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BUNDLE FOR NCLEX PN EXAM 2023
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uworld Nclex - pn test 1 Questions and Answers 2023
The nurse on an inpatient mental health unit is caring for a client with paranoid delusions who is refusing to eat. The client states that all the food and... [Show More] drinks have been poisoned. Which intervention by the nurse is appropriate? provide the client food in unopened, individually packaged food After listening to the parents' reports and seeing the following pediatric clients, the nurse knows that which client demonstrates signs of abuse that may necessitate mandatory reporting? 5- year -old whose x-ray reveals 1 new and 2 healed humerus fractures after falling from a tree. The nurse is discussing the care needs of a client in the last stage of Huntington disease with the family. When the nurse mentions arranging for delivery of a prescribed hospital bed, the client's spouse becomes visibly upset and says, "No hospital bed. I'm just not ready for it yet." What is the best response by the nurse? what upsets you about having a hospital bed? The nurse administers ondansetron to a hospitalized client. Which statement would indicate to the nurse that the ondansetron was effective? The nausea is a lot better The nurse has just received report on 4 clients. Which client should the nurse see first? client receiving Iv normal saline at 250 ml / hr who is reporting puffy legs and a new cough An unaccompanied 16-year-old girl comes to the emergency department with severe abdominal pain and vomiting. The client has a temperature of 102.2 F (39 C) and a pulse of 120/min and is lethargic. The client's parents are out of town, and no guardians can be reached. How should this client's care be handled? Administer care until the parents or guardians can be reached. The nurse reinforces teaching to the parents of a 12-month-old who has begun weaning from breastfeeding. Which statement by the parents indicates that teaching has been effective? I can start substituting breastfeeding sessions with whole cow's milk. The nurse cares for a client with a terminal disease who has an advance directive supporting a do not resuscitate (DNR) code status. The client stops breathing and loses a pulse. The client's adult child states, "I changed my mind. Do whatever you can to save him!" Which intervention is most appropriate at this time? Explain the client's wishes to the client child. The nurse speaks with a client diagnosed with schizophrenia who begins to look away toward the door and grimace. Which statement by the nurse is most therapeutic at this time? what do you see at the door? The nurse reinforces teaching to a 15-year-old primigravid client at 16 weeks gestation during an initial prenatal visit. Which information would be a priority for the nurse to include? stress the importance of consistent prenatal care A female client is visiting the clinic for an annual well-woman examination. The client reports having had sex with women. Which question will help the nurse determine the client's risk for sexually transmitted infections? what barrier methods do you and your partner(s) use? While the nurse is transporting a client to a new unit, the client's chest tube drainage system falls off the bed and the tube becomes dislodged from the chest wall. What is the nurse's priority action? Firmly cover the insertion site with the palm of a clean, gloved hand The nurse cares for a client with a burn on the arm and finds that the area is red, moist, and covered in shiny, fluid-filled vesicles. Which burn stage does the nurse document? Second degree A nurse in the emergency department is caring for 4 clients. Which client should the nurse see first? Client with myasthenia gravis who has a fever and increasing difficulty swallowing The nurse is caring for a client who is being treated for depression and suicidal ideation. Which client statement best indicates that the client is not currently at risk for suicide? I plan to attend my granddaughter's graduation next month. The nurse is caring for a client taking escitalopram who reports no improvement of depressive feelings since starting the medication 2 months ago. What is the best response by the nurse? Let's talk more about how you have taking this medication The nurse removes personal protective equipment (PPE) after completing a wound dressing change for a client in airborne transmission-based precautions. Which PPE should the nurse remove first? Gloves The client admitted to the psychiatric unit with severe anxiety is pacing rapidly in the room, crying, and hyperventilating. The client yells, "I can't believe you took my belongings! Where are you keeping them? This is so frustrating!" What is the appropriate response by the nurse? Your belongings are locked in a safe place to ensure that they are protected while you are here. A client with a history of a seizure disorder has a seizure while sitting in a chair. Which nursing interventions are appropriate during the seizure activity? Select all that apply. Administer oxygen as needed if client becomes cyanotic Move the client from the chair to the floor to prevent a fall Record the duration of seizure activity for documentation A client with type 1 diabetes has prescriptions for NPH insulin and regular insulin. At 7:30 AM, the client's blood glucose level is 322 mg/dL. The nurse expects the client's breakfast to arrive before 8 AM. What action should the nurse take? Click on the exhibit button for additional information. Administer 37 units of insulin: 25 units of NPH insulin mixed with 12 units of regular insulin in the same syringe, drawing up the regular insulin first The new nurse is reinforcing teaching to a client scheduled for electroconvulsive therapy (ECT). What information given by the new nurse would cause the charge nurse to intervene? be sure to take your valproic acid prior to the procedure The nurse is participating in a community health presentation about prevention of tick bites and Lyme disease. Which instructions should the nurse include? Select all that apply. apply a tick repellent spray before outdoor activities avoid hiking through areas of tall grass and thick under brush report bull's- eye rash or flu-like symptoms to the healthcare provider Wear a long sleeve shirt tucked into pants and clothes till shoes while hiking The nurse is caring for a new mother whose infant has been diagnosed with Down syndrome. The client says to the nurse, "I'm so worried. My husband is so devastated that he won't even look at the baby." What is the best response by the nurse? how are you feeling about your baby The nurse is reinforcing self-care and medication teaching for a client diagnosed with vaginal candidiasis who has been prescribed miconazole vaginal cream. Which statement by the client indicates that further teaching is needed? I will refrain from having sex until my partner is also tested and treated for the infection. A 4-year-old boy is diagnosed with Duchenne muscular dystrophy. Which nursing teaching is most appropriate to reinforce for this child's parents? remove throw rugs from the home The nurse checks a client's blood pressure using an automatic, noninvasive machine. The nurse notes that the machine inflates for an unusually long amount of time, and the client reports intense pain in the arm with the cuff. The device suddenly stops inflation and displays an error message. Which action by the nurse is appropriate? send the machine for maintenance and repeat the measurement manually The charge nurse assists a student nurse preparing to apply knee-length compression stockings onto a client with chronic venous insufficiency. Which actions by the student nurse would cause the charge nurse to intervene? Select all that apply. instructs client that stockings will be worn only at night rolls down any excess length at the top of the stocking selects size larger to avoid friction against a leg laceration The nurse is reinforcing teaching to the caregiver of a client with a new prescription for risperidone. Which statement indicates that the caregiver needs further instruction? it is normal for the client to become shaky and restless when agitated The nurse is reviewing a client's preoperative questionnaire, which indicates a religious preference with spiritual needs concerning surgery scheduled later today. Which action is most appropriate at this time? follow up with the client regarding the nature of the spiritual needs or religious practices The new nurse, caring for a 3-month-old client who is sedated in the intensive care unit following surgery, needs to prevent skin breakdown. Which action performed by the new nurse would cause the charge nurse to intervene? placing a donut pillow under the head The nurse is preparing to administer Edison to a 4-year-old client weighing 43 lb. based on the prescription, what is the volume of the medication in milliliters that the child should receive with each dose? 9 An elderly client with diabetes comes to the clinic in winter reporting numbness of the feet. After removing the client's shoes and socks, the nurse notes that the feet are ice cold to the touch and appear waxy and pale. What is the appropriate nursing action? soak the client's lower legs in a warm water bath The home health nurse visits a client with inflammatory bowel disease who recently underwent a total colectomy with ileostomy creation. Which statement by the client indicates that the client understands ileostomy care? I cut the appliance opening slightly larger than my stoma The staff nurse is preparing a presentation about strategies to reduce horizontal violence. The nurse educator is reviewing the presentation beforehand. Which recommendation included in the presentation indicates a need for further teaching? working toward diversification of staff age and gender For which client is it most important for the nurse to reinforce teaching regarding ways to prevent the spread of the condition? client with tinea corporis The nurses on a medical-surgical unit maintain a shared social media page. Which social media posts written by nurses breach client confidentiality? Select all that apply. I'm going to private message everyone a cute story about our sweet client with dementia it breaks my heart that are paraplegic client was so neglected by her husband The client in room five is positive for influenza so please remember your flu vaccines Wash your hands well if you had room for this week! cultures are now positive for clostridium difficile The nurse assists with medication reconciliation for a client visiting the clinic for a follow-up appointment. Which medication reported by the client requires further investigation? Click the exhibit button for additional information. 