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NCLEX Guide
A nurse is conducting health promotion education regarding contraindications to combination oral contraceptive use to a group of women. Which of the following conditions should the nurse include in the teaching?
Hypertension
A nurse is providing teaching to a client who has a depressive disorder and a new prescription for amitriptyline. Which of the following statements by the client indicates understanding of the teaching?
"I know it will be a couple of weeks before the medication helps me feel better."
A nurse is caring for a client who is immobile. Which of the following interventions is appropriate to prevent contracture?
Align a trochanter wedge between the client's legs.
A nurse is assessing a client who is postoperative following abdominal surgery and has an indwelling urinary catheter that is draining dark yellow urine at 25 mL/hr. Which of the following interventions should the nurse anticipate?
Obtain a urine specimen for culture and sensitivity
A nurse is reporting a client's laboratory tests to the provider to obtain a prescription for the client's daily warfarin. Which of the following laboratory tests should the nurse plan to report to obtain the prescription for the warfarin?
INR
A nurse is assessing a client who is taking haloperidol and is experiencing pseudoparkinsonism. Which of the following findings should the nurse document as a manifestation of pseudoparkinsonism?
Shuffling gait
A nurse is caring for a client who is experiencing expressive aphasia and right hemiparesis following a stroke. Which of the following actions by the nurse best promotes communication among staff caring for the client?
Having interdisciplinary team meetings for the client on a regular basis.
A nurse is caring for a 2-year-old toddler. Which of the following food choices should the nurse recommend to promote independence in eating?
Banana slices
Wear loose fitting underwear.
A nurse is caring for an infant who has gastroenteritis. Which of the following assessments findings should the nurse report to the provider?
Sunken fontanels and dry mucous membranes.
A nurse on a medical-surgical unit is notified that a mass casualty event has occurred in the community. Which of the following actions should the nurse plan to take?
Recommend to the provider specific acute care clients for discharge.
A nurse is receiving change-of-shift report for four clients. Which of the following clients should the nurse assess first?
A client who was just given a glass of orange juice for low blood glucose level.
A nurse is performing postmortem care for a recently deceased client prior to the client's family visit. Which of the following actions should the nurse plan to take?
Hold the client's eyes shut for a few seconds.
A nurse is admitting a client who has schizophrenia. The client states, "I'm hearing voices." Which of the following responses is the priority for the nurse to state?
"What are the voices telling you?"
A nurse is administering furosemide IV bolus to a client who has fluid volume excess. The nurse should recognize which of the following as an indication that the medication has been effective?
Weight loss
A nurse is caring for a client who requires nasotracheal suctioning. Identify the sequence the nurse should follow to perform suctioning.
- Turn on the suction and set the pressure.
- Don sterile gloves.
- Insert the catheter during the client's inspiration.
- Apply suction while rotating the catheter.
- Rinse the catheter to remove secretions.
A parish nurse is leading a support group for clients whose family members have committed suicide. Which of the following strategies should the nurse plan to use during group sessions?
Initiate a discussion with clients about ways to cope with changes in family dynamics.
A nurse is developing a care plan for a client who is in Buck's traction and is scheduled for surgery for a fractured femur of the right leg. Which of the following interventions should the nurse delegate to an assistive personnel?
Remind the client to use the incentive spirometer.
A nurse is caring for a client who repeatedly refuses meals. The nurse overhears an assistive personnel (AP) telling the client, "If you don't eat, I'll put restraints on your wrists and feed you." The nurse should intervene and explain to the AP that this statement constitutes which of the following torts?
Assault
A nurse is teaching a client who has a new diagnosis of diabetes mellitus about foot care. Which of the following instructions should the nurse include in the teaching?
Wear clean cotton socks every day.
A nurse is preparing to feed a newly admitted client who has dysphagia. Which of the following actions should the nurse plan to take?
Sit at or below the client's eye level during feedings.
A nurse is caring for a client who has acute glomerulonephritis. Which of the following findings should the nurse expect?
Hematuria
A nurse is caring for a client whose partner recently died. The nurse sits with the client to provide comfort. Which of the following ethical principles is the nurse demonstrating?
Beneficence
A nurse in an emergency department is caring for a child who reports being sexually assaulted by a family member. Which of the following actions should the nurse take?
Explain to the child what will happen when the abuse is reported.
A nurse is providing discharge teaching to a client who is postoperative following the surgical repair of a detached retina. Which of the following statements by the client indicates an understanding of the teaching?
"I should bend at the waist when putting on my shoes."
A nurse is providing discharge teaching about home care of a surgical incision to a client who speaks a different language from the nurse. The nurse is communicating with the client using an interpreter. Which of the following actions should the nurse take?
Speak directly to the client.
A nurse is providing teaching to a client who has a new prescription for enoxaparin. Which of the following medications for pain relief should the nurse include in the teaching that can be taken concurrently with enoxaparin?
Acetaminophen
A nurse is receiving change-of-shift report for a group of clients. Which of the following clients should the nurse plan to assess first?
A client who has a hip fracture and a new onset of tachypnea.
