurse prepares to insert an indwelling urinary catheter for a female client.  The nurse assesses for allergies, explains the procedure to the client, gathers equipment, and then performs perineal care.  Place in order the steps the nurse should take when inserting the urinary catheter.  All options must be used.

The nurse plans to start an IV line on a female client hospitalized with pneumonia.  The nurse reviews the electronic medical record for relevant information and learns that the client is right-handed and has a history of a left-sided mastectomy with lymph node removal.  Which site is best for the nurse to select for the client’s IV line?

The health care provider prescribes 2 mEq (2 mmol)/kg of 8.4% sodium bicarbonate IV to be administered over the next 4 hours.  The client weighs 150 lb, and the pharmacy supplies the following IV solution: 8.4% sodium bicarbonate in 1000 mL of D₅W with 150 mEq (150 mmol) of sodium bicarbonate.  At what rate in milliliters per hour (mL/hr) should the nurse set the infusion pump?  Record your answer using a whole number.

A client arrives in the emergency department on a cold winter day.  The client is calm, alert, and oriented with a respiratory rate of 20/min and a pulse oximeter reading of 78%.  The nurse suspects that the client’s pulse oximeter reading is inaccurate.  Which factors could be contributing to this reading?  Select all that apply.

An adolescent client is brought to the emergency department after being in a serious motor vehicle crash.  The client is undergoing cardiopulmonary resuscitation.  The nurse calls the family to inform them to come to the hospital and a family member asks how the client is doing.  Which is an example of the ethical principle of beneficence when responding to the client’s family?

A client is brought to the emergency department with multiple trauma injuries.  The nurse sees the client’s Jehovah’s Witness identification card.  As part of providing culturally competent care, the nurse would anticipate the client accepting which of the following?  Select all that apply.

A client of the Orthodox Jewish faith with a history of type 2 diabetes mellitus is hospitalized, recovering from a total right hip arthroplasty.  At noon, the client consumed a lean roast beef sandwich with lettuce and mustard, carrot and celery sticks, and fresh fruit.  What would be the most appropriate 2:00 PM snack for this client?

The nurse admits an 81-year-old client with gastroenteritis.  Admission vital signs are temperature 101 F (38.3 C), blood pressure 90/42 mm Hg, pulse 118/min, and respirations 32/min.  Pulse oximetry shows 88%.  The nurse suspects which of the following factors may be affecting accuracy of the pulse oximetry reading?

The health care provider prescribes intravenous fluid resuscitation for a client in hypovolemic shock.  The nurse should anticipate the rapid infusion of which intravenous solution initially?

The nurse working in an extended care facility transcribes a prescription from the health care provider for a single daily dose of 150 mg of ranitidine; this is to be taken orally at bedtime for treatment of gastroesophageal reflux disease.  Of the following prescriptions, which one is transcribed correctly?

A nurse is caring for a homeless client who is moderately malnourished and suffering from pneumonia.  The client needs a peripheral IV line for fluid administration.  Which IV site should the nurse select to reduce the risk for infection?

The nurse is caring for a client on droplet precautions who has a prescription for a CT scan.  When transporting the client to radiology, the nurse should ensure that the transporter uses protective equipment correctly to reduce the environmental spread of infection when the client is outside the room.  Which instruction should the nurse give the transporter?

Which client incident would be classified as an adverse event that requires an incident/event/irregular occurrence/variance report?  Select all that apply.

The charge nurse is planning assignments for the day.  Which clients will require the nursing staff to institute contact precautions?  Select all that apply.

The public health nurse conducts a program at the community senior citizen center about preventing falls at home.  Which statement made by a participant indicates that further education is needed?

The nurse is caring for a client who develops Clostridium difficile colitis after multiple days of antibiotic therapy.  Which infection control measures are appropriate to implement?  Select all that apply.

The nurse cares for an 11-lb (5-kg) infant admitted with dehydration and prepares to calculate intake and output over an 8-hour shift.  Using the data in the exhibit, calculate the total output in milliliters for the 8-hour shift.  Record your answer as a whole number.  See the exhibit button for additional information.

The nurse is feeding a confused client via a small-bore nasoenteric tube.  The nurse observes the client pulling at the tube and then notices an increase in external tube length from the original exit mark.  After immediately stopping the feeding, which action is appropriate for the nurse to take next?

The primary health care provider prescribes a 24-hour urine collection for a client with suspected Cushing syndrome.  Which instructions should the nurse give the client regarding this test?  Select all that apply.

A hospitalized client is scheduled for a percutaneous kidney biopsy at 10 AM.  At 8 AM, the nurse reviews the client’s vital signs and most current serum laboratory results.  Which finding is most important to report to the health care provider (HCP)?