200 mg of celecoxib PO once daily A client is in cardiac arrest, and resuscitation efforts are in progress when the client's spouse arrives. The client's spouse insists on coming into the room. How should the nurse respond? Allow the spouse into the room and provide a chair The clinic nurse instructs a female client on how to collect a clean-catch urine specimen for culture and sensitivity. Which of the following client statements indicate that teaching has been effective? Select all that apply. I will be very careful not to touch the inside or rim of the container I will begin to urinate before passing the container into the stream for collection I will cleanse the area with single use antiseptic wipes prior to urinating The nurse in a psychiatric unit is approached by an aggressive client who grabs the nurse's stethoscope and attempts to strangle the nurse with it. The nurse is able to escape the client's grasp unharmed. Which action should the nurse take first? Beginning scoring other clients out of the room A client comes to the emergency department after being bitten by a bat. The nurse observes 2 small, nondraining puncture wounds resembling pinpricks on the fingertip. Which action should the nurse implement first? scrub the wound with povidone iodine solution or soap and water The nurse on a medical-surgical unit prepares scheduled daily medications for a client and places them in a pill cup. After receiving the pill cup, the client states, "I take a whole tablet of metoprolol at home. Why did you cut this one in half?" What is the best response by the nurse? show me which pill you're talking about so I can verify the prescriptions again A 10-year-old client with autism spectrum disorder is hospitalized for a diagnostic workup. Which is the most appropriate nursing action? Give the client a schedule of daily activities The charge nurse is educating a new nurse on intramuscular injection technique for a 6-year-old with autism spectrum disorder. Which statement by the new nurse indicates that further teaching is required? I will hold the child's hand as a soothing measure The nurse is reinforcing client teaching about newly prescribed cyclosporine. Which client statement indicates a need for further teaching? I am going to a concert with my friends this weekend The nurse is caring for a client who reports severe abdominal pain and vaginal spotting. The client had a positive urine pregnancy test at home, and her last menstrual period was 8 weeks ago. Which client report to the nurse is most concerning? Right shoulder pain and dizziness A nurse is reinforcing teaching to a client newly prescribed verapamil for chronic migraine headaches. Which statement by the client indicates the need for further teaching? I will take this medication at the first sign of a migraine The nurse is reviewing the medical history of a client who has sustained a right tibia/fibula fracture from a fall. The nurse identifies which finding as most likely to hinder healing? peripheral arterial disease The student nurse assists in caring for a client who is scheduled for electroconvulsive therapy for the treatment of depression. Which statement by the student indicates a need for further teaching? Because this client has a mental illness, the agent with medical power of attorney should sign the informed consent document The nurse is reinforcing discharge teaching for a client who is hearing impaired. Which of the following actions should the nurse implement? Select all that apply. Encourage the client to repeat back teaching Ensure adequate lighting in the client's room Said directly in front of the client while speaking Use printed materials with pictures and illustrations A student nurse is accompanying the charge nurse when conducting daily rounds. Which personal protective measure by the charge nurse does the student nurse question? Wears two pairs of gloves when emptying the urinary catheter collection bag of a client with HIV The nurse helps a client with end-stage renal disease and a serum potassium level of 5.2 mEq/L to plan menu choices. Which items would be best to include in the meal plan? Grilled chicken sandwich on white bread, applesauce The nurse receives handoff of care report on four clients. Which client should the nurse see first? client who has a urinary tract infection, temperature of 102° F, and respiratory rate of 25 beats a minute The nurse is reinforcing education about lifestyle choices to help reduce symptoms for a client with gastroesophageal reflux disease. Which of the following statements by the client indicate a correct understanding? Select all that apply. I have switched from coffee to decaffeinated herbal tea in the morning I plan to join a smoking cessation program I brought myself up on a couple of pillows when I go to sleep I will switch to low-fat dairy product and avoid high-fat foods [Show Less]
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NCLEX-PN studies: Lab values Questions and Answers 2023
platelet count 150,000 - 400,000/mL blood protein 6-8 gdL (albumin, globulins, and fibrinogen) LDH1 enzyme marker of Heart and Red cell ne... [Show More] crosis. serum lipase 10 - 140 Units/L (Lab elevation suggests pancreatitis) troponin 0.1 - 0.2. Elevation indicate a heart attack has occured hemoglobin (HgB) (f) 12-16 ; (m) 14 - 18 hematocrit (f) 37-47% ; (m) 42-52 % glycosolated hemoglobin 6-7%. Elevation indicates hyperglycemia history. 4-6 is ideal. cholestrol 140-199. <200 is high cholesterol wbc 4,500 - 11,000 mm3. amylase 25-151. MgEnzyme secreted by the pancreas to digest starch Mg+ (magnesium) 1.5 -2.5 mg/dL. Na+ (sodium) 135-145 K+ (potassium) 3.5-5 BUN (blood urea nitrogen) 10-20 Ca++ Calcium 9-10.5 Cl- (chloride) 96-106 specific gravity 1.005-1.030 Lithium 0.8 to 1.2 mEq/L therapeutic range creatinine 0.5-1.2 dilantin (Phenytoin) 10-20 (anticonvulsant) theophilline 10-20. Used for asthma. Has a serious adverse effect with caffeine. digoxin (Lanoxin, Digitek) 0.5-2 ng/mL PT (prothrombin time) 9.5-11.3 in adult. HCO3 (bicarb) 21-28 rbcs m 4.7-6.1 mil. f 4.2-5.4 mil PT 11-12.5 secs. APTT a test for patients on heparin. APTT value 60-70 secs. PT a test for patients on coumadin/warfarin. glucose 70-100 cholesterol <200 biliruben newborn 1-12 phenylalanine newborn <2, adult <6 Hypo K+ Prom. u waves, depressed st seg, flat T Hyper K+ Tall t-waves, prolonged pr interval, wide qrs Hypocalcemia muscle spasms, convulsions, cramps, tetany, trousseau's chvostek's, prolonged st inveral, prolonged qt segment Phos 3-4.5 Albumin 3.5-5 Specific gravity 1.005-1.030 [Show Less]
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Archer NCLEX-PN Review Questions Answered 2023
Lab Value: chloride 95-105 Lab Value: phosphorus 2.5-4.5 Therapeutic Level: Digoxin 0.8-2.0 ng/mL Therapeutic Level: Lithium 0.6-1... [Show More] .2 Lab Values: Potassium 3.5-5.0 Lab Value: Magnesium 1.5-2.5 Lab Value: Calcium 8.5-10.9 Lab Value: RBC Men: 4.5-6.0 Women: 4.0-5.5 What does a low RBC indicate? (3) anemia cancer hemorrhage What does a high RBC indicate? Polycythemia vera Polycythemia a bone marrow disease that causes too many red blood cells to be made. Lab Value: WBC 5,000-10,000 What does an elevated WBC indicate? infection or inflammation What does a low WBC indicate? viral infection Antidote for Warfarin (Coumadin) Vitamin K antidote for heparin protamine sulfate Aluminum hydroxide (Amphojel) Treatment of GERD and kidney stones. Monitor constipation. Amiordarone (Cordarone) treatment of life-threatening ventricular arrhythmias Adverse effects of Amiodarone (3) diaphoresis dyspnea lethargy Dopamine (3 uses) treatment of hypotension shock low cardiac output Erik Erikson's 8 stages of development trust vs mistrust autonomy vs shame initiative vs guilt industry vs inferiority identity vs diffusion intimacy vs isolation generativity vs self-absorption integrity vs despair Vaccinations with a live virus (4) varicella MMR yellow fever influenza Hematemesis blood in vomit Hemarthrosis blood in a joint Epistaxis nosebleed Melena Black tarry stool Phototherapy can be harmful to ___________ and ____________ in infants eyes, genitals Antidote for benzodiazepines Flumazenil (Romazicon) Lanugo fine, soft hairs present on shoulders, back and forehead of newborns Milia tiny white bumps commonly appear on newborns forehead vernix cheeselike substance that coats the skin of newborns after birth steatorrhea fatty, oily stools hematochezia passage of fresh, bright red blood from the rectum hematochezia indicates lower GI bleed Freud's Stages of Psychosexual Development: Old Ass People Love Grapes Oral Anal Phallic Latent Genital Anorexia patients will develop ________________ to help insulate themselves lanugo omphalocele herniation at the umbilicus (a part of the intestine protrudes through the abdominal wall at birth) McBurney's Point Pain in RLQ with appendicitis Calcium Channel Blockers (Very Nice Drugs) Verapamil Nifedipine Diltiazem LMWH low molecular weight heparin, anticoagulant durg that doesn't cross the placenta Increased risk of _________ with long term LMWH therapy fractures menarche the first menstrual period thelarche beginning of breast development impetigo common bacterial skin infection between age of 2-5 Hemooccult Test a lab test for hidden blood in the stools Kaposi sarcoma (KS) type of skin cancer that glows in the blood vessels and can cause severe illness in the immunocompromised Indications of Cystic Fibrosis (3) steatorrhea meconium ileus salty sweat Grave's disease an autoimmune disorder that is caused by hyperthyroidism and is characterized by goiter and/or exophthalmos exopthalmos bulging eyes Autonomic Dysreflexia S/S -Severe Pounding Headache -Hypertension -Profuse Sweating (especially forehead) -Bradycardia -Nasal Congestion -piloerection -goose flesh Phenylketonuria (PKU) inherited disorder in which the infant lacks a liver enzyme Phenylketonuria treatment is to place the infant on a phenylalanine-free diet that allows the infant to grow with normal brain development. Phenylalanine-free diet eliminate dairy meat eggs Acute Myeloid Leukemia (AML) cancer of the bone and marrow Acute Myeloid Leukemia patients have a _____ platelet count, leading to longer clotting times and ______ bleeding and bruising decreased, increased Acute ketoacidosis symptoms (9) excessive thirst frequent urination nausea and vomiting abdominal pain weakness and fatigue SOB fruit-scented breath weight loss confusion What is the most accessible pulse site in an infant? brachial pernicious anemia Vitamin B12 deficiency perseveration unintentional repetition of a response Rhematoid Arthritis (RA) most crippling for of arthritis. characterized by chronic, systemic inflammation most often affecting joints and synovial membranes causing ankylosis and deformity When do you withhold digoxin? If apical pulse is below 60 antacids with aluminum and calcium cause... constipation Abdominal Aortic Aneurysm (AAA) A rapidly fatal condition in which the walls of the aorta in the abdomen weaken and blood leaks into the layers of the vessel, causing it to bulge. acute adrenal crisis Life-threatening medical emergency caused by a lack of cortisol TURP transurethral resection of the prostate polymigratory arthritis swollen painful joints Erythema marginatum faint areas of red demarcation over the back and abdomen Sydenham's chorea irregular movement of the extremities and facial grimacing Croup a respiratory illness in children caused by a flu virus; inflammation of the larynx, trachea and bronchi Varicella is contagious until all lesions are crusted over [Show Less]
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NCLEX-PN post-test Questions and Answers graded A+
the nurse manger identifies that time spent charting is excessive. the nurse manger states that "staff will form a task force to investigate & develop pote... [Show More] ntial solutions to the problem & then report on this at the next staff meeting." what is the nurse manger's leadership style? transformational upon completing a reveiw of the admission documents, a nurse identifies that an 87yr old pt. does not have an advance directive. what action should the nurse take? inform charge nurse & give info about advance directives a newly license nurse is concerned about time management. which action should be most effective in the initial development of a time management plan? keep a time log for what was done during the hrs. worked info about case management & the role of the case managemen nurse is presented during an orientation session for new nurses. which statement correctly describes an important fact about case management? case management is a collaborative process designed to meet complex client needs a bosnian muslim woman who does not speak english seeks care at a community center. through physical gestures, the woman indicates that she has pain originating in either the pelvic or genital region. assuming several people are available to interpret, who would be the most appropriate choice? a female interpreter who does not know the client. the pt. had a colon resection tow days ago. which statement should the nurse use to give an assignment to an UAP to help the client ambulate? "have the pt. sit on the side of the bed for three to five min. before standing" the home health nurse is visiting a pt. Dx w/ type 1 diabetes & osteoarthritis. the clients has difficulty drawing up the insulin dosage. the nurse should refer the pt. to which community resoruce person? occupational therapist =OT can assist a client to improve the fine motor skills needed to prepare an insulin injection. OT works w/ the taks that are needed for smaller movement to maintain ADL or for work action. PT work w/ general movment problems, mobility stability, ROM or strength training exrcises. the 4yr old needs to have several vaccines prior to strating kindergarten. however, the nurse determines that the MMR vaccine should not be given. what is the best reason why the MMR should not be given too this child? previous life-threatening allergic reaction to the anitbiotic neomycin. =according to the CDC, if a person expereienced a life-threatening reaction to the antibiotic neomycin or gelatin s/he should not get the MMR. Vaccines can be give to children w/ mild cold symptoms, but it might be better to wait until they feel better. there is no relationship between the MMR & an allergy to peanuts. the CDC recommends administering the first MMR between 12 & 15 months & the second dose between 4-6yr old. a school nurse lans to reinforce info about the most effective methods to prevent the spread of head lice in school-age children when speaking at a teacher's conference. the nurse should plan to include which info? children should not share or wear other children's coats, hats, & scarves parents of a 7yr old child call a clinic nurse bc their child was sent home from school due to a rash. the child, seen the day before by the health care provider, was Dx w/ 5th disease (erythema infectiosum) & is otherwise in good health. what would be the appropriate action by the nurse? explain that this rash is no longer contagious & does nott require isolation. =5th disease is a viral w/ an uncertain period of communicability (perhaps 1 wk prior to & 1 wk aafter the onset). children are not contagious after the appearance of the rash, which givers a "slapped cheek" appearance. isolation of the child w/ 5th disease is not necessary except in cases of hospitalized children who are immunosuppressed or having aplastic crises. the parents may need written confirmation of this from the health care provider to give to the school. the nurse is attending an in-service about Health-care infections (HAIs). whcih factor is identified as the mnost common cause of HAIs in the acute care setting? presennce of an indwelling catheters =catheter-associated UTI is the most common HAIs in the acute care hospital setting. Surgical site infecitons, bloodstream, & pneumonia infections are the other categories of infections. the nurse is discussing safety precautions w/ the parents of a child. which activity woud be most hazardous to an 18month old child? riding in a car =car accidents are a leading cause of death in infants & children, as well as a major cause of permanent brain damage & spinal cord injury. drowning is the 2nd most common cause of accidental death among children. four clients are admitted to an adult medical unit on the same shift. the nurse should expect to implement airborne precautions for the client w/ which of the following Dx? positive mantoux test w/ an abnormal chest x-ray =the pt. who must be placed in airborn precautions is the client w/ a positive mantoux test (or PPD) & an abnormal chest film bc these could be suspicious TB lesions. the client would be place in a private rm. health care workers would have to use a HEPA filter respirator when in the rm providing care for the pt. although the confirmed AIDS w/ cytomegalovirus (CMV) is not highly communicable, it can be spread from person to person by direct contact; the virus is shed in the urine, saliva, semen, & to other body fluids. there are a number of reasons for near misses & making medication errors, including heavy workload, inadequate staffing, distractions, interruptions, & inexperience. fatigue, sleep loss are also factors, especially for nurses working in unit w/ high acuity clients. true the nurse listens to report about a new admitted pt. who has a skin ulcer that's test positive for MRSA. what precautions must be taken for this hospitalized pt.? select all that apply -perform hand hygiene after direct contact w/ the pt. & before leaving the rm. -keep the door to the rm closed, w/ a notice for visitors -place the client in a single rm -keep all equipment in the client's rm for his/her sole use. =contact precaution are recommended in acute care setting for MRSA when there's a risk for transmission or wounds that cannot be contained by dressings. the pt. should be in a single rm, w/ the door closed; the sign on the door instruct visistors to report to the nurse before entering the rm. all equipment, such as stethoscopes & BP devices, should be for the client's sole use & kept in the rm. health care workers must perform hand hypgiene (wash hands w/ soap & water) after & before direct contact w/ pt. contact precautions requires health car workers to wear gloves & gown; a face mask is no necessary for routine care. The mother of an infant who is being treated for pesticide poisoning asks, "why is activated charcoal used?" What is an appropriate response by the nurse? "Activated charcoal binds with the poison to limit absorption from the digestive tract" -activate charcoal binds to the poison through the entire GI tract; it is estimated that it reduces absorption by almost 60% activated charcoal is a fine, black powder that is odorless, tasteless, & nontoxic it is often used after gastric lavage in the ER Tx of certain kinds of poisoning. The health care team is planning a D.C. for a 90yr old pt. Dx w/ musculoskeletal weakness. Which intervention would be the priority to help prevent falls in the home? Place night light in the bedroom & bathroom The parents of a toddler asks "how long will our child have to sit in a car seat when riding in a car?" What would be the best response by the nurse? "Until the child is 2yrs-old" -the American academy of pediatric now recommends that infants & toddlers remain in rear-facing car safety seat until age 2yr old (or when they physically outgrow the limits of the seat). They can then transition to sitting in belt-position booster seats when they have reached about 4ft 9inches tall & are between 8-12yrs old. Children under age13yrs should ride in the back seat of the car The nurse is setting up a pt.'s dinner tray. When the nurse turns her back to the pt, the pt grabs the nurse's buttocks & state he is hungry for much more than dinner. Which of the following responses by the nurse is indicated? Complete an incident report -to keep the therapeutic relationship intact, a nurse needs to limits on appropriate behavior & ignores bad behavior. Sexual harassment is a form of violence & is never part of the job. The nurse should report the incident to her supervisor & complete an incident report. The nurse has the right to ask not to be assigned to this pt. The nurse is caring for a client Dx w/ hepatitis C. When reviewing the pt.'s health Hx, which of the following findings does the nurse recognize as the most likely cause for developing hepatitis C ? Receiving blood products transfusion prior to 1992 -the pt. Who was transfused prior to blood screening for hepatitis C (1992) may show findings of hepatitis C many years later. Raw shellfish ingestion & travel to foreign countries w/ poor sewage control can increase the risk of developing hepatitis A, but not hepatitis C. Most commercial tattoos parlor are licensed & follow standard safety precautions, so the likely cause of developing hepatitis B or C after tattoo or piercing is very low. A child is admitted w/ Dx of suspected meningococcal meningitis. Which admission orders should the nurse implement first? Droplets Precautions -meningococcal meningitis is an infection caused by bacteria neisseria meningitis includes droplets precautions, anti-ineffective therapy (a cephalosporins or penicillin), monitor neurological status along w/ v/s, institute seizures precautions, & maintains optimum hydration. In the third trimester, an awake, healthy fetus should move at least 3x/hr. If the baby does not move, the mother should drink a glass of juice & then start a new count True The 3rd stage of labor is placental separation & expulsion & last about5-30min. The 4th stage of labor is maternal adaptation occurring 1-2hr after birth True When the fetus is active it's HR will accelerate by about 15beats/min above the baseline. Average FHR is about 130BPM when near term True Pregnancy test measure the hormone chorionic gonadotropin (hCG) in the urine or in the blood. Levels can be first detected about 12-14 days after conception & peak in the first 8-11 was of pregnancy True There are several findings of pregnancy during first trimester. Increase vascularity in vagina is called Chadwick sign; the increase vascularization & softness of uterine isthmus is Hegar's sign; & the softening of the cervix is Goodell's sign True RhoGAM is administered to Rh negative woman after any possible exposure to fetal blood such as after each ectopic pregnancy, miscarriage, abortion, or amniocentesis. RhoGAM will be given to help prevent problems associated w/ incompatible blood types in future pregnancies True Chloasma is a skin discoloration of pregnancy. The first breast milk is called colostrum. Colostrum is low in fat, high in carbs , protein, & anti bodies & easy for the newborn to digest. True Engagement means that the baby's head no longer floats freely, but has dropped down into the pelvis. In a multipara, engagement normally occurs about two was before birth True The normal color all over for the newborn is pink; a pink baby earns a score of 2. A baby who is pink w/ pale blue toes/feet & fingers will receive a score of 1 on the APGAR test. True Tapping on the glabella (flat bone between the eyebrows) causes a neurologically healthy baby to close both eyes. This is referred to as the glabella reflex. True [Show Less]
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NCLEX PN - Nutrition NCLEX Questions Answered 100% correct
a client is having problems with blood clotting. Which food item should the nurse encourage the client to eat? A) legumes B) citrus fruits C) veg... [Show More] etable oils D) green, leafy vegetables D) green, leafy vegetables rationale: green, leafy vegetables are high in vitamin K, which acts as a catalyst for facilitating blood-clotting factors. Legumes are high in folic acid and thiamine. Citrus fruits are high in vitamin C, which helps with wound healing. Vegetable oil is high in vitamin E, which acts as an antioxidant. when reinforcing instructions to a client with acute diverticulitis, which should the nurse include? A) avoid whole-grain products B) limit fluids to 1000 mL daily C) increase intake of seeds and nuts D) increase intake of raw fruits and vegetables A) avoid whole-grain products rationale: diet therapy for acute diverticulitis involves allowing the bowel to rest by avoiding high-fiber foods, such as whole-grain products and raw fruits and vegetables. Fluids are encouraged rather than restricted. Seeds and nuts are to be avoided so that they do not become trapped in the diverticula and cause irritation. In non-acute stages, a high-fiber diet may be prescribed. a client is a lacto-vegetarian. Which food item should the nurse remove from the tray? A) eggs B) milk C) cheese D) broccoli B) eggs rationale: eggs are not consumed by lacto-vegetarians. Other dairy and plant products are eaten by lacto-vegetarians a low-sodium diet has been prescribed for a client with hypertension. Which food selected from the menu by the client indicates an understanding of this diet? A) baked turkey B) tomato soup C) boiled shrimp D) chicken gumbo A) baked turkey rationale: regular soup (1 cup) contains 900 mg of sodium. Fresh shellfish (1 oz) contains 50 mg of sodium. Poultry (1 oz) contains 25 mg of sodium the nurse is providing dietary instructions to a client with gout. The nurse should tell the client to avoid which food item? A) scallops B) chocolate C) cornbread D) macaroni products A) scallops rationale: scallops should be omitted from the diet of a client who has gout because of the high purine content. The food items in the remaining options have negligible purine content and may be consumed by the client with gout. a clear liquid diet has been prescribed for a client with gastroenteritis. Which item is appropriate to offer to the client? A) soft custard B) orange juice C) clam chowder D) fat-free beef broth D) fat-free beef broth rationale: a clear liquid diet consists of foods that are relatively transparent. Soft custard and orange juice would be included in a full liquid diet because they are opaque, not clear. Clam chowder is opaque and also includes pieces of clams, thus eliminating it from a full liquid diet. A client with heart disease is instructed regarding a low-fat diet. The nurse determines that the client understands the diet if the client states to avoid which food item? A) apples B) cheese C) oranges D) skim milk B) cheese rationale: fruits, vegetables and skim milk contain minimal amounts of fat. cheese is high in fat. the nurse reinforces instructions to a client to increase the amount of riboflavin in the diet. The nurse should tell the client to select which food item that is high in riboflavin? A) milk B) tomatoes C) citrus fruits D) green, leafy vegetables D) milk rationale food sources of riboflavin include milk, lean meats, fish and grains. Tomatoes and citrus fruits are high in vitamin C. Green leafy vegetables are high in folic acid. a client with a burn injury is transferred to the nursing unit and a regular diet has been prescribed. The nurse encourages the client to eat which dietary items to promote wound healing? A) veal, potatoes, gelatin, and orange juice B) chicken breast, broccoli, strawberries, and milk C) peanut butter and jelly sandwich, cantaloupe and tea D) spaghetti with tomato sauce, garlic bread, and ginger ale B) chicken breast, broccoli, strawberries and milk rationale protein and vitamin C are necessary for wound healing. Poultry and milk are good sources of protein. Broccoli and strawberries are good sources of vitamin C. Peanut butter is a source of niacin. Gelatin and jelly have no nutrient value. Spaghetti is a complex carbohydrate the nurse has completed diet teaching for a client who has been prescribed a low-sodium diet to treat hypertension. The nurse determines that there is a need for further teaching when the client makes which statement? A) this diet will help lower my blood pressure B) fresh foods such as fruits and veggies are high in sodium C) this diet is not a replacement for my antihypertensive medications D) the reason I need to lower my salt intake is to reduce fluid retention B) fresh foods such as fruit and vegetables are high in sodium rationale: a low-sodium diet is used as an adjunct to antihypertensive medications for the treatment of hypertension. Sodium retains fluid, which leads to hypertension secondary to increased fluid volume. Fresh foods such as fruits and vegetables are low in sodium. the nurse is preparing to administer an intermittent tube feeding to a client. The nurse aspirates 90 mL of residual from the tube. What should the nurse do with the aspirated residual? A) hold the feeding B) place it into a container for lab analysis C) reinstill the residual and administer the feeding D) deduct the amount of the residual from the new feeding and administer that amount to the client C) reinstill the residual and administer the feeding rationale: unless otherwise instructed or if the residual contents appear abnormal, an amount of less than 100 mL may be reinstituted; then a normal amount of prescribed tube feeding is administered. It is important to return the contents to the stomach to prevent electrolyte imbalances. therefore options A, B, and D are incorrect a child with leukemia is experiencing nausea realted to medication therapy. The nurse, concerned about the child's nutritional status, should offer which during an episode of nausea? A) low-calorie foods B) cool, clear liquids C) low-protein foods D) the child's favorite foods B) cool, clear liquids rationale when the child is nauseated, it is best to offer frequent intake of cool, clear liquids in small amounts because small portions are usually better tolerated. Cool, clear fluids are also soothing and better tolerated when a client is nauseated. It is best not to offer favorite foods when the child is nauseated because foods eaten during times of nausea will be associated with being sick. It is best to offer small, frequent meals of high-protein and high-calories content once the nausea has been controlled with medication or has subsided. the nurse is reinforcing instructions to a client on how to decrease the intake of potassium in the diet. The nurse should tell the client that which food contains the least amount of potassium? A) lettuce B) potatoes C) apricots D) avocados A) lettuce rationale lettuce contains less than 100 mg of potassium. Potatoes, apricots and avocados are potassium-containing foods and should be avoided by the client on a potassium-restricted diet. the nurse is reinforcing instructions to a client regarding how to decrease the intake of phosphorus in the diet. The nurse should tell the client that which food item contains the least amount of phosphorus? A) fish B) oranges C) almonds D) whole-grain bread B) oranges rationale: an orange contains the least amount of phosphorus. Foods high in phosphorus include fish, pork, beef, chicken, organ meats, nuts, whole-grain breads, and cereals a client who is receiving total parenteral nutrition may begin to take small amounts of clear liquids today. The nurse's priority is to collect data regarding which criterion before giving the client anything by mouth. A) the client's appetite B) the client's current weight C) the presence of the swallow reflex D) adequate pulse and blood pressure readings C) the presence of the swallow reflex rationale the nurse ensures that the client has intact gag and swallow reflexes before giving clear liquids. The nurse should also check for the presence of bowel sounds. The pulse, blood pressure, and weight require ongoing monitoring, but they are not the most important items given the wording of the question. The client may be expected to have a poor appetite after being without oral intake for a period of time. [Show Less]
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NCLEX-PN Practice Question 2023 Questions and Answers 100% correct
Chapter 5 Care of Special Populations Priority Concepts Caregiving, Health Disparities Question 1 Which teaching method is most effective when pro... [Show More] viding instruction to members of special populations? 1. Teach-back 2. Video instruction 3. Written materials 4. Verbal explanation Answer 1 Question 2 Which is most appropriate when communicating with a transgender person? 1. Using preferred pronouns 2. Using their first name to address them 3. Using pronouns associated with birth sex 4. Anticipating the client’s needs and making suggestions Answer 1 Question 3 The nurse is volunteering with an outreach program to provide basic health care for homeless people. Which finding, if noted, must be addressed first? 1. Blood pressure 154/72 mmHg. 2. Visual acuity of 20/200 in both eyes 3. Random blood glucose level of 206 mg/dL 4. Complaints of pain associated with numbness and tingling in both feet Answer 4 Question 4 The nurse is completing the admission assessment of a client who is intellectually disabled. Which part of the client encounter may require more time to complete? 1. The history 2. The physical assessment 3. The nursing plan of care 4. The readmission risk assessment Answer 1 Question 5 The nurse working in a correctional facility is caring for a new prisoner. The client asks about health risks associated with living in a prison. How would the nurse respond? 1. “Health care is very limited in the prison setting.” 2. “Living in a prison isn’t different than living at home.” 3. “Living in a prison can predispose a person to different health conditions.” 4. “Living in a prison is similar to living in a condominium complex or dormitory.” Answer 3 Question 6 The nurse is caring for a female client in the emergency department who presents with a complaint of fatigue and shortness of breath. Which physical assessment finding, if noted by the nurse, warrant a need for follow-up? 1. Reddened sclera of the eyes 2. Dry flaking noted on the scalp 3. A reddish-purple mark on the neck 4. A scaly rash noted on the elbows and knees Answer 3 Question 7 The nurse working in a community outreach program for foster children plans care knowing that which health conditions are common in this population? Select all that apply. 1. Asthma 2. Claustrophobia 3. Sleep problems 4. Bipolar disorder 5. Aggressive behavior 6. Attention-deficit / hyperactivity disorder (ADHD) Answer 3, 4, 5, 6 Question 8 The nurse assisting in planning care for a military veteran must prioritize nursing interventions targeted at managing which condition, if present, that commonly occurs in this population? 1. Hypertension 2. Hyperlipidemia 3. Substance abuse disorder 4. Post-traumatic stress disorder Answer 4 Question 9 The nurse caring for a refugee considers which health care need a priority for this client? 1. Access to housing 2. Access to clean water 3. Access to transportation 4. Access to mental health care services Answer 4 Question 10 Which action by the nurse will best facilitate adherence to the treatment regimen for a client with a chronic illness? 1. Arranging for home health care 2. Focusing on managing a single illness at a time 3. Communicating with one provider only to avoid confusion for the client 4. Allowing the client to teach a support person about their treatment regimen Answer 1 Chapter 6 Ethical and Legal Issues Priority Concepts Ethics; Health Care Law Question 1 Which identifies accurate nursing documentation notations? Select all that apply. 1. The client slept through the night. 2. Abdominal wound dressing is dry and intact without drainage. 3. The client seemed angry when awakened for vital sign measurement. 4. The client appears to become anxious when it is time for respiratory treatments. 5. The client's left lower medial leg wound is 3 cm in length without redness, drainage, or edema. Answer 1, 2, 5 Question 2 The licensed practical nurse (LPN) enters a client's room and finds the client lying on the bathroom floor. The LPN calls the registered nurse, who checks the client thoroughly and then assists the client back into bed. The LPN completes an incident report, and the nursing supervisor and primary health care provider (PHCP) are notified of the incident. Which is the next nursing action regarding the incident? 1. Place the incident report in the client's chart. 2. Make a copy of the incident report for the PHCP. 3. Document a complete entry in the client's record concerning the incident. 4. Document in the client's record that an incident report has been completed. Answer 3 Question 3 An unconscious client, bleeding profusely, is brought to the emergency department after a serious accident. Surgery is required immediately to save the client's life. With regard to informed consent for the surgical procedure, which is the best action? 1. Call the nursing supervisor to initiate a court order for the surgical procedure. 2. Try calling the client's spouse to obtain telephone consent before the surgical procedure. 3. Ask the friend who accompanied the client to the emergency department to sign the consent form. 4. Transport the client to the operating department immediately without obtaining an informed consent. Answer 4 Question 4 The nurse arrives at work and is told to report (float) to the pediatric unit for the day because the unit is understaffed and needs additional nurses to care for the clients. The nurse has never worked in the pediatric unit. Which is the appropriate nursing action? 1. Call the hospital lawyer. 2. Call the nursing supervisor. 3. Refuse to float to the pediatric unit. 4. Report to the pediatric unit and identify tasks that can be safely performed. Answer 4 Question 5 The nurse enters a client's room and notes that the client's lawyer is present and that the client is preparing a living will. The living will requires that the client's signature be witnessed, and the client asks the nurse to witness the signature. Which is the appropriate nursing action? 1. Decline to sign the will. 2. Sign the will as a witness to the signature only. 3. Call the hospital lawyer before signing the will. 4. Sign the will, clearly identifying credentials and employment agency. Answer 1 Question 6 The nurse finds the client lying on the floor. The nurse calls the registered nurse, who checks the client and then calls the nursing supervisor and the primary health care provider (PHCP) to inform them of the occurrence. The nurse completes the incident report for which purpose? 1. Providing clients with necessary stabilizing treatments 2. A method of promoting quality care and risk management 3. Determining the effectiveness of interventions in relation to outcomes 4. The appropriate method of reporting to local, state, and federal agencies Answer 2 Question 7 The nurse observes that the client received pain medication 1 hour ago from another nurse, but the client still has severe pain. The nurse has previously observed this same occurrence several times. Based on the nurse practice act, the observing nurse would plan to take which action? 1. Report the information to the police. 2. Call the impaired nurse organization. 3. Talk with the nurse who gave the medication. 4. Report the information to a nursing supervisor. Answer 4 Question 8 A client has died, and the nurse asks a family member about the funeral arrangements. The family member refuses to discuss the issue. Which is the appropriate nursing action at this time? 1. Show acceptance of feelings. 2. Provide information needed for decision making. 3. Suggest a referral a mental health professional. 4. Remain with the family member without discussing funeral arrangements. Answer 4 Question 9 A nurse lawyer provides an education session to the nursing staff regarding client rights with an emphasis on invasion of these rights. The nurse lawyer asks a staff nurse to identify situation the represents an example of invasion of client privacy. Which situation, if identified by a staff nurse, indicates an understanding of a violation of this client right? 1. Threatening to place a client in restraints 2. Performing a surgical procedure without consent 3. Taking photographs of the client without consent 4. Telling the client that he or she cannot leave the hospital Answer 3 Question 10 An older woman is brought to the emergency department. When caring for the client, the nurse notes old and new ecchymotic areas on both of the client's arms and buttocks. The nurse asks the client how the bruises were sustained. The client, although reluctant, tells the nurse in confidence that her daughter frequently hits her if she gests in the way. Which is the appropriate nursing response? 