NCLEX-RN Q banks

Which high-calcium food does the nurse direct the parents of a child with lactose intolerance to include in the child’s diet?

Which laboratory result would the nurse expect to see in a child admitted to the hospital with acute glomerulonephritis?

A client is brought to the labor unit, and, as the nurse is attaching the fetal heart monitor, the client’s membranes rupture spontaneously. The nurse immediately assesses the fetal heart rate, then:

A client is hospitalized after falling asleep at the wheel of his car, hitting and killing a pedestrian crossing the street. The nurse caring for the client notes that the client is crying and upset. What is the appropriate reaction by the nurse?

A client is receiving an intravenous infusion of oxytocin (Pitocin) to stimulate labor. The nurse monitoring the client notes uterine hypertonicity and immediately:

A client is unwilling to leave the house for fear of doing “something bizarre in public.” As a result, the client remains homebound except when accompanied by her husband. The nurse analyzes this data and determines that the client is experiencing:

A client on the mental health unit says to the evening nurse, “The staff on the day shift let me smoke two cigarettes. You only let me smoke one.” Which of the following responses by the nurse is therapeutic?

A client says to the nurse, “My wife retired last year from a lucrative law practice, and I’m really discouraged. I’ll be working until I die, even though I helped pay for her education.” Which response by the nurse is supportive?

A client in the mental health unit points to another client and says to the nurse, “He’s been working with the Taliban, pouring anthrax into our water supply.” How should the nurse respond to the client?

A client arriving to the emergency department in labor screams “the baby is coming. ” In what order should the nurse perform the actions for this precipitous birth? (Select the actions from first to last.)
A. Iron the perineum.
B. Retrieve the emergency birth pack.
D. Guide the fetal head gently from the vaginal opening.
C. Place sterile drapes under the client’s buttocks.
E. Scrub hands with soap and water before applying sterile gloves.

A child’s mother tells the nurse that during a seizure the child has a blank expression and exhibits eyelid fluttering lasting just 5 to 10 seconds. The nurse determines that the child is experiencing:

A child with sickle cell anemia is being discharged after treatment for a crisis. Which instructions for avoiding future crises should the nurse provide to the child and family? Select all that apply.

A child with severe respiratory distress is seen in the emergency department and treated for an acute asthmatic episode. Which assessment finding indicates that the child’s condition is improving?

A child with pyloric stenosis is having excessive vomiting. Which of the following is a potential complication?

A child with hypopituitarism is being started on growth hormone therapy. Nursing considerations should be based on knowledge of which of the following?

A child with hypoparathyroidism is receiving vitamin D therapy. The parents should be advised to watch for which of the following signs of vitamin D toxicity?

A child with cystic fibrosis receives aerosolized bronchodilator medication. This medication should be administered:

Which of the following types of seizures may be difficult to detect?

A child with asthma is having pulmonary function tests. Which of the following explains the purpose of the peak expiratory flow rate?

A child with growth hormone (GH) deficiency is receiving GH therapy. When is the best time for the GH to be administered?

A client who recently witnessed a murder says, “I feel like I’m losing my mind. I keep hearing the gunshots and seeing the victim lying on the ground.” In light of the client’s statement, the nurse should:

A client who is 36 weeks pregnant is demonstrating signs of labor. The client? ‘s last prenatal visit was at 16 weeks gestation. According to the information in the client’s electronic medical record which intervention should the nurse provide first?

A client states to a nurse, “I feel like putting an end to my misery." How should the nurse respond to the client?

A client says, “I’ve had so many crying spells over the past several weeks. My doctor says it’s probably depression.” The nurse sees that the client is sitting slumped in the chair and that the client’s clothing is baggy. Further assessment of this client should be focused on:

A client says, “I have so much trouble caring for my husband’s child from his first marriage. I resent the money we have to pay for child support because we have to deprive my own child of things. How can I stop feeling this way?” Which of the following responses by the nurse is therapeutic?

A client with depression says, “I always make mistakes. I never do anything right.” Which of the following responses by the nurse is therapeutic?

A client with mania is placed in seclusion after an outburst of violent behavior that includes physically assaulting another client. As the client is secluded, the nurse should:

A client with obsessive-compulsive disorder, upset and agitated, walks repeatedly around the nursing unit, following the same route each time. The client says to the nurse, “Walk with me.” Which response by the nurse is appropriate?

A client with severe depression tells the nurse, “I’m feeling much better now.” The client demonstrates increased interaction and energy levels. The nurse implements one-on-one supervision because the behavior indicates that the client:

A client with type 1 diabetes mellitus has just been told that she is 6 weeks pregnant. The nurse provides information to the client about dietary and insulin needs and tells the client that during the first trimester, insulin needs generally:

A client, upset, says, “My ex-wife’s new husband is being relocated to a job across the country, so now I’ll only see my child on holidays and school vacations.” Which of the following responses by the nurse is therapeutic?

