Comprehensive and Predictive NCLEX-style examination with 50 updated questions. Passing score: 70%
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A client has an arteriovenous (AV) fistula in place in the right upper extremity for hemodialysis treatments. When planning care for this client, which measure would the nurse implement to promote client safety?
A client diagnosed with both a wound infection and osteomyelitis is to receive hyperbaric oxygen therapy. During the therapy, which priority intervention would the nurse implement?
A client is scheduled for hydrotherapy for a burn dressing change. Which action would the nurse take to ensure that the client is comfortable during the procedure?
The nurse is caring for a client diagnosed with heart failure who has a magnesium level of 0.75 mEq/L (0.3 mmol/L). Which action would the nurse take?
The nurse is assessing a pregnant client with a diagnosis of abruptio placentae. Which manifestations of this condition would the nurse expect to note? Select all that apply.
The nurse is caring for a client diagnosed with a herniated lumbar intervertebral disk who is experiencing low back pain. Which position would the nurse place the client in to minimize the pain?
A client admitted to the hospital has been prescribed pyridostigmine as treatment for myasthemia gravis. When assessing the client for side effects of the medication, the nurse would ask the client about the presence of which occurrence?
A client who experienced a fractured right ankle has a short leg cast applied in the emergency department. During discharge teaching, which information would the nurse provide to the client to prevent complications?
An adult client who experienced a fractured left tibia has a long leg cast and is using crutches to ambulate. In caring for the client, the nurse assesses for which sign/symptom that indicates a complication associated with crutch walking?
A client diagnosed with myasthenia gravis is experiencing prolonged periods of weakness, and the primary health care provider prescribes an edrophonium test, also known as a Tensilon test. A test dose is administered and the client becomes weaker. How should the nurse interpret these results?
When tranylcypromine is prescribed for a client, which food items would the nurse instruct the client to avoid? Select all that apply.
The clinic nurse prepares to assess a client who is in the second trimester of pregnancy. When measuring the fundal height, what should the nurse expect to note with this measurement regarding gestational age?
A pregnant client tells the nurse that she felt wetness on her peripad and found some clear fluid. The nurse inspects the perineum and notes the presence of the umbilical cord. What is the immediate nursing action?
On assessment of a newborn being admitted to the nursery, the nurse palpates the anterior fontanel and notes that it feels soft. The nurse determines that this finding indicates which condition?
During the postoperative period, the client who underwent a pelvic exenteration reports pain in the calf area. What action would the nurse take?
The client with atrial fibrillation is prescribed sotalol AF. Which assessment finding indicates that the client is experiencing an adverse effect of the medication?
Which action would the nurse take to ensure safety before performing a venipuncture to initiate continuous intravenous (IV) therapy?
The nurse is caring for a client who is receiving tacrolimus daily. Which finding indicates to the nurse that the client is experiencing an adverse effect of the medication?
A client was admitted to the hospital 24 hours ago after sustaining blunt chest trauma. Which is the earliest clinical manifestation of acute respiratory distress syndrome (ARDS) the nurse should monitor for?
The nurse, caring for a client with Buck’s traction, is monitoring the client for complications of the traction. Which assessment finding indicates a complication of this form of traction?
A prenatal client has been diagnosed with a vaginal infection from the organism Candida albicans.What would the nurse expect to note on assessment of the client?
A prenatal client has a suspected diagnosis of iron deficiency anemia. On assessment, which finding would the nurse expect to note as a result of this condition?
The nurse caring for a postpartum client should suspect that the client is experiencing endometritis if what is noted during an assessment?
The nurse is performing an assessment on a postterm infant. Which physical characteristic would the nurse expect to observe in this infant?
A postterm infant, delivered vaginally, is exhibiting tachypnea, grunting, retractions, and nasal flaring. The nurse interprets that these assessment findings are indicative of which condition?
The nurse is caring for a client who had an orthopedic injury of the leg that required surgery and the application of a cast. Postoperatively, which nursing assessment is of highest priority to assure client safety?
