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WorksheetsNCLEX - Physiological Adaptation Day1
Total questions: 24
Worksheet time: 24mins
Name
Class
Date
1.
The nurse is caring for a client with acute pancreatitis. While obtaining the client's blood pressure, the nurse notes a carpal spasm. The nurse should obtain a blood specimen to check the client's serum
a)
Calcium level
b)
Albumin level
c)
Troponin T level
d)
Potassium level
e)
–
2.
The nurse assessing a client's pain would expect the client to make which statement when describing the abdominal pain associated with appendicitis?
a)
My pain is a burning sensation in my upper abdomen.
b)
My pain is an 8 out of 10 and on my left side below my belly button.
c)
My pain is excruciating in my lower abdomen above my right hip.
d)
My pain is intermittent in my abdomen and right shoulder.
e)
–
3.
The nurse is caring for a client with a hemothorax who has a chest tube attached to a closed-chest drainage system. The nurse notes a sudden decrease in drainage from the chest tube over the past 2 hours. Which of the following actions should the nurse take?
a)
Reposition the client.
b)
Auscultate the client's breath sounds.
c)
Replace the closed-chest drainage system.
d)
Prepare the client for removal of the chest tube.
e)
Instruct the client to cough and take deep breaths.
4.
The nurse is caring for a postpartum client 36 hours after a cesarean birth who was just diagnosed with postpartum endometritis. Which prescription is priority for the nurse to administer?
a)
Acetaminophen PO PRN for fever
b)
Clindamycin IV every 8 hours
c)
Lactated Ringer IV bolus once
d)
Methylergonovine PO every 4 hours
e)
–
5.
The nurse is caring for a client who is experiencing the cardiac rhythm in the ECG strip shown. The nurse should recognize that the client is experiencing
a)
Atrial flutter
b)
Ventricular tachycardia
c)
Premature atrial contractions
d)
Premature ventricular contractions
e)
–
6.
The nurse is caring for a client with primary hyperparathyroidism. Which of the following findings would be consistent with the condition?
a)
Seizures
b)
Diarrhea
c)
Muscle weakness
d)
Perioral numbness
e)
–
7.
The nurse caring for a client with pulmonary edema responds to the mechanical ventilator high-pressure alarm. The nurse would assess for which conditions that can trigger the high-pressure alarm?
a)
Biting endotracheal tube
b)
Disconnected ventilator tubing
c)
Endotracheal tube cuff leak
d)
Excessive airway secretions
e)
Kinked ventilator tubing
8.
The nurse is teaching an adolescent client who has developed external otitis for the third time this year. Which of the following information should the nurse include?
a)
Consider wearing custom-fit earplugs for swimming.
b)
Avoid getting water in your ears until they have healed.
c)
Tilt your head from side to side after swimming to help dry your ears.
d)
Apply a warm compress to the outside of your ear to help reduce discomfort.
e)
Keep your ear canals free of wax by cleaning them with cotton-tipped applicators.
9.
The nurse is caring for a client recently diagnosed with a hiatal hernia. Which of the following actions should the nurse take?
a)
Elevate the head of the bed at least 30 degrees
b)
Encourage use of compression garments around the abdomen
c)
Instruct the client to avoid caffeinated beverages
d)
Offer small, frequent, low-fat meals
e)
Tell the client to avoid lifting and straining
10.
Which nursing interventions are appropriate for managing the care of a client receiving mechanical ventilation and continuous IV sedation?
a)
Maintain the head of the bed at 30-45 degrees
b)
Mute ventilator alarms at night to allow the client to rest
c)
Pause sedation daily to assess weaning readiness
d)
Perform oral care with chlorhexidine solution
e)
Place a manual resuscitation bag at the bedside
11.
The nurse is caring for a client with acute diverticulitis who has nausea, vomiting, and rates pain as 8 out of 10. Which interventions should be included?
a)
Administer morphine sulfate as prescribed for pain control
b)
Insert a rectal tube to protect skin from diarrhea
c)
Instruct the client to avoid straining
d)
Maintain NPO status
e)
Start IV infusion of normal saline
12.
