NCLEX RN uworld #09 QUESTIONS AND ANSWERS ALL CORRECT
The nurse should assess the client with _______________ activity first. This client is at
... [Show More] increased risk for injury, aspiration, and airway obstruction.
#71941465 (10) Correct Answer: seizure
The nurse is admitting a client with heart failure related fluid overload. Which ACTION should the nurse complete "FIRST"? #71941465 (11)
1. Administer oxygen
2. Assess the client's breath sounds
3. Initiate cardiac monitoring
4. Insert a peripheral IV catheter. Correct Answer: 2
A young adult with obesity comes to the free clinic for a 2 week post antibiotic follow-up visit for a superficial abdominal skin abscess. The client has a history of major depressive disorder and was hospitalized twice in the past 6 months for ATTEMPTED SUICIDE. The client now reports feeling"EMOTIONALLY UPSET, alone and a the end of my rope." due to difficulty finding a job and inability to qualify for medical insurance. The client is currently prescribed fluoxetine but has not been able to follow up with the prescribing health care provider (HCP). What is the "PRIORITY" nursing diagnosis (ND) at this time? #71941465 (12)
1. Hopelessness
2. Ineffective coping
3. Risk for infection
4. Risk for suicide Correct Answer: 4
The nurse at the radiological imaging center is admitting a client for an MRI of the right knee. Which information obtained by the nurse should be reported IMMEDIATELY to the prescribing health care provider? #71941465 (13)
1. The client ate a full breakfast that morning
2. The client has an implantable cardioverter defibrillator.
3. The client is allergic to providone-iodine
4. The client took all prescribed cardiac medications before arriving. Correct Answer: 2
In the emergency department, a pediatric client is placed on mechanical ventilation by means of an endotracheal tube. Several hours later, the nurse enters the room and finds the client in respiratory distress. It is "MOST IMPORTANT" for the nurse to take which of these actions? #71941465 (14)
1. Assess the client for intercostal retractions
2. Assess the client's blood pressure in both arms
3. Auscultate the client's lung sounds
4. Observe the color of the client's fingernails beds. Correct Answer: 3
A client is suspected of having GRAVE'S DISEASE (hyperthyroidism). Which signs and / or symptoms are EXPECTED to be present in this client. "SELECT ALL THAT APPLY" #71941465 (15)
1. Anxiety
2. Bradycardia
3. Dry skin
4. Heart palpitation
5. Protrusion of the eyeballs
6. Weight gain Correct Answer: 1,4,5
refers to a sustained hyperfunctioning of the thyroid gland due to an increase in thyroid hormones (T3 and T4), It causes symptoms with a high metabolic rate, including weight loss, heart palpitations, heat intolerance, anxiety , hand tremors and insomnia. #71941465 (15) Correct Answer: Hyperthyroidism
The nurse receives notification from the telemetry room that a client appears to be in ventricular fibrillation (VF). The nurse immediately goes to the client's room and finds the client unresponsive and pulseless. Place the intervention in the "APPRO-
PRIATE ORDER. ALL OPTIONS MUST BE USED.
#71941465 (16)
1. Administer IV epinephrine 1 mg push
2. Initiate cardiopulmonary resuscitation
3. Call the emergency response team
4. Defibrillate the client at 200 joules
5. Administer intravenous (IV) amiodarone 300 mg push Correct Answer: 3,2,4,1,5
The nurse reviews the most current laboratory results clients. Which result should the nurse report to the health care provider "IMMEDIATELY"?
#71941465 (17)
1. Client who has cellulitis of the leg with a white blood cell (WBC) count of 13,000
2. Client who has chronic kidney injury with hematocrit 0f 28% and hemoglobin of 9 g/dL.
3. Client who has type 2 diabetes mellitus with a 2 hour postprandial serum glucose of 165 mg/dL
4. Client who is 1 month post kidney transplant with a urinalysis showing WBCs and bacteria. Correct Answer: 4
A nurse is assisting a new mother as she is breastfeeding her infant. The infant has been diagnosed with TETRALOGY OF FALLOT. During feeding, the infants becomes cyanotic and is having difficulty of breathing. What should be the nurse's"FIRST" action ? #71941465 (18)
1. Administer morphine to the infant.
2. Administer oxygen via mask
3. Assess the infant's vital signs and pulse oximetry.
4. Place the infant in the knee-chest position. Correct Answer: 4
is a congenital cardiac defect that typically has 4 characteristics pulmonary stenosis, right ventricular hypertrophy, overriding aorta and ventricular septal defect. #71941465 (18) Correct Answer: Tetralogy of Fallot
The school nurse creates a cafeteria menu for a newly enrolled child with celiac disease. Which lunches would be APPROPRIATE for this child. "SELECT ALL THAT APPLY" #71941465 (19)
1. Beef barley soup with mixed vegetables and French bread.
2. Grilled chicken, baked potato, and strawberry yogurt.
3. Mexican corn tacos with ground beef and cheese
4. Peanut butter and jelly on rice cakes with an oatmeal cookie.
5. Rice noodles with chicken and broccoli. Correct Answer: 2,3,5
The nurse is assessing for the presence of jugular venous distension (JVD) on a newly admitted client with a history of heart failure. Which is the "BEST" position for the nurse to place the client in when observing for JVD? #71941465 (20)
1. Head of the bed elevated to a 45 degree angle
2. Head of the bed elevated to a 60 degree angle
3. Head of the bed elevated to a 90 degree angle
4. Head of the bed flat Correct Answer: 1
The nurse should consider which of the following client reports as an indication of an ALLERGIC REACTION? #71941465 (21)
1. "I can't eat broccoli or cabbage when I take warfarin."
2. "I get a headache when using my nitro-
glycerin patch."
3. "My feet swell when I take felodipine."
4. "My lips swell when I eat bananas or avocados." Correct Answer: 4
is suspected when there is a food allergy to banana, kiwis, or avocados. #71941465 (21) Correct Answer: Latex allergy
The nurse prepares to administer morning medications to assigned clients. Which prescription should the nurse CLARIFY with the health care provider? #71941465 (22)
1. Clopidogrel for client with history of stroke and platelet count of 154,000/mm
2. Losartan for client with hypertension who is 8 weeks pregnant.
3. Prednisone for client with herpes simplex lesions and bells palsy.
4. Tiotropium for client with pneumonia and chronic obstructive pulmonary disease. Correct Answer: 2
presents as acute onset of unilateral facial paralysis related to inflammation of the facial nerve (ie. cranial nerve V11) that may be triggered by a viral illness (eg. herpes simplex virus. ) Standard treatment includes corticosteroids ( eg. prednisone) within 72 hours of symptom onset.
#71941465 (22) Correct Answer: Bell palsy
is an ace inhibitors have black box warnings that indicate contraindication in pregnancy.
#71941465 (22) Correct Answer: Losartan
The evening shift nurse reviews the preoperative checklist and latest serum laboratory values for an elderly client with a ruptured DIVERTICULUM who is scheduled for surgery in the early morning. Which laboratory value is "MOST IMPORTANT" for the nurse to report to the health care provider?"
#71941465 (23)
1. Creatinine level 2.5 mg/dL
2. Potassium level of 3.5 mEq/L
3. Sodium level 134 mEq/L
4. White blood cell count 16,000/mm Correct Answer: 1
An elevated __________________ level preoperatively increases the risk for postoperative kidney injury. #71941465 (23) Correct Answer: serum creatinine [Show Less]