Comprehensive and Predictive NCLEX-style examination with 50 updated questions. Passing score: 70%
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The nurse is creating a plan of care for a client diagnosed with a dissecting abdominal aortic aneurysm. Which interventions would be included in the plan of care? Select all that apply.
A client with peripheral vascular disease has undergone angioplasty of the iliac artery. Which technique would the nurse perform to best detect bleeding from the angioplasty in the region of the iliac artery?
A client states, “I’m sure I have restless leg syndrome.” The nurse determines that the client is in need of further teaching on the condition when the client identifies the presence of which characteristics? Select all that apply.
A client with peripheral vascular disease who underwent peripheral arterial bypass surgery 16 hours ago reports that there is increasing pain in the leg that worsens with movement and is accompanied by paresthesias. Based on these data, which action would the nurse take?
The nurse in an ambulatory care clinic takes a client’s blood pressure (BP) in the left arm; it is 200/118 mm Hg. Which action would the nurse take next?
The nurse is caring for a client diagnosed with preeclampsia. When the client’s condition progresses from preeclampsia to eclampsia, what would the nurse’s first action be?
The nurse admits a client who is bleeding freely from a scalp laceration that resulted from a fall. The nurse would take which action first in the care of this wound?
A client admitted to the nursing unit with a closed head injury 6 hours ago has begun to vomit and reports being dizzy and having a headache. Based on these data, which is the most importantnursing action?
A client is brought into the emergency department after sustaining a possible closed head injury. Which assessment would the nurse perform first?
A client with a spinal cord injury is at risk of developing footdrop. What intervention would the nurse use as a preventive measure?
To monitor for a temporary but common postsurgical complication of a transsphenoidal resection of the pituitary gland, the nurse would regularly perform which assessment?
Which piece of equipment would the nurse routinely use to assess the fetal heart rate of a woman at 16 weeks of gestation?
The nurse is creating a discharge plan for a postoperative client who had a unilateral adrenalectomy. What area of instruction would the nurse include in the plan to minimize the client’s risk for injury?
The nurse is caring for a client who has undergone transsphenoidal surgery for a pituitary adenoma. In the postoperative period, which information would the nurse provide to the client to minimize the risk for surgery-related injury?
A client is receiving desmopressin intranasally. Which assessment parameters would the nurse monitor to determine the effectiveness of this medication?
As the nurse begins to administer scheduled doses of furosemide and nifedipine, the client asks for an as needed (PRN) dose of aluminum hydroxide. Which action by the nurse would best ensure the effectiveness of all the medications?
The nurse monitors the client taking amitriptyline for which common side effect of this antidepressant?
Which nursing question would elicit the most thorough assessment data regarding the client’s recent sleeping patterns?
A client is admitted after attempting suicide by ingesting a prescribed antipsychotic medication. What is the most important piece of information the nurse should obtain initially?
The nurse determines that a client understands the purpose of a phytonadione injection for her newborn when she is heard making which statement to the baby’s father?
The nurse is assigned to give a child a tepid tub bath to treat hyperthermia. After the bath, which action would the nurse take?
The nurse caring for an infant demonstrating diarrhea would monitor the infant for which earlysign of dehydration?
Acetylsalicylic acid (aspirin) is prescribed for a client diagnosed with coronary artery disease before a percutaneous transluminal coronary angioplasty (PTCA). The nurse administers the medication understanding that it is prescribed for what purpose?
The nurse reviews a primary health care provider’s prescriptions and notes that a topical nitrate is prescribed. The nurse notes that acetaminophen is prescribed to be administered before the nitrate. The nurse implements the prescription with which understanding about why acetaminophen is prescribed?
The nurse performs an assessment on a client newly diagnosed with rheumatoid arthritis. The nurse expects to note which early manifestations of the disease? Select all that apply.
A client with a history of myocardial infarction is prescribed warfarin sodium has been instructed to limit the intake of foods high in vitamin K. The nurse determines that the client understands the instructions if the client indicates that which food items need to be avoided? Select all that apply.