A nurse is performing a skin assessment on a client who has dark skin. Which of the following locations on the clients body should the nurse observe to assess cyanosis?
Palms of the hands
A charge nurse is teaching staff members about factors that increase a client's risk to become violent. Which of the following risk factors should the nurse include as the best predictor for future violence?
Previous violent behavior
A nurse is assessing a client who is in active labor. Which of the following findings should the nurse report to the provider?
FHR baseline 170/bpm
A quality control nurse is reviewing medication prescriptions for a group of clients. Which of the following prescriptions should the nurse identify as being complete?
Digoxin 0.25 mg PO daily
A nurse is providing an in-service about client evacuation during a fire. Which of the following clients should the nurse instruct the staff to evacuate first?
A client who is ambulatory and receiving oxygen.
A nurse is assessing a child who has bacterial pneumonia. Which of the following manifestations should the nurse expect?
Malaise
A nurse is planning care for a client who is scheduled for a thoracentesis. Which of the following actions should the nurse plan to take?
Instruct the client to avoid coughing during the procedure.
A nurse is assessing a 2-year-old toddler. Which of the following findings should the nurse expect?
Non tender, protruding abdomen
A nurse manager is updating protocols for the use of belt restraints. Which of the following guidelines should the nurse manager include?
Document the client's condition every 15 minutes.
A nurse in a PACU is transferring care to a nurse on the medical-surgical unit. Which of the following statements should the nurse include in the hand-off report?
"The estimated blood loss was 250 mL's"
A nurse in an emergency department is caring for a client who has a closed head injury. Which of the following actions should the nurse take first?
Determine the client's Glasgow Coma Scale score.
A nurse in an emergency department is caring for a client following a motor- vehicle crash. The client's Glasgow Coma Scale rating is 15. Which of the following findings should the nurse expect?
The client is oriented times three.
A nurse is reviewing a client's cardiac rhythm strips and notes a constant P-R interval of 0.35 seconds. Which of the following dysrhythmias is the client displaying?
First degree atrioventricular block
A nurse is caring for a client who has end-stage kidney disease. The client's child asks the nurse about becoming a living donor for their parent. Which of the following conditions in the child's medical history should the nurse identify as a contraindication to the procedure?
Hypertension
A nurse is auscultating for crackles on a client who has pneumonia. Where should the nurse auscultate?
The right upper quadrant of the abdomen.
A nurse is teaching about immunizations to a client who is pregnant. Which of the following statements should the nurse include in the teaching?
"You can receive the immunization for influenza at anytime during your pregnancy."
A nurse is planning teaching for a client and their family about home oxygen therapy. Which of the following information should the nurse plan to include in the teaching?
Avoid using nail polish remover around the client.
A nurse is instructing a school-age client who has asthma about the use of a peak expiratory flow meter. Which of the following instructions should the nurse include in the teaching?
"Blow into the meter as hard and quickly as possible."
A nurse is caring for a client who is 12 hours postoperative and has a third-degree perineal laceration. The client reports not having a bowel movement for 4 days. Which of the following medications should the nurse administer?
Magnesium hydroxide 30 mL PO
A nurse is providing discharge teaching to the parents of a toddler who has cystic fibrosis. Which of the following instructions should the nurse include?
"Perform chest percussion and postural drainage at least twice daily."
A nurse is caring for a client who has an implanted venous access port. Which of the following should the nurse use to access the port?
A non-coring needle
A nurse is assessing a client immediately following a cardiac catheterization. The nurse should notify the provider for which of the following findings?
Hematoma over the insertion site.
A nurse is assessing a client who has preeclampsia and is receiving magnesium sulfate via continuous IV infusion. For which of the following therapeutic effects should the nurse monitor the client?
Deep tendon reflexes of 2+
Herpes zoster
A nurse is planning care for a client who has a prescription for a bowel-training program following a spinal cord injury. Which of the following actions should the nurse include in the plan of care?
Administer a cathartic suppository 30 minutes prior to scheduled defecation times.
A nurse is admitting a client who is hesitant to create advanced directive due to concerns about affording legal representation. Which of the following statements should the nurse make?
"Advanced directives can be a verbal agreement between you and your provider until legal review can be obtained."
A nurse is preparing to insert an IV catheter for a client. Which of the following actions should the nurse plan to take?
Elevate the client's arm prior to insertion.
A nurse in an emergency department is assessing an adolescent who has conduct disorder. Which of the following questions is the priority for the nurse to ask the client?
"Do you have thoughts of harming yourself?"
A nurse is caring for a school-age child who is postoperative and received morphine via IV bolus for pain 10 minutes ago. Which of the following findings is the nurses priority?
Bradypnea
A nurse is planning to teach a client about taking prednisone. Which of the following instructions should the nurse include?
Increase dietary calcium
A nurse is caring for a client who is receiving penicillin G via IV piggyback. Which of the following actions should the nurse take?
Instruct the client o notify the provider if diarrhea develops.
A nurse is planning care for a school-age child who is 4 hours postoperative following appendicitis. Which of the following actions should the nurse include in the plan of care?
Administer analgesics on a scheduled basis for the first 24 hours.
