You are the charge nurse. A client with chronic pain reports to you that the nurses have not been responding to requests for pain medication. What is your
... [Show More] initial action?
A. Check the medication administration records (MARs) for the past several days.
B. Ask the nurse educator to provide in-service training about pain management.
C. Perform a complete pain assessment on the client and take a pain history.
D. Have a conference with the nurses responsible for the care of this client.
2. Which client is most likely to receive opioids for extended periods of time?
A. A client with fibromyalgia
B. A client with phantom limb pain in the leg
C. A client with progressive pancreatic cancer
D. A client with trigeminal neuralgia
3. A 56-year-old patient comes to the walk-in clinic reporting scant rectal bleeding and intermittent diarrhea and constipation for the past several months. There is a history of polyps and a family history of colorectal cancer. While you are trying to teach about colonoscopy, the patient becomes angry and threatens to leave. What is the priority diagnosis?
A. Diarrhea/ Constipation related to altered bowel patterns
B. Deficient Knowledge related to the disease process and diagnostic procedure
C. Risk for Deficient Fluid Volume related to rectal bleeding and diarrhea
D. Anxiety related to unknown outcomes and perceived threats to body integrity
4. As the charge nurse, you are reviewing the charts of clients who were assigned to the care of a newly graduated RN. The RN has correctly charted dose and time of medication, but there is no documentation regarding non-pharmaceutical measures. What action should you take first?
A. Make a note in the nurse's file and continue to observe clinical performance.
B. Refer the new nurse to the in-service education department.
C. Quiz the nurse about knowledge of pain management and pharmacology.
D. Give praise for correctly charting the dose and time and discuss the deficits in charting.
5. A nurse is caring for a patient who is unstable and requires vital signs measured every 15 minutes by an electronic blood pressure machine. The nurse notices the machine begins to measure the blood pressure at varied intervals and the readings are inconsistent. Which of the following actions should the nurse take?
A. Turn on the machine every 15 minutes to measure the patient’s blood pressure.
B. Record only blood pressures needed at the required 15 minute intervals.
C. Obtain automatic and manual readings and compare them.
D. Disconnect the machine and measure the blood pressure manually every 15 minutes.
6. The nurse is preparing to perform mouth care for an unresponsive patient. Which of the following actions should the nurse plan to take?
A. Place the patient supine.
B. Keep both side rails up.
C. Raise the level of the bed.
D. Inspect the patient’s mouth using a finger sweep.
7. A nurse is inserting an IV catheter for a patient that results in blood spill on her gloved hand. The patient has no documented bloodstream infection. Which of the following actions should the nurse take?
A. Wash the gloved hands and then throw the gloves away.
B. Prepare an incident report to document the event.
C. Carefully remove the gloves and follow with hand hygiene.
D. Ask the provider to order a blood culture to determine the risk of infection.
8. A nurse is receiving a client from the PACU who is postoperative following abdominal surgery.Which of the following actions should the nurse take to transfer the patient from the stretcher to the bed?
A. Lock the wheels on the bed and the stretcher.
B. Instruct the patient to raise his arms above his head.
C. Elevate the stretcher 1in above the height of the bed.
D. Log roll the patient.
9. A nurse in the emergency department is assessing a patient who reports diarrhea and decreased urination for 4 days. Which of the following actions should the nurse take to assess the patient’s skin turgor?
A. Push a fingernail bed until it blanches, release it, and observe how long it takes the skin to become pink.
B. Grasp a skin fold on the chest under the clavicle, release it, and note whether it springs back.
C. Press the skin above the ankle for 5 seconds, release it, and note the depth of the impression.
D. Measure the skin fold thickness at the upper arm using a pair of calibrated skinfold calibers.
10. The nurse is caring for clients on a medical unit. Which task should the nurse implement first?
A. Change the abdominal surgical dressing for a client who has ambulated in the hall.
B. Discuss the correct method of placing Montgomery straps on the client with the UAP.
C. Assess the male client who called the desk to say he is nauseated and just vomited.
D. Place a call to the extended care facility to give the report on a discharged client.
11. The nurse is preparing a client diagnosed with peptic ulcer disease for a barium study of the stomach and esophagus. Which nursing intervention is the priority for this client?
