NCLEX practice

A nurse is caring for a hospitalized client with a diagnosis of CHF who suddenly complains of SOB and dyspnea. The nurse takes which immediate nursing action?

• Calls the physician

• Administers oxygen to the client

• Elevates the head of the client's bed

• Prepares to administer furosemide (Lasix)

A nurse caring for a client with an MI is helping the client fill out the diet menu request form. The nurse recommends that the client select which of the following beverages from the menu?

• Tea

• Cola

• Coffee

• Fruit juice

A client admitted to the hospital with coronary artery disease complains of dyspnea when at rest. The nurse determines that which of the following items would be of the most help to the client?

• Providing a walker to aid in ambulation

• Elevating the head of the bed to at least 45 degrees

• Performing continuous monitoring of oxygen saturation

• Placing an oxygen cannula at the bedside for use if needed

A nurse working in a long term care facility is assigned to care for four clients on the hospice unit. When planning client rounds, which client would the nurse collect data from first?

• The client who was complaining of severe back pain during the previous shift

• The client who is being discharged home today and will need assistance packing

• The client who is bed bound and needs to be turned and repositioned every 2 hours

• The client who needs assistance applying antiembolic stockings before ambulating to the dining room for breakfast

A nurse enters a client's room and finds the client slumped down in a chair. The client's breathing is shallow, and a pulse is present. Based on this data, the nurse determines that the priority would be to:

• Call the doctor immediately

• Have the secretary call a code blue

• Check the vital signs and level of consciousness

• Ask the unit clerk to call the family immediately

A nurse is caring for a client who has bipolar disorder with aggressive social behavior. Which of the following activities would initially be most appropriate for this client?

• Chess

• Writing

• Ping-pong

• Basketball

A nurse reinforces instructions to the parents of an infant with hip dysplasia regarding the care of the Pavlik harness. Which instruction provided by the nurse is accurate?

• The harness must be worn 8 hours a day

• The harness is removed to check the skin and for bathing

• The infant should never be moved when out of the harness

• The harness must be removed for feedings and diaper changes

A nurse is developing a plan of care for a client with Meniere's disease. The priority nursing interventions should focus on which of the following?

• Safety measures

• Dietary restrictions

• Activity limitations

• Knowledge about medication therapy