The nurse is preparing to infuse 2 units of packed red blood cells (PRBCs) to a client with a gastrointestinal bleed.  Which actions should the nurse take?  Select all that apply.

A client with type 1 diabetes has a prescription for 20 units of NPH insulin daily at 7:30 AM and regular insulin before meals, based on a sliding scale.  At 7:00 AM, the client’s blood glucose level is 220 mg/dL (12.2 mmol/L), and the client’s breakfast tray has arrived.  What action should the nurse take? See the exhibit button for additional information.

The health care provider prescribes a continuous heparin infusion at 18 units/kg/hr for a client who has a pulmonary embolus and weighs 198 lb.  The infusion bag contains 25,000 units of heparin in 500 mL of D₅W.  At what rate in milliliters per hour (mL/hr) does the nurse set the IV infusion pump?  Record your answer using a whole number.

The nurse is caring for a client with advanced Alzheimer disease.  Which techniques are appropriate when speaking with this client?  Select all that apply.

An elderly war veteran with prostate cancer and coronary artery disease is hospitalized for urosepsis.  The client becomes angry with the unlicensed assistive personnel (UAP), who is trying to help the client bathe.  Later, the UAP expresses frustration with the client to the registered nurse.  Which statement would be the most appropriate response?

A client is being seen in the clinic after receiving an external breast prosthesis after a mastectomy.  What question from the nurse best evaluates the effectiveness of the prosthesis on body image?

The unit implemented a quality improvement program to address client pain relief.  Which set of criteria is the best determinant that the goal has been met?

The nurse teaches a parent how to administer an oral liquid medication to a 2-month-old client.  The nurse knows that the parent understands the teaching when the parent does which of the following?

The nurse observes a student nurse administer ear drops to an elderly client to help loosen cerumen.  The nurse intervenes when the student performs which action?

A nurse prepares a client for knee arthroscopy requiring general anesthesia.  Which actions should the nurse complete?  Select all that apply.

A nurse has received report from the off-going shift that a client is confused and has been identified as a high risk for falls.  The nurse shares this information with the unlicensed assistive personnel (UAP).  Which finding by the nurse requires intervention?

The nurse at the radiological imaging center is admitting a client for an MRI of the right knee.  Which information obtained by the nurse should be reported immediately to the prescribing health care provider?

A comatose client in the intensive care unit has an indwelling urinary catheter.  Which action(s) should the nurse implement to reduce the incidence of catheter-associated urinary tract infections (UTIs)?  Select all that apply.

A nurse is caring for a client who is intubated and has a subclavian central venous catheter.  Which nursing intervention is most important to prevent the spread of infection to this client?

The nurse prepares to care for a client being admitted with a confirmed diagnosis of Middle East respiratory syndrome.  Which personal protective equipment will the nurse use when providing care to the client?

One unit of packed RBCs (PRBCs) is prescribed for a client experiencing complications of sickle cell anemia.  Which of the following actions by the nurse are appropriate?  Select all that apply.  See the exhibit button for additional information.

The nurse notes muffled heart tones in a client with a pericardial effusion.  How would the nurse assess for a pulsus paradoxus?

The nurse attempts to flush a client’s subclavian vein central venous access device with normal saline using a 10-mL syringe, but meets resistance, is unable to aspirate blood, and suspects an occlusion.  What should the nurse do next?

While preparing to insert a peripheral IV line, the nurse notices scarring near the client’s left axilla.  The client confirms a history of left breast cancer and modified radical mastectomy.  Which actions should the nurse take?  Select all that apply.

The nurse prepares to administer an IV infusion of potassium chloride through a peripheral vein to a client with hypokalemia.  The health care provider’s prescription states: IV potassium chloride 10 mEq (10 mmol)/100 mL 5% dextrose in water now, infuse over 30 minutes.  What is the nurse’s priority action?

The 70-year-old client with type 2 diabetes and hypertension is scheduled for ureteral stent removal in 2 hours.  The preoperative protocol ECG is done in the inpatient unit, and results indicate a “possibly acute” ST segment elevation.  What action is most important for the nurse to take?

The nurse is drawing blood from a client’s peripheral vein for laboratory specimens.  Which of the following are correct nursing actions?  Select all that apply.

A client scheduled for surgery indicates on their preoperative questionnaire a religious preference with spiritual needs.  Which action is most appropriate for the nurse to make currently?

The nurse reviews the laboratory results for an adult male client admitted with septic shock.  Which value requires the most immediate action?  See the exhibit for additional information.

The nurse is caring for a group of clients.  Which finding requires immediate action by the nurse?

The nurse learns that an Orthodox Jewish client has not started taking recently prescribed diltiazem extended-release capsules.  The client states “I cannot take the medication in this form.”  What is the nurse’s first action?

