Nclex

After receiving a report from the night nurse, which of the following clients should the nurse see FIRST?

• A 31-year-old woman refusing sucralfate before breakfast

• A 40-year-old man with left-sided weakness asking for assistance to the commode

• A 52-year-old woman complaining of chills who is scheduled for a cholecystectomy

• A 65-year-old man with a nasogastric tube who had a bowel resection yesterday

A client tells the nurse that she is allergic to eggs, dogs, rabbits, and chicken feathers. Which order should the nurse question?

• TB skin test

• Rubella vaccine

• ELISA test

• Chest X-ray

Which of these assessment findings should the healthcare provider expect to identify as an early clinical characteristic of multiple sclerosis (MS)?

• Vision loss

• Dementia

• Muscle atrophy

• Clonus

Which interventions are most likely to promote maximum self-care for a patient recovering from a stroke? Select all that apply.

• Encourage participation in activities of daily living

• Educate patient on risks of repeat stroke

• Assess neurological function every shift.

• Assist patient to track motor function and mobility levels

• Provide adaptive equipment as indicated

The physician orders tobramycin sulfate 3 mg/kg IV every 8 hours for a 3-year-old boy. The nurse enters the client’s room to administer the medication and discovers that the boy does not have an identification bracelet. Which of the following should the nurse do?

• Ask the parents at the child’s bedside to state their child’s name.

• Ask the child to say his first and last name

• Have a coworker identify the child before giving the medication

• Hold the medication until an identification bracelet can be obtained

A 50-year-old male client comes to the nurses’ station and asks the nurse if he can go to the cafeteria to get something to eat. When told that his privileges do not include visiting the cafeteria, the client becomes verbally abusive. Which of the following approaches by the nurse would be MOST effective?

• Tell the client to lower his voice, because he is disturbing the other clients

• Ask the client what he wants from the cafeteria and have it delivered to his room

• Calmly but firmly escort the client back to his room

• Assign the nursing assistive personnel (NAP) to accompany the client to the cafeteria

The nurse delivers external cardiac compressions to a client while performing cardiopulmonary resuscitation (CPR). Which of the following actions by the nurse is BEST?

• Maintain a position close to the client’s side with the nurse’s knees apart.

• Maintain vertical pressure on the client’s chest through the heel of the nurse’s hand.

• Re-check the nurse’s hand position after every 10 chest compressions.

• Check for a return of the client’s pulse after every 8 breaths by the nurse.

The results of an adult patient’s blood pressure screening on three occasions are 120/80 mmHg, 130/76 mmHg, and 118/86 mmHg. How will the healthcare provider interpret this information

• Normal blood pressure

• Hypertension Stage 2

• Hypertension Stage 1

• Prehypertension

The healthcare provider is assessing a patient using the Global Assessment of Functioning (GAF) scale. Which of these patient characteristics will the GAF measure?

• Overall physical health status

• Performance of activities of daily living without pain

• Ability to have friends and keep a job

• Current nutritional and hydration status

A patient with a diagnosis of lung cancer is receiving chemotherapy and reports nausea and loss of appetite resulting in decreased food intake. What should the healthcare provider recommend to promote adequate nutrition? Advise the patient to:

• Eat small meals throughout the day

• Eat only when feeling hungry

• Eat only favorite foods to increase appetite

• Eat large meals but less frequently throughout the day