1. "I have a legal obligation to report this type of abuse." 2. "I promise I won't tell anyone, but let's see what we can do about this." 3. "Let's talk about ways that will prevent your daughter from hitting you." 4. "This should not be happening. If it happens again, you must call the emergency department." Answer 1 Chapter 7 Prioritizing Client Care: Leadership, Delegation, and Emergency Response Planning Priority Concepts Leadership; Health Care Organizations Question 1 The nurse is recording a nursing hands-off (end-of-shift) report for a client. Which information needs to be included? 1. As-needed medications given that shift 2. Normal vital signs that have been the same since admission 3. All of the tests and treatments the clients has had since admission 4. Total number of scheduled medications that the client received on that shift. Answer 1 Question 2 The nurse is planning the client assignments for the day. Which is the most appropriate assignment for the assistive personnel (AP)? 1. A client who requires wound irrigation 2. A client who requires frequent ambulation 3. A client who is receiving continuous tube feedings 4. A client who requires frequent vital signs after a cardiac catheterization Answer 2 Question 3 The nurse employed in a long-term care facility is planning the client assignments for the shift. Which client would the nurse assign to the assistive personnel (AP)? 1. A client who requires a 24-hour urine collection 2. A client who requires twice-daily dressing changes 3. A client with diabetes mellitus who requires daily insulin and the reinforcement of dietary measures A client who has been placed on a bowel management program and requires rectal suppositories and a daily enema Answer 1 Question 4 The nurse is assigned to care for four clients. When planning client rounds, which client would the nurse check first? 1. A client in skeletal traction 2. A client who is dependent on a ventilator 3. A postoperative client preparing for discharge 4. A client admitted during the previous shift with a diagnosis of gastroenteritis Answer 2 Question 5 The nurse employed in an emergency department (ED) is assigned to assist with the triage of clients arriving at the ED. The nurse would assign priority to which client? 1. A client complaining of muscle ache, headache, and malaise 2. A client who twisted their ankle when they fell in-line skating 3. A client with a minor laceration on the index finger sustained while cutting an eggplant A client with chest pain who states that they just ate pizza that was made with a very spicy sauce Answer 4 Question 6 The nurse is educating a new nurse about mass casualty events (disasters). Which statement by the new nurse indicates a need for further teaching? Select all that apply. 1. “An event is termed a mass casualty when it overwhelms local medical capabilities.” 2. “Mass casualty events do not require an increase in the number of staff that are needed.” 3. “A mass casualty event occurs only within the health care facility and could endanger staff.” 4. “Mass casualty events may require the collaboration of many local agencies to handle the situation.” 5. “A mass casualty event occurs if a fight between visitors occurs in the emergency department.” Answer 2, 3, 5 [Show Less]
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NCLEX-PN Practice Questions with complete Answers 2023
The nurse is administering sublingual nitroglycerin to a client. Immediately afterward, the client may experience: throbbing headache or dizziness. ... [Show More] A client with iron deficiency anemia has been admitted to the medical-surgical unit. Which assessment findings are characteristic of this type of anemia? Dyspnea, tachycardia, and pallor The nurse is caring for a client taking an anticoagulant. Which instruction regarding anticoagulant therapy should the nurse give the client? Limit foods high in vitamin K. The nurse delivers a client's 10 a.m. medications. The client is away from his room for a diagnostic study. Which action is most appropriate for the nurse to take? Lock the medications in the medicine preparation area until the client returns. The nurse is caring for a client receiving patient-controlled analgesia (PCA) for pain management. Which statement about PCA is true? Pain relief is initiated by the client as needed. The nurse is caring for a client with type 1 diabetes mellitus who exhibits confusion, light-headedness, and aberrant behavior. The client is still conscious. The nurse should first administer: 15 to 20 g of a fast-acting carbohydrate such as orange juice. The nurse is caring for an elderly female with osteoporosis. When teaching the client, the nurse should include information about which major complication? Bone fracture The nurse is speaking to a group of women about early detection of breast cancer. The average age of the women in the group is 47. Following the American Cancer Society guidelines, the nurse should recommend that the women: have a mammogram annually. The nurse is instructing a premenopausal woman about breast self-examination. The nurse should tell the client to do her self-examination: immediately after her menses. The nurse is teaching a group of women to perform breast self-examination. The nurse should explain that the purpose of performing the examination is to discover: changes from previous self-examinations. The American Cancer Society recommends routine screening to detect colorectal cancer. Which screening test for colorectal cancer should the nurse recommend? Flexible sigmoidoscopy beginning at age 50 Which nursing diagnosis should the nurse expect to see in a care plan for a client in sickle cell crisis? Acute pain related to sickle cell crisis What can the nurse do to prevent lipodystrophy when administering insulin to a diabetic client? Rotate the injection sites. For a diabetic client with a foot ulcer, the physician orders bed rest, a wet-to-dry dressing change every shift, and blood glucose monitoring before meals and at bedtime. Why are the wet-to-dry dressings used for this client? Because they debride the wound and promote healing by secondary intention. An obese client is admitted to the hospital for abusing amphetamines in an attempt to lose weight. Which nursing intervention is appropriate for this client? Identify alternative ways for the client to lose weight. Policy and procedure dictate that hand washing is a requirement when caring for clients. Which statement about hand washing is true? Frequent hand washing reduces transmission of pathogens from one client to another. The nurse is evaluating a postoperative client for infection. Which sign or symptom would be most indicative of infection? Red, warm, tender incision The nurse is caring for a client with a fractured hip. The client is combative, confused, and trying to get out of bed. The nurse should: obtain a physician's order to restrain the client when less restrictive interventions fail. The nurse is caring for a bedridden, elderly adult. To prevent pressure ulcers, which intervention should the nurse include in the care plan? Post a turning schedule at the client's bedside. A client who has recently had surgery for prostate cancer expresses to the nurse feelings of anger toward God, his church, and the clergy. Which intervention is appropriate for this client? Encouraging the client to discuss concerns with the clergy The nurse is working in a support group for clients with acquired immunodeficiency syndrome (AIDS). Which point about preventing transmission of the human immunodeficiency virus (HIV) is most important for the nurse to stress? Following safer-sex practices The nurse is preparing to begin one-person cardiopulmonary resuscitation. The nurse should first: establish unresponsiveness. The nurse is providing home care instructions to a client who has recently had a skin graft. It's most important that the client remember to: protect the graft from direct sunlight. The nurse is caring for a client who underwent a subtotal gastrectomy 24 hours earlier. The client has a nasogastric (NG) tube. The nurse should: irrigate the NG tube gently with normal saline solution as prescribed. A client is to be discharged from an acute care facility following treatment for right leg thrombophlebitis. The nurse notes that the client's leg is pain-free, without redness or edema. The nurse's actions reflect which step of the nursing process? Evaluation The nurse is caring for a client who recently underwent a total hip replacement. The nurse should: limit client hip flexion while sitting. When caring for a client who's being treated for hyperthyroidism, it's important to: balance the client's periods of activity and rest. Which intervention should the nurse try first with a client who exhibits signs of sleep disturbance? Provide the client with sleep aids, such as pillows, back rubs, and snacks. When preparing a client for an enema, the nurse should help him into the: left-lateral Sims' position. The nurse is caring for a client with a right ankle sprain. When applying cold to the client's injury, the nurse should: apply it immediately after the injury occurs. The nurse is teaching a client with a family history of atherosclerosis. To decrease the risk of atherosclerosis, the nurse should encourage the client to: increase his activity level. The nurse is teaching a client diagnosed with basal cell epithelioma. The most common cause of basal cell epithelioma is: exposure to the sun. The nurse is giving instructions to a client who's going home with a cast on his leg. Which point is most critical? Reporting signs of impaired circulation A client undergoes a surgical procedure that requires the use of general anesthesia. Following general anesthesia, the client is most at risk for: atelectasis. The nurse is caring for a client who recently underwent a tracheostomy. The first priority when caring for a client with a tracheostomy is: keeping his airway patent. The nurse is working on a surgical floor. The nurse must logroll a client following a: laminectomy. A client underwent cataract removal with an intraocular lens implant. The nurse