A client has just returned to the room after having a mammogram.  The client is teary and in a shaky voice says to the nurse, “The radiology technician told me that it looks really bad – the tumor in my breast is very large.”  Which is the best response by the nurse?

The nurse is preparing to administer an IM immunization to a 6-month-old infant.  Which needle length and injection site would be the most appropriate to minimize a local reaction to the vaccine components?

The nurse is precepting a new graduate nurse (GN) who is administering a prefilled enoxaparin injection to an obese client.  Which action by the GN indicates the need for further education from the nurse preceptor?

A client who is intubated and on mechanical ventilation is receiving continuous enteral tube feedings at 30 mL/hr via a small-bore nasogastric tube.  Which actions should the nurse take to prevent aspiration in this client?  Select all that apply.

A nurse in the surgical admitting unit is preparing a client for elective coronary artery bypass surgery.  Which statement by the client should the nurse report immediately to the health care provider (HCP)?

A nurse is performing a dressing change for a hospitalized client with an infected surgical incision.  Which actions should the nurse take?

The nurse is preparing to care for a client with acute myelogenous leukemia who is going through induction chemotherapy.  The client’s laboratory results are shown in the exhibit.  Which intervention would be a priority for this client?  See the exhibit button for additional information.

A client has been admitted with a catheter-associated, vancomycin-resistant enterococcal bacteremia.  Which interventions should the nurse implement?  Select all that apply.

There has been an explosion at a local chemical plant.  A private car arrives at the emergency department with 4 victims whose clothes are saturated with a strong-smelling liquid.  The victims are wheezing.  The nurse should implement which intervention first?

The nurse is evaluating a return demonstration by the client of a dry dressing change.  Which action by the client would cause the nurse to intervene?

A health care provider prescribes cefuroxime 30 mg/kg/day PO divided in equal doses every 12 hours for a child with a urinary tract infection.  The child weighs 34 lb.  Based on the available concentration of cefuroxime, how many mL would the nurse administer per dose?  See the exhibit button for additional information.  Record your answer using one decimal place.

The nurse prepares equipment for insertion of a large-bore nasogastric (NG) tube for a hospitalized client.  Which actions should the nurse take to measure and mark the tube?  Select all that apply.

The nurse is drawing a blood specimen from the client’s right basilic vein.  The client cries out, retracts the arm, and reports feeling “pins and needles” in the right arm.  Which action by the nurse is appropriate?

A charge nurse is monitoring a newly licensed registered nurse.  What action by the new nurse would warrant intervention by the charge nurse?

The nurse is to administer prescribed heparin 70 units/kg IV bolus before initiating the continuous infusion as prescribed.  Heparin 1,000 units/mL is available.  The client weighs 108 lb.  How many milliliters of heparin bolus should the nurse administer?  Record your answer using one decimal place.

A 7-year-old client receives a scalp laceration to the back of the head while on a playground, and the new nurse prepares to irrigate the wound.  Which actions by the new nurse would require the experienced nurse to intervene?  Select all that apply.

A nurse is caring for a client who is meeting with the palliative care team.  After the meeting, the client’s family asks for clarification about palliative care.  Which statements about palliative care are accurate?  Select all that apply.

A client is scheduled for coronary artery bypass surgery in the morning.  In the middle of the night, the nurse finds the client wide awake.  The client demonstrates symptoms of extreme anxiety and tells the nurse about wanting to refuse the surgery.  Which statement by the nurse would be most appropriate?

A legally blind client is being prepared to ambulate 1 day after an appendectomy.  What is the most appropriate action by the nurse?

The nurse is caring for a client with a feeding tube that has become obstructed.  Which intervention should the nurse implement first to unclog the tube?

The registered nurse (RN) is providing nursing care with a licensed practical nurse and unlicensed assistive personnel.  The RN administers hydromorphone 1.5 mg IVP per STAT order to a client with severe abdominal pain.  Three hours later, the client rates pain as a 9 on a scale of 0-10 and requests pain medication.  What is the most appropriate action for the RN to take?

The nurse observes a student nurse administer a tuberculin skin test using the intradermal route.  The nurse intervenes when the student performs which action?

A nurse is preparing to administer 2 continuous IV medications concurrently via a 20-gauge IV.  What is the nurse’s priority action?

The home health nurse visits a client who is rehabilitating after a tibial fracture.  Which interventions are appropriate to include in the client’s teaching plan to promote safety in the home when using crutches?  Select all that apply.

A home health nurse is supervising a home health aide who is changing the dressing for a client with a chronic heel wound.  Which actions by the aide indicate adherence to appropriate infection control procedures?  Select all that apply.

The nurse is caring for a client with Clostridium difficile colitis.  Which of the following infection control measures by the nurse are appropriate?  Select all that apply.

A home health nurse is teaching the spouse of an elderly client who experienced a stroke ways of reducing risks for falls in the home.  Which suggestion by the spouse would be the most effective plan to prevent falls?

