NCLEX QUESTIONS

The nurse in a longterm care facility is making client care assignments for unlicensed assistive personnel (UAP). Which of the following statements by the nurse would provide the UAP with the best directions about the assignment?

• "Encourage the client to increase daily fluid intake>"

• "Ambulate the client 20 ft (6.7m) every 4 hours beginning at 0900".

• "Assist the client to perform passive range-of-motion (ROM) exercises."

• "Reinforce physical therapy instructions about the proper use of a walker".

Answer explanation

Ambulating the client 20 feet every f 4 hours beginning a 0900 is a direct report and is the best directions provided here.

The nurse is reinforcing teaching with a client who is using a mechanical lift. Which of the following information should the nurse reinforce?

• "Place you hands on the sling".

• "You should lie prone on the sling".

• "Place your arms across your chest".

• "You will need to rock to a standing position".

The nurse is reinforcing teaching with a client about the signs of hunger in a newborn. Which of the following signs should he nurse reinforce?

Select all that apply.

• open hands

• quivering bottom lip

• rooting movements

• sucking on the hands

• hand-to-mouth movements

The nurse is assisting to evaluate the coping strategies of the spouse of a client who had a stroke 5 days ago. Which of the following statments by the spouse would indicate ineffective coping?

• " I sleep only short periods of time since my spouse became ill".

• " I feel frustrated when my spouse turns away and will not talk with me".

• :" I eat my mealsmin my spouse's room so my spouse will not have to eat meals alone".

• " I have been performing a few household chores each day before visiting my spouse".

The nurse is reinforcing teaching with a client about using crutches . Which of the following information should the nurse reinforce?

• " The stairs should be avoided while using crutches".

• " The elbows must stay straight while ambulating with crutches".

• "Three finger widths should separate the axillae and the crutches".

• " Bearing weight on the affected leg should be avoided when using the 4-point crutch gait".

The nurse has reinforced teaching with a client with schizophrenia who is receiving prescribed olanzapine. Which of the following statements by the client would indicate a correct understanding of the teaching?

• "The medication may cause a dry mouth and or metallic taste".

• " I should consume a low -residue diet while taking olanzapine".

• "Restlessness and agitation are common side efects of olanzapine".

• " I will have a blood specimen obtained to monitor the therapeutic level of the medication".

The nurse is caring for a client with peptic ulcer disease (PUD) who vomited 150 mL of blood-tinged green liquid. Which of the client's laboratory test results would be priority to check?

• serum pH

• hematocrit (HCT)

• serum sodium level

• blood urea nitrogen (BUN) level

The nurse is talking with a client who had a subtotal gastrectomy 1 month ago. Whcih of the following statements by the client would be a priority to follow up?

• " I occasionally take over-the-counter (OTC) laxatives."

• "I eat several small meals each day."

• " I avoid drinking liquids with my meals".

• " I feel tired all the time ."