The nurse reviews lab results of a client who reports fatigue for the last month. Based on hypothyroidism labs, which symptoms would be expected?
a)
Bradycardia
b)
Cold intolerance
c)
Constipation
d)
Hair loss
e)
Warm, moist skin
13.
The nurse is caring for a client with suspected pheochromocytoma. The client has diaphoresis, severe headache, and blood pressure of 200/110 mm Hg. Which actions should the nurse take?
a)
Prepare the client for surgery
b)
Administer radioactive iodine
c)
Administer IV antihypertensive medication
d)
Initiate a 24-hour urine specimen collection
e)
Palpate the abdomen to assess for tenderness
14.
Four clients were involved in a motor vehicle accident. Which client requires priority care?
a)
Client with blood pressure 90/70 mm Hg and deviated trachea
b)
Client with concussion who was unconscious for 5 minutes
c)
Client with grossly swollen upper thigh and BP 80/60 mm Hg
d)
Client with thoracic spine pain and paralysis of both legs
e)
–
15.
A client with peripheral artery disease makes the following statements. Which requires immediate follow-up?
a)
I am glad that the hair on my legs will return with treatment.
b)
I take my atorvastatin in the morning with my other medications.
c)
I avoid walking when my feet hurt so I do not make the pain worse.
d)
I elevate my legs in the recliner and use a heating pad if my feet are cold.
e)
–
16.
A client experiencing an outbreak of genital herpes makes the following statement. Which indicates a need for further teaching?
a)
I will be sure we use condoms during intercourse as long as I have lesions.
b)
I will not touch the lesions to prevent spreading the virus to other parts of my body.
c)
I will use a hair dryer on a cool setting to dry the lesions after showering.
d)
I will use warm running water and mild soap without perfumes to wash the area.
e)
–
17.
A client with pinworm infection is being assessed. Which findings would the nurse expect?
a)
Vomiting
b)
Constipation
c)
Restlessness
d)
Perianal itching
e)
Disturbed sleep
18.
The home health nurse is caring for an 85-year-old client. Which report requires immediate follow-up?
a)
A painful red area on the buttocks
b)
New onset dependent edema of the feet
c)
Progressive loss of central vision
d)
No memory of activities performed yesterday
e)
–
19.
A client being evaluated for suspected ectopic pregnancy reports sudden severe abdominal pain and dizziness. Which findings suggest rupture?
a)
Blood pressure 82/64 mm Hg
b)
Crackles on auscultation
c)
Distended jugular veins
d)
Pulse 120/min
e)
Shoulder pain
20.
The nurse in the emergency department is caring for a client with hypothyroidism and decreased consciousness. What action should be taken first?
a)
Administer IV levothyroxine
b)
Place a warming blanket
c)
Prepare for endotracheal intubation
d)
Obtain TSH, T3, T4 blood panel
e)
–
21.
A laboring client experiences rupture of membranes followed by abrupt fetal heart rate change. What should the nurse do first?
a)
Administer IV fluid bolus
b)
Assess for umbilical cord prolapse
c)
Notify the health care provider
d)
Prepare for emergency cesarean birth
e)
–
22.
During an obstetrical emergency simulation for uterine inversion, which nurse statement requires correction?
a)
I will administer IV oxytocin before the uterus is corrected.
b)
I will establish a second IV line with an 18-gauge catheter.
c)
I will initiate blood pressure monitoring every 3–5 minutes.
d)
I will notify anesthesia and operating room staff immediately.
e)
–
23.
A hypothermic client arrives at the emergency department. What additional intervention is a priority?
a)
Attach cardiac monitor
b)
Cover the client's head
c)
Draw blood for electrolytes and glucose
d)
Place an additional large-bore IV catheter
e)
–
24.
The nurse cares for a client who had a seizure 10 minutes ago and is now confused with a headache. Which seizure phase is the client experiencing?
a)
Ictal phase
b)
Aural phase
c)
Postictal phase
d)
Prodromal phase
e)
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