A client in the mental health unit picks up a fire extinguisher and throws it at a nurse standing by the nurses’ station.  What is the most important intervention by the nurse?

The nurse should consider which of the following client reports as an indication of an allergic reaction?

Which interventions should the nurse perform when assisting the health care provider with removal of a client’s chest tube?  Select all that apply.

The nurse is assisting a client who has a bedside needle liver biopsy scheduled.  Which are the essential actions?  Select all that apply.

A child with congenital heart disease weighing 44 lb is prescribed furosemide 1 mg/kg PO every 8 hours.  It is available as an oral solution of 10 mg/mL.  How many milliliters (mL) of furosemide should the nurse administer to the client each dose?  Record your answer using a whole number.

The nurse is assessing a client’s peripheral pulses.  The nurse palpates the top portion of the client’s foot.  The right pulse is easily palpable, and the left pulse is diminished but still palpable.  How should the nurse document these findings?

A nurse is instructing the caregiver of an 8-month-old client regarding administration of oral amoxicillin.  The client is prescribed 25 mg/kg/day of amoxicillin in 2 divided doses for 5 days.  The client weighs 16.5 lb and the amoxicillin solution is prepared as 125 mg/5 mL.  How many mL of amoxicillin should the nurse instruct the caregiver to administer for each dose?  Record the answer using two decimal places.

The nurse prepares to draw up regular and NPH insulins into one syringe.  Place in order the steps the nurse should take when mixing the insulins.  All options must be used.

A pediatric client weighing 66 lb is prescribed ibuprofen 5 mg/kg by mouth every 6 hr PRN for fever.  It is available as an oral solution of 20 mg/mL.  How many milliliters (mL) of ibuprofen should be given to the client per dose?  Record your answer using one decimal place.

A client is undergoing chest tube placement in the emergency department after being involved in a motor vehicle collision.  The client’s spouse arrives and demands to be with the client.  Which action should the nurse take?

A client with renal failure recently started dialysis and is unable to work due to ongoing health problems.  The client’s spouse has started working for a cleaning service to replace the lost income.  The dialysis nurse notices that the client has become withdrawn and increasingly frustrated by small inconveniences when coming to dialysis.  Which is the most appropriate first response by the nurse?

The client screams at the nurse, “You are all incompetent here!  I have been waiting for 2 hours!”  How should the nurse respond initially?

The nurse is interviewing a non-English-speaking client.  Which best practices will the nurse use when working with a professional medical interpreter for clients of limited English proficiency?  Select all that apply.

The nurse observes a client self-administering nasal fluticasone.  Which observation would require the nurse to intervene and provide further teaching?

A nurse on the telemetry unit is preparing client medications in the medication room at the nurse’s station.  The nurse should perform which actions to be consistent with client safety practices related to medication administration?  Select all that apply.

The nurse has unlicensed assistive personnel (UAP) caring for a client with an acute attack of Meniere disease.  Which action by the UAP will require follow-up by the nurse?

Which client is most at risk for hospital-acquired methicillin-resistant Staphylococcus aureus (MRSA)?

The nurse is contributing to the plan of care for a client who has active varicella with open, moist lesions.  Which of the following actions are appropriate to include in the plan of care?  Select all that apply.

A client is able to partially bear weight and follow the nurse’s instructions.  Which would be the most appropriate method for the nurse to use to safely transfer this client?

The nurse is caring for an older adult client who is confused and has a high risk for falls.  The client is incontinent of urine and frequently attempts to get out of bed unassisted to use the restroom.  Which nursing interventions are appropriate when caring for this client?  Select all that apply.

The nurse caring for a client with tuberculosis (TB) transports the client to the radiology department for a chest x-ray.  The nurse ensures that the client uses which personal protective equipment when out of the negative-pressure room?

The nurse prepares to assist the health care provider with a lumbar puncture on a child with suspected meningitis.  Place the procedural steps in the correct order.  All options must be used.

Which procedures are appropriate for the nurse to use when obtaining an adult client’s blood for a laboratory test?  Select all that apply.

The nurse helps the health care provider perform a thoracentesis at the bedside.  In which position does the nurse place the client to facilitate needle insertion and promote comfort?

A 2-year-old is admitted to the emergency department for anaphylactic reaction to a bee sting.  The nurse teaches the parent about emergency use of epinephrine injection.  Which statement indicates that the parent understands the instruction?  Select all that apply.

The nurse assesses the breath sounds of a 2-day postoperative total laryngectomy client and determines that suctioning is needed to clear secretions.  The client is off the mechanical ventilator and is receiving humidified oxygen via a tracheostomy mask.  Place the steps for suctioning the tracheostomy tube in the correct order.  All options must be used.