Comprehensive and Predictive NCLEX-style examination with 50 updated questions. Passing score: 70%
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The nurse creates a care plan for a client receiving hemodialysis through an arteriovenous (AV) fistula in the right arm. The nurse includes which interventions in the plan to protect the AV fistula from injury? Select all that apply.
The newborn nursery nurse is performing an admission assessment on a newborn with the diagnosis of cephalohematoma. Which intervention would the nurse implement to assess for the primary symptom associated with subdural hematoma?
A client has received atropine sulfate preoperatively. The nurse monitors the client for which effect of the medication in the immediate postoperative period?
A client experiencing calcium oxalate renal calculi is told to limit dietary intake of oxalate. The nurse is confident that the teaching has been effective when the client includes which items on a list of foods high in oxalate? Select all that apply.
The nurse is conducting a health history on a client diagnosed with hyperparathyroidism. Which question asked of the client would elicit information about this condition?
The nurse provides information to a client diagnosed with insulin-dependent diabetes mellitus. Which manifestations resulting from a blood glucose level less than 70 mg/dL (3.9 mmol/L) would the nurse include in the information? Select all that apply.
The ambulatory care nurse is assessing a client with chronic sinusitis. The nurse determines that which manifestations reported by the client are related to this problem? Select all that apply.
A client is diagnosed with hypothyroidism. The nurse performs an assessment on the client, expecting to note which findings? Select all that apply.
A client is diagnosed with diabetes insipidus. The nurse would plan interventions to address which manifestations of this disorder? Select all that apply.
A client diagnosed with pneumonia reports a decreased sense of taste that has greatly affected the motivation to eat and drink. Which action would the nurse take to help increase the client’s appetite?
The nurse notes that a large number of clients reporting the presence of flulike symptoms are being seen in the clinic. Which recommendations would the nurse provide to these clients? Select all that apply.
The nurse instructing a client with chronic pancreatitis about measures to prevent its exacerbation would provide which information? Select all that apply.
A client is diagnosed with cholecystitis. The nurse reviews the client’s medical record, expecting to note documentation of which manifestations of this disorder? Select all that apply.
A client is experiencing pulmonary edema as an exacerbation of chronic left-sided heart failure. The nurse would assess the client for what manifestation?
A client begins to experience a tonic-clonic seizure. Which actions would the nurse take to assure client safety? Select all that apply.
The nurse is monitoring a client diagnosed with a ruptured appendix for signs of peritonitis. The nurse would assess for which manifestations of this complication? Select all that apply.
While preparing to administer an intravenous (IV) medication, the nurse notes that the medication is incompatible with the IV solution. Which intervention would the nurse take to assure the client’s safety?
The nurse is preparing to administer eardrops to an infant. The nurse would plan to proceed by taking which step to assure the appropriate instillation of the medication?
A client has arrived at the labor and delivery unit in active labor. The nursing assessment reveals a recurrent history of diagnosed genital herpes and the presence of lesions in the genital tract. Which intervention would the nurse initiate?
A client is admitted to the cardiac intensive care unit after coronary artery bypass graft (CABG) surgery. The nurse notes that in the first hour after admission, the mediastinal chest tube drainage was 75 mL. During the second hour, the drainage has dropped to 5 mL. The nurse interprets this data and implements which intervention?
The nurse is assessing a client diagnosed with pleurisy 48 hours ago. When auscultating the chest the nurse is unable to detect the pleural friction rub, which was auscultated on admission. This change in the client’s condition confirms which event has occurred?
The nurse provides information to a client with a colostomy resulting from treatment for cancer. When discussing measures to help manage colostomy odors, the nurse will encourage the client to regularly consume which foods? Select all that apply.
When a client experiences frequent runs of ventricular tachycardia, the primary health care provider prescribes flecainide. Because of the effects of the medication, which nursing intervention is specific to this client’s safety?