A. Obtain informed consent from the client for the diagnostic procedure.
B. Discuss the need to increase oral fluid intake after the procedure.
C. Explain to the client that he or she will have to drink a white, chalky substance.
D. Tell the client not to eat or drink anything prior to the procedure.
12. Which client warrants immediate intervention from the nurse on the medical unit?
A. The client diagnosed with dyspepsia who has eructation and bloating.
B. The client diagnosed with pancreatitis who has steatorrhea and pyrexia.
C. The client with diverticulitis who has left lower quadrant pain and fever.
D. The client with Crohn’s disease who has right lower abdominal pain and diarrhea.
13. The nurse and the unlicensed assistive personnel (UAP) are caring for clients on a medical-surgical unit. Which task should not be assigned to the UAP?
A. Instruct the UAP to feed the 69-year-old client who is experiencing dysphagia.
B. Request the UAP change the linens for the 89-year-old client with fecal incontinence.
C. Tell the UAP to assist the 54-year-old client with a bowel management program.
D. Ask the UAP to obtain vital signs on the 72-year-old client diagnosed with cirrhosis.
14. Which behavior by the unlicensed assistive personnel (UAP) requires immediate intervention by the nurse?
A. The UAP is refusing to feed the client diagnosed with acute diverticulitis.
B. The UAP would not place the client on the bedside commode who was on bed rest.
C. The UAP placed the client with a continuous feeding tube in the supine position.
D. The UAP placed sequential compression devices on the client who is on strict bed rest.
15. The nurse is concerned about the documentation form for blood administration, and other staff members agree the documentation is cumbersome and needs to be revised. Which action is most appropriate for the nurse to implement first?
A. Discuss the blood administration flow sheet with the chief nursing officer.
B. Contact an individual to help design a new blood transfusion flow sheet.
C. Learn to adapt to the present form and do not take any further action.
D. Volunteer to be on an ad hoc committee to research alternate flow sheets.
16. The charge nurse is transcribing HCP orders for a client scheduled for a barium enema. In addition to the radiology department, which department of the hospital should be notified of the procedure?
A. The cardiac catheterization department.
B. The dietary department.
C. The nuclear medicine department.
D. The hospital laboratory department.
17. The charge nurse is making assignments on a medical unit. Which client should the nurse assign to the graduate nurse?
A. The client who has received three units of packed red blood cells (RBCs).
B. The client scheduled for an esophagogastroduodenoscopy in the morning.
C. The client with short bowel syndrome who has diarrhea and a K+level of 3.3 mEq/L.
D. The client who has just returned from surgery for a sigmoid colostomy.
18. Which client should the nurse assess first after receiving the p.m. shift assessment?
A. The client with Barrett’s esophagus who has dysphagia and pyrosis.
B. The client with proctitis who has tenesmus and passage of mucus through the rectum.
C. The client with liver failure who is jaundiced and has ascites.
D. The client with abdominal pain who has an 8-hour urinary output of 150 mL/hr.
19. The nurse on the cardiac unit has received the shift report from the outgoing nurse. Which client should the nurse assess first?
A. The client who has just been brought to the unit from the emergency department (ED) with no report of complaints.
B. The client who received pain medication 30 minutes ago for chest pain that was a level 3 on a 1-to-10 pain scale.
C. The client who had a cardiac catheterization in the morning and has palpable pedal pulses bilaterally.
D. The client who has been turning on the call light frequently and stating her care has been neglected.
20. The nurse on the cardiac unit is preparing to administer medications after receiving the morning change-of-shift report. Which medication should the nurse administer first?
A. The cardiac glycoside to the client who has an apical pulse of 58.
B. The loop diuretic to a client with a serum K+ level of 3.2 mEq/L.
C. The antidysrhythmic to the client in ventricular fibrillation.
D. The calcium-channel blocker who has a blood pressure of 110/68.
21. Which client should the telemetry nurse assess first after receiving the a.m. shift report?
A. The client diagnosed with deep vein thrombosis who has an edematous right calf.
B. The client diagnosed with mitral valve stenosis who has heart palpitations.
C. The client diagnosed with arterial occlusive disease who has intermittent claudication.
D. The client diagnosed with congestive heart failure who has pink frothy sputum.
22. The charge nurse is making assignments for clients on a cardiac unit. Which client should the charge nurse assign to a new graduate nurse?
A. The 44-year-old client diagnosed with a myocardial infarction.
B. The 65-year-old client admitted with unstable angina.
C. The 75-year-old client scheduled for a cardiac catheterization.
D. The 50-year-old client complaining of chest pain.
23. The charge nurse is making assignments for a 30-bed cardiac unit staffed with three registered nurses (RNs), three licensed practical nurses (LPNs), and three unlicensed assistive personnel (UAPs). Which assignment is most appropriate by the charge nurse?
