Comprehensive and Predictive NCLEX-style examination with 50 updated questions. Passing score: 70%
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When taking the blood pressure of a small child, the nurse notes that of the cuffs available, one is too large and one is too small. What would be the best nursing action?
When examining the mouth and throat of a child, the nurse understands which of the following? Select all that apply.
The nurse needs to palpate the abdomen of a preschooler. Light palpation of the abdomen is often perceived by the child as tickling. Which of the following nursing measures is most likely to minimize the sensation of tickling and promote cooperation and relaxation during the examination?
A client with which of the following diagnoses should be given highest priority for obtaining a blood pressure measurement?
The nurse understands which of the following accurate principles about applying heat and cold applications.
At the change of shift report the nurse is told one of his assigned clients is experiencing Cheyne-Stokes respirations. What would the nurse expect to find on the assessment of this client?
A client is near death; his heart rate is 148 beats per minute and respirations are 38 breaths per minute. There is a decrease in function in all other body systems. What would the nurse explain to the family regarding the symptoms the client is exhibiting?
The nurse is admitting a 35-year-old woman who is in the advanced stages of breast cancer. The woman tells the nurse that she does not want any heroic measures taken to prolong her life. What is the best nursing action?
The nurse is working with a group of clients. Which client would be the most appropriate to refer for hospice care?
The hospice nurse is planning an admission visit to the home of a client who has metastatic breast cancer. What will be important for the nurse to do on the home visit?
The nurse is caring for a child who is in the end stages of cancer. The parents ask you how they will know when death is imminent. What sign is indicative of imminent death?
What is the physiologic principle behind the effective use of epidural anesthesia during surgery?
The nurse is caring for a client who is 6 hours postoperative for an abdominal laparotomy. The client has an order for morphine, IV prn every 3 to 4 hours. With regard to effective pain management, what nursing actions will provide the most effective pain control?
The nurse is entering the room of a client admitted for back pain. He asks the nurse if she could give him something for pain. Which of the following should the nurse do first?
A client with metastatic cancer has been taking oxycodone and amitriptyline for pain control at home. She is in constant severe pain and is at the pain clinic for evaluation. When developing a pain management control program for this client, the nurse should initially obtain which information related to the client’s pain?
In encouraging the client to use pain medication after surgery, the nurse should explain that
The nurse is monitoring a client who is receiving bedside conscious sedation with midazolam hydrochloride during a colonoscopy. The nursing assessment reveals the client has nystagmus, slurred speech, and responds slowly to verbal commands. What is the best nursing action?
The nurse is reviewing the healthcare provider’s orders for a postoperative client. The client has just returned from surgery for aortic aneurysm repair. He is NPO, he has a nasogastric tube, and vital signs indicate a pulse rate of 110, respirations 20, and BP 112/78; however, he is very drowsy and moans in his sleep. Which nursing intervention or assessment is a priority in caring for this client?
The nurse is assessing a group of clients who will be having surgery. Which client would be at the highest risk for postoperative complications?
A postoperative client says it hurts too much to deep breathe and cough every 2 hours and refuses to carry out the activity. What is the best initial nursing action?
The nurse is completing a preoperative assessment. What data from the assessment should the nurse investigate more thoroughly?
The nurse is assessing a client’s incision on the second postoperative day. There is warmth and tenderness around the incision site. There is a 3 mm area of peri-incisional erythema. The wound is well approximated with no drainage. What is the best nursing action?
A client with diabetes is being admitted for abdominal surgery. What nursing actions would the nurse implement to promote wound healing for this client?
A 3-year-old child is admitted into day surgery for repair of an inguinal hernia. The child begins to cry when the nurse takes her favorite blanket from her before transferring her from her room to the operating room. What is the best nursing action?
An older adult female immigrant tells the nurse that where she grew up women had no voice in the family, because the men made all the decisions. Over the past 20 years since becoming a US citizen, I have the same voice and control in the family that my husband has. What is this an example of?
A nurse wants to improve cultural competence. What action shows progress toward this goal?
The nurse is caring for a client who is unconscious and is dying. The family has requested a priest to come. Which of the following sacraments would the family of a Catholic client request at this time?
The clinic nurse answers a phone call from an Asian American client who is experiencing a fever. The client wants to self-treat first before taking an antipyretic medication. What would the nurse suggest to the client?
What is ethnocentrism?
What is the most effective approach to obtaining a cultural assessment on a client?
A client is experiencing spiritual distress related to loneliness and social alienation. What would be included in spiritual nursing interventions?
When the nurse asks the client, “How has being sick affected your spiritual practices?” the nurse is trying to determine the need in what spiritual dimension?
A nurse manager has been notified to obtain a bed for a client. Of the following clients, which one would the nurse anticipate being able to discharge?
Which of the following clients would the emergency room (ER) nurse see first?
After morning report, the nurse prioritizes care of the following assigned clients. Which client would the nurse see first?
During morning report, a staff nurse organizes her client load based on the clients’ levels of acuity. Which of the following clients would the nurse see first?
A staff nurse is beginning the evening shift. The day nurse has advised her that the suction equipment in the room of a client who has had surgery is not working properly. What is a priority nursing action?
To optimally use the level of preparation of the LPN/LVN, which task should the RN delegate to the LPN/LVN?
The charge nurse has observed the following: one nurse’s aide is usually pleasant and helpful; the other is often abrasive and angry. What is the most important guideline to be observed by the charge nurse, who must resolve the conflict between the two nurse’s aides?
When planning nursing activities to improve time management, the nurse should schedule which activity?
A female client in the medical-surgical unit is diagnosed with anemia and complains of weakness. Which of the following assignments could be designated to the nursing assistant?
A nursing assistant is bathing an incontinent, comatose client under the supervision of the RN. The nurse would know to redirect the nursing assistant if he did which of the following?
The nurse is in charge of nursing care on the afternoon shift in an ambulatory care center. Which client would the charge nurse evaluate first?
Which of the following tasks should the charge nurse delegate to an experienced LPN working on the adult medical unit?
The charge nurse on an acute care unit has been directed to determine who can be transferred to a residential and/or a rehabilitation facility. For which client would the nurse contact the physician regarding a transfer? A client
What is an important consideration for the nurse when delegating an assignment?
An RN from a postpartum unit has been reassigned to a cardiac unit because of staffing issues. The nurse is very uncomfortable and does not feel competent to deliver care on this unit. What is the best nursing action she can take?
A nursing supervisor would be most concerned about which statement made by a staff nurse after the completion of an incident report?
The Joint Commission’s (TJC) National Patient Safety Goals clearly state that healthcare facilities must implement safe approaches and procedures for client safety. Which practice has been instituted as a result of these goals established by TJC?
Which client should the nurse see first after receiving the shift report?