The nurse provides information to a client diagnosed with gastroesophageal reflux disease (GERD). What information would the nurse include when discussing foods that contribute to decreased lower esophageal sphincter (LES) pressure and thus worsen the condition? Select all that apply.
The nurse is developing an educational session on client advocacy for the nursing staff. The nurse would include which interventions as examples of the nurse acting as a client advocate? Select all that apply.
The registered nurse (RN) planning the assignments for the day is leading a team composed of a licensed practical nurse (LPN) and an assistive personnel (AP). Based on licensure, which client is most appropriate to assign to the LPN?
The nurse is delegating unit nursing tasks for the day. Which tasks would the nurse delegate to the assistive personnel (AP)? Select all that apply.
In the middle of bathing a client, the unit secretary notifies the nurse that there is an emergency telephone call. Which action would the nurse implement to best assure client safety?
The nurse manager reviewing the purposes for applying restraints to a client determines that further education is necessary when a nursing staff member makes which statement supporting the use of a restraint?
A client diagnosed with epilepsy has a prescription for valproic acid 250 mg once daily. To maximize the client’s safety, which time is best for the nurse to schedule administration of the medication?
Which findings documented in the history of an older adult client would require the nurse to implement an accident prevention protocol? Select all that apply.
Which actions would the nurse take when obtaining a sputum culture from a client with a diagnosis of pneumonia? Select all that apply.
The nurse is developing a hospital policy on guidelines for telephone and verbal prescriptions. Which guidelines would the nurse include in the policy? Select all that apply.
The nurse employed in a preschool agency is planning a staff education program to prevent the spread of an intestinal parasitical disease. Which prevention measure would the nurse include in the educational session?
Which interventions would the nurse perform when inserting an indwelling urinary catheter in order to maintain both the integrity of the catheter and the client’s safety? Select all that apply.
The nurse is planning care for a client admitted with suicidal ideations. To best assure client safety the nurse would implement additional precautions during which time period?
The nurse is assisting with the transfer of a client from the operating room table to a stretcher. Which interventions would the nurse implement to ensure client safety? Select all that apply.
The nurse is planning care for a client with a prescription for an anticoagulant agent as part of treatment for a deep vein thrombosis. Which would the nurse identify as a potential concern for this client?
A client reporting abdominal pain has a diagnosis of acute abdominal syndrome but the cause has not been determined. Which prescription would the nurse question at this time?
A friend of the parents of a newborn with a diagnosis of congenital tracheoesophageal fistula contacts the home health nurse with an offer to help. Which is the best nursing action at this time to address the needs and rights of the family?
The nurse is preparing to administer prescribed heparin sodium 5000 units subcutaneously for deep vein thrombosis prophylaxis. Which action would the nurse take to safely administer the medication?
A client asks the nurse to act as a witness for an advance directive. Which is the best intervention for the nurse to implement?
The nurse provides home care instructions to the mother of a child with a diagnosis of chickenpox about preventing the transmission of the virus. Which is the best statement for the nurse to include in the instructions?
An older adult client has been identified as a victim of psychological abuse. Which action by the nurse is the priority nursing intervention?
A client with a diagnosis of leukemia asks the nurse questions about preparing a living will. Which recommendation from the nurse would be the best method of preparing this document?
A client with a diagnosis of subarachnoid hemorrhage secondary to ruptured cerebral aneurysm has been placed on aneurysm precautions. To promote safety, the nurse would ensure that which intervention is provided to the client?
The nurse is about to administer a prescribed intravenous dose of tobramycin when the client reports vertigo and ringing in the ears. Which action would the nurse take next?
The nurse is preparing to administer prescribed amiodarone intravenously. To provide a safe environment, the nurse would ensure that which specific safety consideration is in place for the client before administering the medication?
During the admission process of a client being admitted for surgery, the client asks the nurse if a living will, prepared 3 years ago, remains in effect. Which response is most appropriate for the nurse to provide the client?