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WorksheetsNCLEX - Reduction of Risk Potential Day1 (Part 1)
Total questions: 15
Worksheet time: 15mins
Name
Class
Date
1.
The nurse is caring for a 65-year-old client who had an acute myocardial infarction 3 days ago and is reporting tenderness and warmth of the left calf. Which of the following actions would be a priority for the nurse to take?
a)
Ask the client how long the leg has been tender and warm
b)
Monitor ECG and assess for ectopic beats
c)
Obtain the client's vital signs and pulse oximetry reading
d)
Perform a neurovascular assessment of the lower extremities
2.
The nurse helps the health care provider perform a thoracentesis at the bedside. In which position does the nurse place the client to facilitate needle insertion and promote comfort?
a)
Fetal position, lying on unaffected side with knees drawn to the abdomen and hands clasped around them
b)
Lying on the affected side with head of the bed elevated to 30-45 degrees
c)
Prone with head turned to the affected side and arms over the head, supported by a pillow
d)
Upright leaning forward over the bedside table, with arms supported on pillows
3.
The nurse is caring for a client who had a surgical procedure and received IV hydromorphone for pain 30 minutes ago. The nurse notes the client is difficult to arouse and has shallow breathing. Which of the following actions should the nurse take?
a)
Notify the health care provider.
b)
Continue to stimulate the client.
c)
Prepare to administer naloxone.
d)
Prepare to administer alprazolam.
e)
Assess the client's respiratory rate.
4.
The nurse is caring for a client who has a pulmonary contusion. The nurse should recognize that the client is at risk for developing
a)
metabolic acidosis
b)
metabolic alkalosis
c)
respiratory acidosis
d)
respiratory alkalosis
5.
The nurse is caring for an ambulatory client who has a new order for continuous cardiac monitoring via a portable unit. It would require follow-up if the nurse
a)
verifies that gel is present on each electrode and is not dried out
b)
cleanses and dries the skin before placing the electrodes on the client
c)
clips excessive hair off the client before applying the electrodes
d)
places one electrode each on the client's upper and lower extremities
6.
The nurse receives report on 4 clients. Which client conditions require priority assessment?
a)
34-year-old with acute pericarditis reporting left-sided chest pain that is worse with inspirations
b)
54-year-old post right femoropopliteal bypass surgery reporting sudden-onset severe right foot pain
c)
64-year-old post hip replacement reporting sudden-onset right-sided chest pain and dyspnea
d)
70-year-old with pneumonia; rapid, irregular pulse of 140/min; and blood pressure of 130/86 mm Hg
7.
The nurse completes a neurological examination on a client who has suffered a stroke to determine if damage has occurred to any of the cranial nerves. The nurse understands that damage has occurred to cranial nerve IX based on which assessment finding?
a)
A tongue blade is used to touch the client's pharynx; gag reflex is absent
b)
Only one side of the mouth moves when the client is asked to smile and frown
c)
The absence of light touch and pain sensation on the left side of the client's face
d)
When the client shrugs against resistance, the left shoulder is weaker than the right
8.
The nurse prepares to admit a client with worsening cirrhosis who is on the waiting list for a liver transplant. Based on the client's electronic health record, the nurse anticipates which assessment findings?
a)
Ascites
b)
Bruising
c)
Constipation
d)
Itching
e)
Lethargy
9.
The nurse working in an intensive care unit receives a prescription from the primary health care provider to discontinue a triple-lumen subclavian central venous catheter. Which interventions will help prevent air embolism on removal?
a)
Applying an air-occlusive dressing
b)
Instructing the client to bear down
c)
Instructing the client to lie in a supine position
d)
Pulling the line harder if there is resistance
e)
Pulling the line out when the client is inhaling
10.
An 86-year-old client with diabetes and gastroparesis has had repeated hospitalizations for aspiration pneumonia following a stroke and is now hospitalized with altered level of consciousness. Which nursing action is most appropriate to decrease the client's risk for developing aspiration pneumonia?
a)
Assessing client's breath sounds every 2 hours
b)
Placing client in the side lying position in bed
c)
Titrating client's oxygen to maintain saturation ≥93%
d)
Turning and repositioning the client every 2 hours
11.
Which client is in need of follow-up education by the nurse?
a)
Client with peripheral arterial disease (PAD) who insists on dangling leg over the side of the bed when sleeping
b)
Client with Raynaud's phenomenon who routinely soaks hands in warm water before going out
c)
Client with venous leg ulcer who refuses to wear elastic compression stockings during the day
d)
Postsurgical client who points and flexes feet when lying in bed
12.
A client is transferred from the post-anesthesia recovery unit to the surgical unit following an open cholecystectomy. Which interventions are most important for the nurse to perform to prevent postoperative pneumonia?
a)
Administer morphine only if the pain is >8 on a 1-10 pain scale
b)
Ambulate within 8 hours after surgery, if possible
c)
Have client cough with splinting every hour
d)
Have client deep breathe and use the incentive spirometer every hour
e)
Maintain pneumatic compression devices when client is in bed
13.
The nurse is teaching a client who had a scleral buckle to repair a detached retina. Which of the following information should the nurse include?
a)
Report any sudden or worsening eye pain to your health care provider.
b)
Expect to see occasional flashes of light during your recovery.
c)
Avoid activities that may cause nausea or vomiting.
d)
Limit reading and writing to prevent eye strain.
e)
Avoid lifting heavy objects or straining.
14.
The nurse cares for a client who returns from the operating room after a tracheostomy tube placement procedure. Which of the following is the nurse's priority when caring for a client with a new tracheostomy?
a)
Changing the inner cannula within the first 8 hours to help prevent mucus plugs
b)
Checking the tightness of ties and adjusting if necessary, allowing 1 finger to fit under these ties
c)
Deflating and re-inflating the cuff every 4 hours to prevent mucosal tissue damage
d)
Performing frequent mouth care every 2 hours to help prevent infection
15.
The nurse prepares to insert an indwelling urinary catheter in a client who is disoriented to time, place, and person and cannot follow directions or commands. Which intervention is most important when inserting the urinary catheter?
a)
Ensure the client understands the procedure prior to implementation
b)
Maintain a sterile field and keep the urinary catheter sterile
c)
Place the catheter supply kit between the client's legs in the center of the bed
d)
Throw swabs used to clean the perineum directly into the biohazard bin
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