A depressed client tells the nurse, “I’m powerless, and I’m not worthy of having friends. Sometimes I take too many pills.” The nurse’s priority in planning care for this client is:

A father and mother are carriers of phenylketonuria (PKU). Their 2-year-old daughter has PKU. The couple tells the nurse that they are planning to have a second baby. Because their daughter has PKU, they are sure that their next baby won’t be affected. What response by the nurse is most accurate?

A father and mother are carriers of phenylketonuria (PKU). Their 2-year-old daughter has PKU. The couple tells the nurse that they are planning to have a second baby. Because their daughter has PKU, they are sure that their next baby won’t be affected. What response by the nurse is most accurate?

A female patient taking an ACE inhibitor learns that she is pregnant. What will the nurse tell this patient?

A female patient who begins taking spironolactone (Aldactone) as an adjunct to furosemide (Lasix) complains that her voice is deepening. What will the nurse do?

A female patient who is not taking any other medications is prescribed aliskiren (Tekturna), a direct renin inhibitor (DRI). The nurse reviews medication information with the patient. Which statement by the patient indicates understanding of the teaching?

A female patient with essential hypertension is being treated with hydralazine (Apresoline) 25 mg twice daily. The nurse assesses the patient and notes a heart rate of 96 beats per minute and a blood pressure of 110/72 mm Hg. The nurse will request an order to:

A first-time father is changing the diaper of his 1-day-old daughter. He asks the nurse, “What is this black, sticky stuff in her diaper?” The nurse’s best response is:

A four- year- old has a right nephrectomy to remove a Wilms tumor. The nurse knows that it is essential to:

A gay man is brought to the emergency department by the police. The client tells the nurse, “I was beaten up. I guess I just have to expect this kind of treatment for the rest of my life.” Which statement by the nurse is therapeutic?

A girl with systemic lupus erythematosus (SLE) wants to go to the beach with her friends on the day after their junior prom. The girl asks the nurse for guidance regarding sun exposure. The nurse should tell the client:

A home care nurse visits a mother who delivered a healthy newborn 4 days ago and assesses how the mother is doing breastfeeding her infant. What does the nurse ask the mother to do to permit assessment of whether the infant is receiving an adequate amount of milk?

A home health nurse is performing an assessment of a client’s skin. The nurse, noting multiple threadlike lines, both straight and wavy, beneath the skin, recognizes the presence of scabies. Which of the following precautions should the nurse institute before completing the assessment of the client?

A home health nurse provides instructions to the spouse of a client taking tacrine hydrochloride (Cognex) for the management of moderate dementia associated with Alzheimer’s disease. Which information should the nurse provide to the spouse?

A home health nurse teaches a client about home modifications to reduce the risk of falls. Which statements by the client indicate a need for further teaching? Select all that apply.

A hospitalized 5 year old boy recovering from surgery refuses to drink fluids. Which intervention is best for the nurse to implement?

A hospitalized client with a diagnosis of delirium often becomes disoriented and confused during the night. Which of the following interventions does the nurse implement?

A hospitalized client, experiencing confusion, is at risk of falling because she continually tries to climb out of bed. Which of these safety devices that the nurse might suggest is the least restrictive?

A hurricane is forecast to make landfall in 48 hours, and the staff of the emergency department of an area hospital is advised to prepare for causalities. Which action should the nurse manager who receives the telephone call regarding this warning take first?

A labor nurse is caring for a client with a known history of sickle cell anemia. Which action does the nurse implement as a priority to help prevent sickle cell crisis?

A lumbar puncture is performed on a child with suspected bacterial meningitis, and the cerebrospinal fluid (CSF) obtained for analysis. The nurse determines that the diagnosis is confirmed if which findings are noted?

A man calls the nurse’s station and states that his wife, who delivered 2 days ago, is happy one minute and crying the next. The man says, “She was never like this before the baby was born.” The nurse’s initial response could be to:Select all that apply.

A maternity nurse providing an education session to a group of expectant mothers describes the purpose of the placenta. Which statement by one of the women attending the session indicates a need for further discussion of the purpose of the placenta?

A maternity nurse should be aware of which fact about the amniotic fluid?

A maternity nurse should be aware of which fact about the amniotic fluid?

A mental health nurse finds a client in the hospital day room self-inflicting cigarette burns. After removing the cigarette and attending to the burns, what is the nurse’s next action?

A military nurse who is in charge of planning a vaccination clinic to administer the smallpox vaccine to military personnel is preparing a pamphlet that sets forth guidelines for care of the vaccination site. Which guideline should the nurse include in the pamphlet?

A mother brings her infant in at age 6 weeks with complaints of poor feeding, lethargy, fever, irritability, and a vesicular rash. The nurse suspects:

A licensed practical nurse (LPN) tells the registered nurse (RN) that she administered acetaminophen (Tylenol) to a client by way of the rectal route rather than the prescribed oral route because the client was extremely nauseated. The RN most appropriately: