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The nurse discovers that client lying face down on the floor. Which action does the nurse take first? a. Assess the patency of the client's airway b. Determine whether the client is responsive c. Check the client's carotid pulse d. Reposition the client onto the back B A nurse works 3 weeks at a 100-bed suburban hospital after working several months at a 40-bed rural hospital. The nurse prefers the total client care delivery system that was used at the rural hospital, rather then the team leading system of client care that is used at the suburban hospital. Which action does the nurse take? a. Works with in the system at the hospital to change the type of client care delivery b. Discuss his thoughts about the type of client care delivery system with the nurses supervisor c. Asks the nurses peers why this type of client care delivery system is used d. Suggests a change in the type of client care delivery system to the director of nursing B The nurse cares for the client diagnosed with a left traumatic below knee amputation (BKA) with a tourniquet in place. The client also has a tear from the perineum to the rectum. Which action is the nurse take first?
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a. Apply anti-shock trousers b. Assesses the clients level of consciousness c. Remove the tourniquet d. Check the client's blood pressure and pulse D During morning rounds, the client diagnosed with schizophrenia tells the nurse, "I know you are conspiring with my spouse to keep me locked away." Which statement by the nurse is the most appropriate? a. "What makes you think your spouse is trying to hide your existence?" b. "Are you saying that you think your spouse doesn't love you?" c. "I can see that you are frightened about being here but I am a nurse in a hospital." d. "I'm not conspiring with your spouse. I first met your spouse when you are admitted to the hospital." c During a routine prenatal visit, the nurse auscultates the fetal heart rate (FHR). If the fetal position is left sacrum posterior (LSP), at which site does the nurse expect to find the fetal heart (FHT)? a. Below umbilicus, on the mothers right b. Below umbilicus, on the mothers left c. Above umbilicus, on the mothers left d. Above umbilicus, on the
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b. The clients blood pressure is 100/60 mmHg c. The clients serum theophylline level is 25 mcg/mL d. The client is sleepy C The nurse teaches the client about the schedule cardiac catheterization. Which statement, if made by the client to the nurse, indicates that the teaching was effective? a. "I understand that there is little or no risk associated with this procedure." b. "I may experience a little pounding sensation in my chest during the procedure." c. "I will be in and out of the procedure room in about 30 minutes." d. "I will be able to walk in the hall soon after the procedure is completed." B During the second stage of labor, the client's partner asks the nurse, "Can I go get a cup of coffee from the cafeteria?" Which response by the nurse is best? a. "I will get you a cup of coffee." b. "It would be best if you stayed here at this time." c. "Ask your partner if it is acceptable to leave." d. "Why do you want to leave the room?" B The nurse observes a nursing assistive personnel (NAP) enter the room
NUR 192 Kaplan Diagnostic A TEST NCLEX latest
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of the client diagnosed with tuberculosis (TB) to provide morning care. Which observation, if you made by the nurse, does not require an intervention? a.The NAP enters the room while wearing goggles and a hair covering b. That NAP enters the room while wearing a mask and sterile gloves c.The NAP enters the room while wearing a gown and clean gloves d. The NAP enters the room while wearing a particulate respirator and a gown D The nurse teaches the client about ferrous sulfate. Which statement by the client indicates to the nurse that the client understands the education? a. "I should take this medication when I take my antacid."
NUR 192 Kaplan Diagnostic A TEST NCLEX latest
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16.The adolescent receives 10 units of intermediate-acting insulin every morning at 0700. If the client requires the insulin dosage reduced, the nurse expects the client to present with which symptom? a.Declines lunch at 1200 b.Reports hunger at 0900 c.Experiences confusion at 1600 d.Becomes sleepy at 2100 C The nurse discovers the client in the bathroom attempting self-harm. Which action does the nurse take first? a. Removes the client from the bathroom and escorts the client to the bedroom b. Stays with the client and continually monitors for self-destructive behaviors c. Initiates a discussion with the client concerning reasons for self-harm d. Distracts the client from trying to hurt self by talking about the family. B The nurse admits a 2-month-old infant for surgical correction of hypospadias. Which assessment does the nurse complete? a. Check this scrotal sac and palpate the testes b. Inspect the position of the urinary meatus
NUR 192 Kaplan Diagnostic A TEST NCLEX latest
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c. Obtained a urine sample for analysis d. Measure intake and output hourly B The patient of an 18 month old toddler ask the nurse, (Which toy is most appropriate for my child?) The nurse from recommend which toy? a. A story book b. A stuffed animal
NUR 192 Kaplan Diagnostic A TEST NCLEX latest
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22.The parents of the 18 month old toddler with a fractured femur visits with the child in the hospital. The parents say they must go home, the child screams, cries, and hits the parents. Which statement does the nurse suggest the parents tell the child? a."We will return in a little while." b."We will come back at 1000 hours." c."We will return when the sun comes up." d."We will come back as soon as we can." C 23.The nurse supervises a nursing assistive personnel (NAP) caring for the client after abdominal surgery. Which observation requires an intervention by the nurse? a. The NAP massages the client's leg using long, firm strokes b. The NAP massages the client arms using smooth, gentle strokes c. The NAP assist the client to put the joints through range of motion exercises d. The NAP positions the client side-lying and applies lotion to the back A The nurse cares for the client diagnosed with anorexia nervosa. Which goal is the highest priority initially? a. Stabilize the clients weight
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b. Encourage the client to gain insight about body image c. Maintain the clients fluid and electrolyte balance d. Increase the clients caloric intake C
- The nurse administers medications to the client diagnosed with bipolar disorder. The client approaches the nurse and begins to throw things. Which action does the nurse take? a. Get another nurse to assist with the client b. Give the client the medications, so the client will calm down c. Admonishes the client, and suggested the client collect self d. Sits down and asks the client what is bothering the client
NUR 192 Kaplan Diagnostic A TEST NCLEX latest
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and last name B The nurse changes the dressing on a client two days after a bowel resection. After opening a sterile pack and putting on the sterile gloves at the clients bedside, the nurse notes the dressing needed for the dressing change are missing. Which action does the nurse take next? a.Remove the gloves, obtained the missing dressings, and replaces the clubs to continue with the procedure b.Closes the pack, obtained the missing dressing and new gloves, and reopen the pack to continue with procedure c.Presses the call light, ask the nurse assistive personnel to bring the missing dressings to the clients room, and then continues with the procedure d.Remains in place at the clients bedside while the nursing assistive personnel obtains the missing dressings, and then continues with the procedure D
- The client receives parenteral nutrition (PN) via the internal jugular vein. Which action does the nurse take if the next container of PN solution is not available when it is needed? a. Slows down the PN infusion until the new solution is available b. Hangs a container of 0.9% NaCl until the new solution is available c. Hangs a container of 10%
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D/W until the new solution is available d. Uses a heparin lock until the new solution is available C The nurse cares for the client with a history of chronic alcohol abuse, nutritional problems, and confabulation. In planning for the clients nursing care, which action is the first priority of the nurse? a.Restrict visitors to minimize environmental stimuli b.Provide a high-calorie, high- protein diet as ordered c.Start a intravenous line of D5W with thiamine as ordered d.Monitor behaviors for documentation of confabulation C The nurse cares for the school- aged Child diagnosed with cystic fibrosis (CF). The healthcare provider orders aerosol therapy. The nurse knows which is the expected outcome? a.The child's appetite improves b. The child displays no evidence of infection
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The nurse cares for the client diagnosed with a left tibia fracture. The client has a long - leg walking cast applied. Several hours later, the client states, "I can't feel my toes." It is most important for the nurse to take a which action? a. Ask the client to wiggle the toes b.Observe the foot for edema c. Assess the clients femoral pulse d.Check the skin temperature of the foot D
- The charge nurse notes that during a staff meeting designed to discuss client care concerns, a nurse that is a non-native speaker of English remains silent. Which action does the charge nurse take? a. Require all the nurses at the meeting to verbalize their thoughts about the topic under discussion b. Allow extra time during the meeting for questions and summarize the discussion of the group c. Take the none-native nurse a side after the meeting and restate the major conclusions of the discussion d. Check with the non-native nurse before the conclusion of the discussion to see if the discussion topics were understood B The nurse cares for the client with a chest tube attach to a three-chamber water sealed drainage system. While attempting to get out of bed, the
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client accidentally disconnect the chest tube from the water-seal drainage system. Which action does the nurse take first? a.Inserts the end of the chest tube in a container of sterile saline solution b.Clamps the chest tube near the water- seal drainage system c. Applies a dressing to the chest tube insertion site d.Obtains a new water- seal drainage system A The nurse teaches the client, scheduled for a total right hip arthroplasty, preoperatively. Teaching includes postoperative exercises. Which exercise, if perform by the client, indicates further teaching is necessary? a.The client performs straight leg lifts
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property of the hospital B 40.The nurse cares for a client diagnosed with primary adrenocorticol insufficiency. The nurse expects to observe which laboratory finding? a.Decreased sodium and glucose; increased potassium b.Decrease sodium and potassium; increased glucose c.Increased sodium and potassium; decreased glucose d.Increased sodium and glucose; decreased potassium A The nurse works with the client who has a history of alcoholism. Which statement, if made by the client to the nurse, indicates that the client has gained some insight into alcoholism? a."I know I can stop drinking if I put my mind to it." b."For the sake of my family, I will never drink again." c."I know this is a lifelong problem, and I'll need continued support." d."I know that Alcoholics Anonymous (AA) is available in case the problem gets worse." C The parent arrives from overseas to visit. The child discovers the parent depressed, disheveled, and suspicious of family members. The nurse include which nursing order in the care plan? a.Encourage family involvement in clients treatment.
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b.Involve the local international community and the clients care c.Set limits on family visits until the client is stable d. Assign the client to structured group activity A 43.The home health nurse changes dressings four times a week for the client diagnosed with stage III pressure ulcer. The hospital admitting nurse notes that the dressing was not applied as ordered. Which action is most important for the nurse to take? a. Contact the nursing supervisor in the hospital to report the discrepancy b. Contact the home health nurse who has been caring for the client to report the discrepancy c. Contact the home health supervisor to report the discrepancy X-d. Document the discrepancy between what was ordered and the condition of the dressing
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