A. Assign an RN to perform all sterile procedures.
B. Assign an LPN to give all IV medications.
C. Assign an UAP to complete the a.m. care.
D. Assign an LPN to write the care plans.
24. The nurse on a cardiac unit is discussing a client with the case manager. Which information should the nurse share with the case manager?
A. Discuss personal information the client shared with the nurse in confidence.
B. Provide the case manager with any information that is required for continuity of care.
C. Explain that client confidentiality prevents the nurse from disclosing information.
D. Ask the case manager to get the client’s permission before sharing information.
25. The nurse assesses erratic electrical activity on the telemetry reading while the client is talking to the nurse on the intercom system. Which task should the nurse instruct the UAP to implement?
A. Call a Code Blue immediately.
B. Check the client’s telemetry leads.
C. Find the nurse to check the client.
D. Remove the telemetry monitor.
26. The charge nurse on the cardiac unit has to float a nurse to the emergency department for the shift. Which nurse should be floated to the emergency department?
A. The nurse who has 4 years of experience on the cardiac unit.
B. The nurse who just transferred from critical care to the cardiac unit.
C. The nurse with 1 year of experience on the cardiac unit who has been on a week’s sick leave.
D. The nurse who has worked in the operating room for 2 years and in the cardiac unit for 3 years.
Lab Values to Know for NCLEX
Arterial Blood Gases (ABG’s)
pH: 7.35-7.45
PaO2: 80-100 mm Hg
PaCO2: 35-45 mm Hg
HCO3: 22-26 mEq/L
Oxygen Saturation - >95%
Cholesterol
Total Cholesterol: <200 mg/dL
HDL: Females: 35-80 mg/dL
HDL: Males: 35-65 mg/dL
LDL: <130 mg/dL
Triglycerides: <150 mg/dL
Complete Blood Count
WBC: 5,000 – 10,000 mg/uL
Platelets: 150,000 – 400,000 mm3
Hemoglobin: Females: 12-16 g/dL Males: 14-18 g/dL
Hematocrit: Females: 37-47% Males: 42-52%
Anticoagulation labs
PT (prothrombin time): 11-12.5 seconds (therapeutic: (for someone on warfarin) 1.5-2.5 times the normal range – 16-31 seconds)
aPTT (partial thromboplastin time): therapeutic range: 30 – 40 sec; for someone on heparin, it is 1.5-2 times the normal range: 45-80 seconds
INR (international normalized ratio): on warfarin: 2-3; no warfarin: 0.8-1.1
D-dimer: 0-250 ng/mL (may also be reported as positive or negative)
Fibrinogen levels: 170-340 mg/dL
Electrolytes
Sodium: 135-145 mEq/L
Potassium: 3.5-5 mEq/L
Chloride: 98-106 mEq/L
Calcium: 9-10.5 mg/dL
Magnesium: therapeutic: 1.3-2.1; someone on mg: 4-7
Phosphorus: 3.5-4.5
Liver Enzymes – Hepatic panel
AST (aspartate aminotransferase): 5-40 units/L
ALT (alanine aminotransferase): 8-20 units/L
ALP (alkaline phosphatase): 42-128 units/L
Amylase: 56-90 IU/L
Lipase: 0-110 units/L
Total bilirubin: 0-1 mg/dL
Albumin: 3.5-5 g.dL
Prealbumin:
Alpha-fetoprotein: <40 mcg/L
Kidney Function Tests
Ammonia: 15-110 mg/dL
BUN: 10-20 mg/dL
Serum creatinine: 0.6-1.2 mg/dL
Creatinine clearance: Females: 80-125 mL/min Males: 90-139 mL/min
Glomerular filtration rate (GFR): 125 mL/min
Urine specific gravity: 1.003-1.030
Diabetic testing
Fasting blood glucose: <110 mg/dL
Oral glucose tolerance test: <140 mg/dL
Glycosylated hemoglobin (HbA1c): 5% or less indicates absence of diabetes mellitus; 5.7%-6.4% indicates prediabetes mellitus; 6.5% or higher indicates diabetes mellitus
Thyroid test
T3: 70-205 ng/dL
T4: 4-12 mcg/dL
TSH: 0.4-6 microunits/mL [Show Less]