The nurse is caring for a newly delivered breast-feeding infant. Which nursing intervention would best prevent jaundice in this infant?
The nurse creates a postoperative plan of care for a client undergoing an arthroscopy. The nurse would include which priority action in the plan?
The nurse is caring for a client diagnosed with active tuberculosis who is prescribed rifampin therapy. The nurse instructs the client to expect which side effect of this medication?
The nurse sends a sputum specimen to the laboratory for culture from a client with suspected active tuberculosis (TB). The results report that Mycobacterium tuberculosis is cultured. How would the nurse correctly analyze these results?
A coronary care unit (CCU) nurse is caring for a client admitted with acute myocardial infarction (MI). The nurse would monitor the client for which most common complication of MI?
The nurse in the newborn nursery is planning for the admission of a large for gestational age (LGA) infant whose mother is diabetic. In preparing to care for this infant, the nurse would obtain equipment to perform which diagnostic test?
The nurse caring for a client receiving intravenous (IV) therapy monitors for which signs of infiltration of an IV infusion? Select all that apply.
A client receiving total parenteral nutrition (TPN) through a subclavian catheter suddenly develops dyspnea, tachycardia, cyanosis, and decreased level of consciousness. Based on these findings, which is the best intervention for the nurse to take for the client?
A client has a total serum calcium level of 7.5 mg/dL (1.88 mmol/L). Which clinical manifestations would the nurse expect to note on assessment of the client? Select all that apply.
A client is experiencing acute cardiac and cerebral symptoms as a result of excess fluid volume. Which measure would the nurse implement to increase the client’s comfort until specific therapy is prescribed by the primary health care provider?
The nurse creates a discharge plan for a client who had an abdominal hysterectomy. Which activity instructions would the nurse include in the plan? Select all that apply.
The nurse has a prescription to ambulate a client with a nephrostomy tube four times a day. The nurse determines that the safest way to ambulate the client while maintaining the integrity of the nephrostomy tube is to implement which intervention?
A client newly diagnosed with polycystic kidney disease asks the nurse to explain again what the most serious complication of the disorder might be. The nurse would provide the client with information concerning which condition?
The nurse is creating a plan of care for a client who has returned to the nursing unit after left nephrectomy. Which assessments would the nurse include in the plan of care? Select all that apply.
The nurse instructs a mother of a child who had a plaster cast applied to the arm about measures that will help the cast dry. Which instructions would the nurse provide to the mother? Select all that apply.
A client is receiving cisplatin as part of a treatment plan for esophageal cancer. On assessment of the client, which findings indicate that the client is experiencing an adverse effect of the medication?
A child is admitted to the hospital with a diagnosis of nephrotic syndrome. The nurse expects to note documentation of which manifestation in the medical record? Select all that apply.
Twelve hours after delivery, the nurse assesses the client for uterine involution. The nurse determines that the uterus is progressing normally toward its prepregnancy state when palpation of the client’s fundus is at which level?
A client is scheduled for a subtotal gastrectomy (Billroth II procedure) to treat stomach cancer. The nurse explains that the procedure will have which surgical results?
A client diagnosed with diabetes mellitus receives 8 units of regular insulin subcutaneously at 7:30 am. The nurse would be most alert to signs of hypoglycemia at what time during the day?
The nurse creates a postoperative plan of care for a client scheduled for a hypophysectomy. Which interventions would be included in the plan of care? Select all that apply.
After undergoing a thyroidectomy, a client is monitored for signs of damage to the parathyroid glands postoperatively. The nurse would determine which finding suggests damage to the parathyroid glands?
The nurse is performing an admission assessment on a client admitted with a diagnosis of Raynaud’s disease. The nurse assesses for the associated symptoms by performing which actions?
The nurse teaches a postpartum client about postdelivery lochia. The nurse determines that the education has been effective when the client says that on the second day postpartum, the lochia should be which color?