A client experiencing an exacerbation of their asthma symptoms requires mechanical ventilation. An arterial blood gas (ABG) specimen is to be sent to the laboratory for analysis. What information would the nurse include on the laboratory requisition? Select all that apply.
The nurse is reviewing the laboratory results for a client diagnosed with chronic heart failure (HF) who is receiving torsemide 5 mg orally daily. What value would indicate to the nurse that the client might be experiencing an adverse effect of the medication?
During history taking of a client admitted with newly diagnosed Hodgkin’s disease, the nurse would ask the client about which expected symptom?
The nurse is assessing a 3-day-old preterm neonate being treated for a diagnosis of respiratory distress syndrome (RDS). Which assessment finding indicates that the neonate’s respiratory condition is improving?
The nurse is caring for a term newborn. Which assessment finding would predispose the newborn to the occurrence of jaundice?
To ensure client safety, which assessment is most important for the nurse to make before advancing a client recovering from an appendectomy from liquid to solid food?
The nurse, caring for a client in the active stage of labor, is monitoring the fetal status and notes that the monitor strip shows a late deceleration. Based on this observation, which action would the nurse take immediately?
The nurse is caring for an obese client on a weight loss program. Which method would the nurse use to most accurately assess the program’s effectiveness?
A client has fallen and sustained a leg injury. Which question would the nurse ask to help determine if the client sustained a fracture?
Which arterial blood gas (ABG) values would the nurse anticipate in the client with a bowel obstruction who has a nasogastric tube attached to continuous suction?
The nurse is monitoring a client with malnutrition who is receiving total parenteral nutrition (TPN). Which action would the nurse take when obtaining a finger-stick glucose reading of 425 mg/dL (23.7 mmol/L)?
The nurse provides information to a preoperative client who will be receiving relaxation therapy. What effects would the nurse teach the client to expect regarding this type of therapy? Select all that apply.
A client has developed atrial fibrillation resulting in a ventricular rate of 150 beats/min. The nurse would assess the client for which effects of this cardiac occurrence? Select all that apply.
A preschooler with a history of cleft palate repair comes to the clinic for a routine well-child checkup. To determine whether this child is experiencing a long-term effect of cleft palate, which question would the nurse ask the parent?
The nurse is performing a respiratory assessment on a client being treated for an asthma attack. The nurse determines that the client’s respiratory status is worsening based upon which finding?
The nurse is assessing the casted extremity of a client for signs of infection. Which finding is indicative of the presence of an infection?
The home care nurse assesses a client diagnosed with chronic obstructive pulmonary disease (COPD) who is reporting increased dyspnea. The client is on home oxygen via a concentrator at 2 L/min, and has a respiratory rate of 22 breaths/min. Which action would the nurse take?
The home care nurse is making a follow-up visit to a client after receiving a renal transplant. Which assessment data support the possible existence of acute graft rejection? Select all that apply.
The nurse is caring for a client who is receiving tobramycin sulfate intravenously every 8 hours for a lower urinary tract infection. Which result would indicate to the nurse that the client is experiencing an adverse effect of the medication?
A client’s telemetry monitor displays ventricular tachycardia. Upon reaching the client’s bedside, which action would the nurse take first?
Which nursing assessment question would be asked to help determine the client’s risk for developing malignant hyperthermia in the perioperative period?
A client who is being treated for acute heart failure has the following vital signs: blood pressure (BP), 85/50 mm Hg; pulse, 96 beats/min; respirations, 26 breaths/min. The primary health care provider prescribes digoxin. To evaluate a therapeutic response to this medication, which changes in the client’s vital signs would the nurse expect?
A client diagnosed with hypertension has been taking a prescribed calcium channel blocker for approximately 2 months. The home care nurse monitoring the effects of therapy would determine that drug tolerance has developed if which is noted in the client?
A client with a known history of panic disorder comes to the emergency department and states to the nurse, “Please help me. I think I’m having a heart attack.” What is the priority nursing action?