is giving the client discharge instructions. These instructions should include which of the following? Avoid straining during bowel movements. When caring for a client with a nursing diagnosis of Impaired swallowing related to neuromuscular impairment, the nurse should: elevate the head of the bed 90 degrees during meals. When performing an assessment, the nurse collects the following data: impaired coordination, decreased muscle strength, limited range of motion, and the client's reluctance to move. This data indicates which nursing diagnosis? Impaired mobility The nurse is teaching a client with genital herpes. Education for this client should include an explanation of: the importance of informing his partner of the disease. A 25-year-old client asks the nurse how often and when she should perform breast self-examinations. The nurse should tell her: every month, 7 to 10 days after menses starts. A male client should be taught about testicular examinations: before age 20. When performing an abdominal assessment, the nurse should follow which examination sequence? Inspection, auscultation, percussion, and palpation The nurse is providing teaching to a client who's at risk for coronary artery disease (CAD). The nurse tells the client that CAD has many risk factors. Risk factors that can be controlled or modified include: obesity, inactivity, diet, and smoking. The nurse is collecting data on a client admitted with a diagnosis of small bowel obstruction. When assessing the client's pulse rate, the nurse should: count the apical or radial pulse for 60 seconds. When inserting a urinary catheter, the nurse can facilitate the insertion by asking the client to: breathe deeply. The nurse is caring for a client with a colostomy. The client tells the nurse that he makes small pin holes in the drainage bag to help relieve gas. The nurse should teach him that this action: destroys the odor-proof seal. A client is prescribed transcutaneous electrical nerve stimulation (TENS) for pain relief. The rationale for using TENS is to: block painful stimuli traveling over small nerve fibers. The nurse must assess skin turgor of an elderly client. When evaluating skin turgor, the nurse should remember that: inelastic skin turgor is a normal part of aging. The nurse is assessing a client who may be in the early stages of dehydration. Early manifestations of dehydration include: thirst or confusion. A client who recently had a stroke requires a cane to ambulate. When teaching about cane use, the rationale for holding a cane on the uninvolved side is to: distribute weight away from the involved side. The nurse is developing a teaching plan for a client who must undergo an above-the-knee amputation of the left leg. After a leg amputation, exercise of the remaining limb: should begin the day after surgery. The nurse is preparing to remove a previously applied topical medication from a client. The rationale for removing previously applied topical medications before applying new medications is to: avoid administering more than the prescribed dose. The nurse is administering eyedrops to a client with glaucoma. To achieve maximum absorption, the nurse should instill the eyedrop into the: conjunctival sac. [Show Less]
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NCLEX style questions PN Fundamentals Final Review Questions Answered 100% correct Scored A+
Assess the client physically When managing the care of a client, which of the following nursing actions is most appropriate to preform first? gathe... [Show More] r basic information from the client According to most nurse practice acts, if a charge nurse assigns a LPN to admit a new client, what is the practical nurses primary role? ineffective airway clearance At a team conference, staff members discuss a clients nursing diagnoses. Which one of the following nurse diagnoses is of highest priority? revise the interventions or target date for achieving the goal The LPN notes that an expected outcome of bathing independently has not been reached by the target date. What action is most appropriate to take at this time? the clients family When gathering nursing date on a newly admitted client, which of the following is an appropriate source to consult for additional information? nurse writes names of clients on dry erase board in public area Which practice could jeopardize the health agency's accreditation? writer squeezes information into a line written hours earlier Which example of poor documentation places the writer in the most legal jeopardy? charting by exception Which method of documentation is used when the nurse charts only abnormal assessment findings or care that deviates from the agency's standard? client has a highly contagious disease For which of the following situations is breaching confidentiality appropriate ? analysis When using the SOAP method of documentation, what does the "A" represent? 15 seconds What is the minimum amount of time required for performing an alcohol-based hand rub? the fingernails are less than 1/4 inch, the nurse removed all remnants of fingernail polish, rubs tips pf the fingers against the opposite palm containing an alcohol-based product Which of the following are appropriate aseptic practices in relation to hand hygiene? cease sharing towels and washcloths What is the most important health teaching the nurse can provide to a client with an eye infection? swab earlobes daily with alcohol If the nurse provides the following information to a person who has just had his or her earlobes pierced, which is most important for reducing the potential infection? the nurse performs hand hygiene, picks up first glove cuff at folded edge with fingers and thumb, pulls glove on without touching the gloves outer surface When donning sterile gloves, which actions are correct? appearance of respiratory secretions Besides documenting the characteristics of the cough, what other assessment information is essential? move up and down beginning in the axilla Which explanation is best when teaching a client how to palpate breast tissue during a breast self examination? assessing the clients pupillary responses A nurse caring for a client with a head injury performs all of the following assessments. Which one is most important at this time? fifth intercostal in the left mid clavical Where is the best location for the nurse to auscultate an S1 heart sound? read the letters standing at a distance of 20 feet What is the most accurate instruction a nurse can provide before using a Snellen chart to assess a client's vision? client says an anesthetic will be given before the examination Which of the following indicates that a client needs more teaching before a sigmoidoscopy? remove clients metal necklace Which nursing action is essential before performing a chest roentgenogram (X-ray)? do not douche for several days before appointment Which of the following instructions is most appropriate if a specimen for a Pap test will be obtained at the time of a pelvic examination? wash hands, test strip matches, strip matches meter, cover strip completely Which of the following actions are correct when measuring a clients capillary blood glucose? ask client to rate pain form 0 to 10 When a nurse observes that a client with upper abdominal pain is curled in a fetal position and rocking back and forth, which action would help most to further assess the clients pain? phantom pain What type of pain is a client with an amputated arm experiencing who states " I know my arm is not there, but I can feel it throbbing?" pulse rate may be rapid A nurse can expect that acute pain may have which of the following effects on the clients vital signs? administer pain medication every 3 hours as prescribed Which of the following is the best action for a hospice nurse to take to provide maximum pain relief when caring for a client with terminal cancer? antidepressants, anticonvulsants Which of the following categories of medications would be considered adjuvants? client becomes restless When a client returns from surgery, which sign is an early indication that the clients oxygenation status is compromised? 95% to 100% If a client is adequately oxygenated, in what range should a pulse oximeter identify as the Sp02 measurement reservoir bag collapses during inspiration When administering oxygen with a partial rebreather mask, which of the following observations is most important to report to the respiratory therapy department? 2 L per minute Which of the following oxygen flow rates is most appropriate for a client with emphysema, a chronic lung disease? the fluid rises and falls with respirations When the nurse monitors the water-seal chamber of a commercial chest tube drainage system that is draining by gravity, which finding suggests that the system is functioning appropriately? wear gloves When a nurse empties the secretions from a wound suction container, which of the following infection control measures is most important? respiratory hygiene/ cough adequate When a person comes to the emergency department with respiratory symptoms, which of the following infection control measures is appropriate to use initially? remove gloves one at a time When exiting the room of a client being cared for with contact precautions, what is the first step in removing personal protection items? wear two pairs of vinyl gloves What is the best advice the nurse can give to someone who is allergic to latex, yet must wear gloves for standard precautions? avoid going to crowded places Other than obtaining an immunization against influenza, what is the best advice the nurse can give to high-risk people to avoid acquiring this infection? support wet cast with the palms of the hands As the physician wraps the arm of a client with rolls of wet plaster, what is the most appropriate method the nurse should use for supporting the wet cast [Show Less]
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NCLEX-PN review Questions and Answers 2023
