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NCLEX review E1

Total questions: 57

Worksheet time: 1hrs 20mins

Name
Class
Date
1.

A nurse is instructing a client on the use of an incentive spirometer. Which statement by the client indicates understanding?

a)

I will place the adapter on my finger to read my blood oxygen saturation level

b)

I will lie on my back with my knees bent

c)

I will rest my hand over my abdomen

d)

I will take in a deep breath and hold it before exhaling

2.

A nurse is caring for a client who just experienced a generalized seizure. What action should the nurse preform first?

a)

Keep the client in a side-lying position

b)

Document the duration of the seizure

c)

Reorient the client to the environment

d)

Provide client hygiene

3.

When should a nurse notify the rapid response team?

a)

Patient who has a pressure injury of the right heel whose blood glucose is 300 mg/dl

b)

Patient who reports right calf pain and shortness of breath

c)

Patient who has blood on a pressure dressing in the femoral area following a cardiac catheterization

d)

Patient who has dark red coloration of left toes and absent pedal pulse

4.

Which of the following principles should underlie an emergency preparedness activities?

a)

Disasters most often happen in the midwest ans gulf coast

b)

Disasters can happen at anytime and anyplace

c)

Disasters can be predicted if we are prepared

d)

Disasters happen most often in urban/rural areas

5.

The important quality being demonstrated by a Nurse in a role of a counselor and a teacher is:

a)

Assertiveness

b)

Firmness

c)

Intelligence

d)

Active Listening

6.

You made a mistake by giving the wrong medicine. You notify the client’s doctor and write an incident report. You are demonstrating:

a)

Responsibility

b)

Authority

c)

Accountability

d)

Autocracy

7.

The nurse is caring for a client with a blood sugar reading of 390. Is this subjective or objective data?

a)

subjective

b)

objective

8.

A client tells the healthcare provider, "My leg itches." The complaint of itching is considered to be __________ data.

a)

subjective

b)

objective

9.

The nurse carries out interventions in which phase of the nursing process?

a)

evaluation

b)

assessment

c)

nursing diagnosis

d)

planning

e)

implementation

10.

The nurse carries out interventions in which phase of the nursing process?

a)

evaluation

b)

assessment

c)

nursing diagnosis

d)

planning

e)

implementation

11.

The first step of the problem-solving process is to:

a)

choose an alternative with the best chance of success

b)

consider all possible solutions to the problem

c)

clearly define the problem

d)

predict the likelihood of the outcome occurring

12.

When aid residents in reducing their fear and anxiety you are helping them in which stage of Maslow's?

a)

Basic Physical Needs

b)

Safety and Security

c)

Love and Belonging

d)

Self Actualization

13.

Blood that is Rh positive has...

a)

red blood cells with Rh antigens and Anti-Rh antibodies floating around the plasma

b)

red blood cells with Rh antigens, but no Anti-Rh antibodies floating around the plasma

c)

red blood cells that do not have Rh antigens, and no Anti-Rh antibodies floating around the plasma

d)

red blood cells that do not have Rh antigens, and Anti-Rh antibodies floating around the plasma

14.

If you were to give paracetamol drops to an 8 month old weighing 7.5kgs, How much in ML will you give if you desire to give 12 mg/kg/dose?

(a)  

15.

A 7 yr old child was given cefuroxime 250 mg/5ml oral suspension 5ml BID. Weight is 20 kgs. Compute for the mg/day.

(a)  

16.

Give 5 components of APGAR

4 lines
17.

A nurse is planning care for a child who has suspected epiglottitis. Which of the following actions should the nurse take?

a)

Obtain a throat culture.

b)

Place the child in an trendelenberg position.

c)

Transport the child to radiology for a throat x-ray.

d)

Place the child in an upright position.

18.
A nurse is teaching the mother of a 5-year-old child with cystic fibrosis about pancreatic enzymes. Which statement by the mother indicates the need for further instruction?
a)
"I will give my son the enzymes between meals."
b)
"The enzymes probably won't cause many adverse effects."
c)
"The enzymes help him digest fat."
d)
"I will put the enzyme crystals in his applesauce."
19.
A nurse is teaching the mother of a 5-year-old child with cystic fibrosis about pancreatic enzymes. Which statement by the mother indicates the need for further instruction?
a)
"I will give my son the enzymes between meals."
b)
"The enzymes probably won't cause many adverse effects."
c)
"The enzymes help him digest fat."
d)
"I will put the enzyme crystals in his applesauce."
20.
A nurse is monitoring an infant who is 3 months old and has sneezing, coughing, nasal congestion, intermittent fever, and apneic spells. These nurse should recognize these findings are associated with which of the following diagnoses?
a)
Influenza
b)
Bronchiolitis
c)
Croup
d)
Epiglottitis
21.
A nurse is presenting an in-service about the use of postural drainage for infants who have cystic fibrosis. Which of the following positions should the nurse identify as being contraindicated for the infant?
a)
Trendelenburg
b)
Sitting on a nurse's lap leaning forward
c)
Supine
d)
Sitting on a 's lap leaning backward
22.
A newly admitted sickle cell client is experiencing symptoms of pain, dactylitis, and swollen joints. The nurse should recognize that these symptoms are indicative of 
a)
acute sequestration crisis
b)
aplastic crisis. 
c)
acute chest syndrome. 
d)
vaso-occlusive crisis. 
23.
A nurse is providing instruction to the parent of a child with acute group A ß-hemolytic streptococci. What information should the nurse include in the instruction?
 
 
 
 
a)
Avoid the use of warm compresses around the head or neck
b)
Intramuscular injections will be required monthly.
c)
Replace the child’s toothbrush after 24 hr on antibiotics.
d)
  Keep the child home from school for at least 1 week.
24.

A nurse in a PACU is admitting a client who is postoperative following a tonsillectomy. Which of the following actions should the nurse plan to take to prevent aspiration?

a)

Place a bedside humidifier at the head of the client's bed.

b)

Suction the nasopharynx as needed.

c)

Withhold fluids until the client demonstrates a gag reflex.

d)

Perform chest physiotherapy.

25.

A nurse is providing discharge instructions to the parent of a 10-year-old child following a cardiac catheterization. Which of the following instructions should the nurse include?

a)

Keep the child home for 1 week.

b)

Give the child acetaminophen for discomfort.

c)

Offer the child clear liquids for the first 24 hr.

d)

Assist the child to take a tub bath for the first 3 days.

26.

Which of the following items is included in a valid informed consent? Select all that apply

a)

Patient must be 16 years of age or older

b)

Patient must be 18 years of age or older

c)

Consent must be freely given

d)

A physician must obtain informed consent

e)

A physician assistant may obtain informed consent

27.

Patients who smoke are urged to stop...

a)

At least 60 days before surgery

b)

At least 30 days before surgery

c)

At least 7-10 days before surgery

d)

At least 14 days before surgery

28.

ASA (aspirin) should be discontinued...

a)

7-10 days before surgery

b)

1-3 days before surgery

c)

At least 30 days before surgery

d)

At least 60 days before surgery

29.

The use of herbal medicines should be discontinued...

a)

At least 2 days before surgery

b)

At least 2 weeks before surgery

c)

At least 30 days before surgery

d)

At least 7-10 days before surgery

30.

Which of the following statements is the correct way for patients to splint incisions when they cough?

a)

Put the palms of the fingers together and interlace the fingers snugly and place hands across incision

b)

Hold one hand gently directly over the incision and breathe deeply before coughing

c)

Hold both hands on top of each other strongly exerting pressure over the incision

d)

Have the patient deep breathe while they provide medium pressure over the incision

31.

Deep breathing is an important pre-operative teaching area. Which one of the following would be included in your teaching for the pre-operative patient?

a)

Take a deep breath and hold for 5 seconds, repeat 15 times twice daily

b)

Take a deep breath and hold for 10 seconds

c)

Take a deep breath and hold for 3 seconds, repeat 15 times twice daily

d)

Take a deep breath and hold for 5 seconds, repeat 5 times twice daily

32.

Healthy patients are allowed clear liquids up to...

a)

4 hours before an elective surgical procedure

b)

3 hours before an elective procedure

c)

2 hours before an elective procedure

d)

8 hours before an elective procedure

33.

Healthy patients are allowed clear liquids up to...

a)

4 hours before an elective surgical procedure

b)

3 hours before an elective procedure

c)

2 hours before an elective procedure

d)

8 hours before an elective procedure

34.

The patient who is considered at risk for surgical complications is...

a)

A patient with arthritis

b)

A patient with HTN (hypertension)

c)

A dehydrated patient

d)

A patient who smokes

35.

Which of the following conditions is commonly associated with obese patients and of primary concern when scheduled for surgery? Select all that apply

a)

Wound infection

b)

Sleep apnea

c)

Wound dehiscence

d)

Hypoventilation

36.

Which of the following surgeries would be classified as emergent?

a)

Kidney stones

b)

Urethral stones

c)

Fractured skull

d)

Cataract

37.

The preoperative phase of surgery begins with...

a)

the decision to proceed with surgical intervention

b)

the patient being admitted to the pre-admission testing unit

c)

the patient being transferred to the OR suite

d)

the patient signing admission paperwork

38.

Which health care provider informs the patient of the benefits and risks of surgery prior to going to surgery?

a)

Registered Nurse

b)

Surgeon

c)

OR administrator

d)

Licensed Physicians Assistant

39.

Which of the following items is included in a valid informed consent? Select all that apply

a)

Patient must be 16 years of age or older

b)

Patient must be 18 years of age or older

c)

Consent must be freely given

d)

A physician must obtain informed consent

e)

A physician assistant may obtain informed consent

40.

Which statement is correctly stated as an expected client outcome?

a)

Client will ambulate safely.

b)

Client will be able to safely walk down the hallway.

c)

Nurse will assist the client with ambulation three times daily.

d)

Client will ambulate with assistance to nurse's station on second postoperative day.

41.

The nurse knows which intervention is a dependent intervention?

a)

Obtaining a client's BP

b)

Massaging a client's back

c)

Administering medications to a client

d)

Assessing a client's lung sounds

42.

The nurse knows which intervention is a dependent intervention?

a)

Obtaining a client's BP

b)

Massaging a client's back

c)

Administering medications to a client

d)

Assessing a client's lung sounds

43.

The nurse is caring for a client recovering from a CVA (cerebrovascular accident). When reviewing orders, the nurse notes that a healthcare provider has written an order for the client to ambulate, while another has written for strict bedrest. What is the most appropriate nursing intervention?

a)

Collaborate with the physical therapist to determine if the client can ambulate

b)

Assess the client to determine the client's ability to ambulate

c)

Instruct the client to clarify with the healthcare provider ambulation orders

d)

Clarify ambulation orders with healthcare providers

44.

One hour after receiving pain medication, a postoperative client reports intense pain. What is the nurse's most appropriate first action?

a)

Discuss the frequency of pain medication orders with the client.

b)

Assess the client to determine the cause of the pain

c)

Consult with the healthcare provider for additional pain orders

d)

Assist the client to reposition and splint the incision site

45.

A nurse is reviewing lab reports. The nurse recalls blood plasma is located in which of the following fluid compartments?

a)

Intracellular fluid (ICF)

b)

Extracellular fluid (ECF)

c)

Interstitial fluid

d)

Intravascular fluid

46.

A nurse is teaching the staff about antidiuretic hormone (ADH). Which information should the nurse include? Secretion of ADH is stimulated by:

a)

Increased serum potassium

b)

Increased plasma osmolality

c)

Decreased renal blood flow

d)

Generalized edema

47.

When planning care for a dehydrated patient, the nurse remembers the principle of water balance is closely related to _____ balance.

a)

Potassium

b)

Chloride

c)

Bicarbonate

d)

Sodium

48.

When planning care for a dehydrated patient, the nurse remembers the principle of water balance is closely related to _____ balance.

a)

Potassium

b)

Chloride

c)

Bicarbonate

d)

Sodium

49.

Which statement by the staff indicates teaching was successful concerning aldosterone? Secretion of aldosterone results in:

a)

Decreased plasma osmolality

b)

Increased serum potassium levels

c)

Increased blood volume

d)

Localized edema

50.

A 5-year-old male presents to the ER with delirium and sunken eyes. After diagnosing him with severe dehydration, the primary care provider orders fluid replacement. The nurse administers a hypertonic intravenous solution. Which of the following would be expected?

a)

Symptoms subside quickly

b)

Increased ICF volume

c)

Decreased ECF volume

d)

Intracellular dehydration

51.

Which of the following patients is the most at risk for developing hypernatremia? A patient with:

a)

Vomiting

b)

Diuretic use

c)

Dehydration

d)

Hypoaldosteronism

52.

Which of the following patients is the most at risk for developing hypernatremia? A patient with:

a)

Vomiting

b)

Diuretic use

c)

Dehydration

d)

Hypoaldosteronism

53.

Which of the following buffer pairs is considered the major plasma buffering system?

a)

Which of the following buffer pairs is considered the major plasma buffering system?

b)

Carbonic acid/bicarbonate

c)

Sodium/potassium

d)

Amylase/albumin

54.

Which patient is most prone to metabolic alkalosis? A patient with:

a)

Retention of metabolic acids

b)

Hypoaldosteronism

c)

Excessive loss of chloride (Cl)

d)

Hyperventilation

55.

For a patient experiencing metabolic acidosis, the body will compensate by:

a)

Excreting H+ through the kidneys

b)

Hyperventilating

c)

Retaining CO2 in the lungs

d)

Secreting aldosterone

56.

Hyypermagnesemia is defined as:

a)

> 0.5 mEq/L

b)

>1 mEq/L

c)

>2 mEq/L

d)

>2.5 mEq/L

57.

All the following can occur with hyperkalemia EXCEPT:

a)

Peaked T waves

b)

Narrowed PR interval

c)

Widened QRS

d)

Loss of P wave