What is the nursing process? Assess Forming nursing diagnosis Planning and Goal Setting Implementation Evaluation What are some therapeutic com... [Show More] munication barriers? Giving advice, judging, stereotyping, being defensive, appearing distracted or uninterested, agreeing or disagreeing, appearing biased, not being a good listener or excessive probing What is HELLP Syndrome? This is preeclampsia with Liver involvement: Hemolysis(breakdown of RBCs) Elevated Liver Function Tests Low Platelet Count How many arteries and veins are in the umblical cord? 2 arteries, 1 vein What is Ortilani's Sign The click that is heard or felt when the infant is supine and knees are flexed and hips are abducted = hip dyslpasia What are the dietary considerations for pancreatitis? Avoid aldohol bland foods small, frequent meals decrease fat 1 tsp = how many mL? 5 mL What is Ptosis? Drooping Which cranial nerve is the optic? 2 The Lub sound of Lub-dub is closure of which heart valves? Closure of Tricuspid and Mitral Valves(Systole) = Lub Which sign is the softening of the cervix? Goodell's Drugs ending in "olol" belong to which drug classification? Beta-Blockers = particularly for the management of cardiac arrhythmias, cardioprotection after myocardial infarction (heart attack), and hypertension What is the normal Lithium value? normal = < 1.5 mEq/L toxic = > 2 mEq/L Where is the location to listen to the Pulmonic valve? Left second intercostal space Enema position is on the left or right side? left What is the antidote for acetaminophen? Mucomyst (N-acetylcysteine) What are the dietary considerations for Celiac Disease? No gluten Increase calories Increase protein Drugs ending in "statin" belong to which drug classification? Antihyperlipidemics = used in the treatment of hyperlipidemias. They are called lipid-lowering drugs (LLD) or agents What is a continuous seizure that must be interrupted by emergency measures? Status Epilepticus What are the meds most often used to treat status epilepticus? diazepam (Valium) phenytoin (Dilantin) phenobarbitol (Luminol) Which body positioning is called the "shock" position? Modified Trendelenburg = Supine with legs straight and elevated at the hips and head is slightly raised (increases bloodflow to heart and brain) Which blood type is the universal 'recipient'? AB+ Which blood type is the universal 'donor type'? O- What is stroke volume? the amount of blood ejected by the heart in any one contraction What is cardiac output? Volume of blood ejected by the heart in one minute: cardiac output = heart rate x stroke volumne Do Mydriatic drops constrict or dilate the pupils? Dilate -- myDriatic (d for dilate) How do you mix insulin? Clear before Cloudy (NPH)!!! 1. draw up air to equal total insulin 2. wipe vial runner with alcohol 3. inject the amount of air to equal the amount of cloudy insulin into the cloudy vial. BE CAREFUL NOT TO INJECT INTO THE SOLUTION 4. Inject the remaining air into clear vial and draw up the clear insulin 5. reinsert the needle into the cloudy vial and withdraw the desired amount What are the dietary considerations for Acute Renal Failure? Increase carbs Limit protein decrease sodium fluid restriction What are the dietary considerations for Chronic Renal Failure? Avood high potassium foods Low sodium High iron High calcium Vitamins B, C & D Normal Sodium Values? 135 - 145 1 tbsp = how many mL? 15 mL What is the normal PT value? 9.5 - 12.0 seconds The Dub sound of Lub-Dub is closure of which heart valves? Closure of the pulmonic and aortic valves (Distole) = Dub What are the normal Creatinine values? 0.6 - 1.5 mg/dl Which cranial nerve is the Vagus? 10 - gag reflex, swallowing, talking What is the normal heart and blood flow in the correct order? Blood enters: Right Atgrium => Tricuspid valve => Right Ventricle => Pulmonic Valve => Pulmonary Veins => Left Atrium => Mitral valve (bicuspic) => Left Ventricle => Aortic Valve => out to body Normal Blood Ph 7.35 - 7.45 Peripheral Edema, bounding pulses, jugular vein distention, decreased or absent urinary output are signs of right or left sided heart failure? Right-sided 1 kg = how many liters of water? 1 L Which cranial nerve is our sense of smell or Olfactory? 1 What are the dietary considerations for Cushings? Increase protein and potassium Decrease sodium and calories What is the normal heart rate of an adult? 60-100 per minute What is the normal PTT value? 20 - 45 seconds Where is the location to listen to the Aortic valve? Right second intercostal space What are normal calcium values? 8.5 - 10.5 "When taking a BP, if the arm is below the heart level, will the BP reading be elevated or decreased? Elevated Whichncranial nerve is our sense of hearing and balance or Acoustic? 8 1 oz = how many mL? 30 mL Where is the location to listen to the Mitral valve? Left mid-clavicular line Normal Potassium values 3.5 - 5.0 What is Nagele's rule? 1st day of last menstrual cycle, minus 3 months, plus 7 days = estimated date of delivery What is the normal respiratory rate of an adult? 12-20 per minute Cyanosis, increased RR, decreased BP, pulmonary crackles are signs of right or left sided heart failure Left-sided What is the normal value for Digoxin? normal = < 2 ng/mL toxic = > 2 ng/mL What is the antidote for heparin? protamine sulfate [Show Less]
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NCLEX PN Questions Answered 2023
Reduce symptoms of Raynauds disease? Wearing gloves when handling frozen food What is Raynauds disease? reduced blood flow due to spasm of arterie... [Show More] s of the feet and hands When removing a chest tube, what should you instruct the patient to do? hold breathe and bear down When you notice blanching, coldness and edema at the IV site, what should you do? Remove the IV What is considered a normal Blood Glucose level? 70-100 What PPE to use for MRSA patient? Gloves Gown Goggles Mask What is an EARLY sign of digoxin toxicity, from the drug digoxin? Anorexia What are normal Magnesium levels? 1.6 - 2.6 mg What are signs of elevated magnesium levels? Drowsiness Sedation Lethargy Muscle weakness Areflexia What is Areflexia? Absence of the reflexes What position should you place a patient with acute epiglottitis? Sit upright What position to use for Soapsuds enema? Left side SIMS position What is the 1st step when looking into the NCLEX exam? Step 1: Access the NCSBN website at www.ncsbn.org (Obtain info for international nurses) For state licensing? Contact the state in which you are taking the NCLEX in and determine specific requirements for that state What is the process for sending the state official documents? They must come from the "Licensing Authority" Is the NCLEX exam administered in other languages? No (ONLY in English) What is your Initial response after a patients trach tube becomes dislodged? Use a manual BVM/resuscitation device? What is the "immediate" action to take after a heart failure patient presents with shortness of breath/dyspnea? Raise the head of the bed How soon after the administration of nitroglycerin should the patient see relief? 5 mins (Burning sensation/vertigo are common side effects) What is a concern when a patient is taking Warfarin? Bleeding easily (Educate patient on straight razor use) What is Dystocia? Abnormal labor or childbirth What is the 1st step in the Nursing process? Data collection What is the 2nd step in the Nursing process? Planning What is the 3rd step in the Nursing process? Implementation What is the 4th step in the Nursing Process? Evaluation What is the medication "Tigan" used for? Nausea and Emesis Iron supplements should be taken with what? Vitamin C rich juices (Tomato juice, Orange juice) When noticing that the fundus of a postpartum patient is soft and spongy, what should you do? Massage the fundus gently until it is firm Drugs that end in "lol" are normally used for what? Beta Blocker (for hypertension) ("Lo" Lowers the BP) What OTC tabs should patients not take with medication? Antacids tabs (effects the absorption of the med) Which tabs should not be crushed? Enteric Coated/sustained release tabs Can nurses adjust or change a patients medication? NO (only the Doctor can do this) T/F Patients should consult a doctor before taking OTC or any herbal preparations? True Can Abandonment charges be filed against nurses who walk out if staffing is inadequate? Yes Can nurses refuse to float? No, unless their Union contract states they only work in a specific area Do Nurses need to get their own Insurance against malpractice? YES Who issued the Patients Bill of Rights? American Hospital Association What is habeas Corpus, and can a mentally ill patient request it? Requesting a release from care/Yes they can T/F Catholics, Christians and Jehovah witness are the only religions that allow organ donations? True T/F Orthodox Judaism may allow organ donation with the Rabbis approval? True What are Incident reports used for? Identifying risk situations and Improving care Do Incident reports get filed in the Patients record? No What are the components of a medication prescription? Date/Time Med name Dosage Route Frequency Signature How is a Telephone medication order abbreviated? t.o Can a nurse sign or be a witness to a signature for a "Living Will" for her patient? No, must be signed by someone who isn't staff or be notarized What is managed care? Strategies used to reduce the cost of health care. T/F Case management involves collaboration with an Interprofessional health care team? TRUE What are the 5 types of leaders? 1) Autocratic-Dominates the group, maintains strong control and address problems with clearly defined tasks. 2) Democratic-Participative style, all members of the team should have input. 3) Laissez-faire-Passive, inactive and delegates responsibility to the group (Lazy) 4) Situational-Leads based on current circumstance/situation. 5) Bureaucratic-Leader believes that the team is motivated by EXTERNAL forces, relies on policies/procedures for decision making. What is Inter-personal and Intra-personal conflict? Intra-within a person Inter-within the group When does discharge planning begin? When patient is admitted What is Priority 1, 2, and 3 of the Emergency room triage? Priority 1-Emergent (Chest pain, respiratory distress, major arterial bleed, chemical splashes to the eye) Priority 2-Urgent (Not life-threatening, unless not treated within 1-2 hours, eval every 30-60 mins) Priority 3-Minor issues, eval every 1-2 hours) What is Phlebitis? Inflammation of a vein [Show Less]
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