WorksheetsNCLEX - Mock Test 1
Total questions: 100
Worksheet time: 50mins
Name
Class
Date
1.
The nurse is making room assignments for multiple clients. Which of the following semi-private room assignments would be appropriate?
a)
a client with gastroenteritis and a client with chemotherapy-induced nausea and vomiting (10%)
b)
a client who had a bowel resection 1 day ago and a client with asthma exacerbation (75%)
c)
a client who had a total hip arthroplasty 2 days ago and a client with influenza (4%)
d)
a client with iron-deficiency anemia and a client with intractable diarrhea (10%)
e)
-
2.
The nurse is talking with a client with major depressive disorder. Which of the following statements by the client would best indicate that the client is not currently at risk for suicide?
a)
I lost my imipramine prescription and I need a refill. (3%)
b)
I plan to attend my grandchild's graduation next month. (77%)
c)
I will sign a 'no-suicide' contract at today's appointment. (8%)
d)
I seem to have a lot more energy since I started therapy. (10%)
e)
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3.
The nurse is caring for a client who has a do not attempt resuscitation (DNAR) directive. The client experiences cardiac arrest, and the client's adult child states, "Please, do whatever you can to save my parent!" Which of the following actions should the nurse take?
a)
Contact the health care provider to confirm the DNAR directive. (6%)
b)
Activate the emergency response team and initiate CPR. (6%)
c)
Request the presence of the client's health care proxy. (6%)
d)
Explain the DNAR directive to the client's child. (79%)
e)
-
4.
The nurse is caring for a client who sustained a fracture of the right tibia and fibula. Which of the following factors would increase the client's risk for delayed bone healing?
a)
BMI of 29.5 kg/m2 (14%)
b)
family history of osteoporosis (21%)
c)
history of peripheral artery disease (59%)
d)
consumes one glass of wine per day (4%)
e)
-
5.
The nurse is caring for a client who is receiving a transfusion of packed RBCs through a peripherally inserted central catheter (PICC). During the transfusion, the client receives a new prescription for IV amphotericin B. It would be most appropriate for the nurse to
a)
administer amphotericin B through an open lumen of the PICC (14%)
b)
insert a peripheral venous access device and administer the amphotericin B (19%)
c)
interrupt the transfusion and administer the amphotericin B (1%)
d)
wait 1 hour after the transfusion is complete before administering amphotericin B (64%)
e)
-
6.
The nurse is reading comments on a public social media page maintained by a group of nurses. Which of the following social media posts by a nurse breaches client confidentiality? Select all that apply.
a)
I private-messaged everyone a cute story about our sweet client with dementia.
b)
The client in room 5 is positive for influenza, so please remember to get your influenza vaccines!
c)
Wash your hands well if you cared for the client in room 4; the client's cultures are positive for Clostridioides difficile.
d)
Client acuity has been high lately, but I am grateful to work with supportive staff members! and "It breaks my heart that our client with paraplegia was so neglected by the family."
e)
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7.
The nurse is teaching a client who has a new prescription for risperidone. Which of the following statements by the client would require follow-up?
a)
I will contact my health care provider if I have a fever or muscle stiffness. (9%)
b)
I may become shaky and restless when I am agitated. (65%)
c)
I may sleep more often when taking this medicine. (13%)
d)
I will try to change positions slowly. (11%)
e)
-
8.
The nurse is talking with a staff member who states, "My client has a history of substance use disorder and constantly requests pain medicine. I just administered normal saline instead of morphine because it is too early for another dose of morphine." Which of the following actions should the nurse take next?
a)
Report the incident to the facility's ethics committee. (8%)
b)
Follow facility protocol for completing an incident report. (23%)
c)
Instruct the staff member to document the incident and notify the unit manager. (18%)
d)
Instruct the staff member to notify the health care provider about the client's uncontrolled pain. (49%)
e)
-
9.
The nurse is caring for assigned clients. The nurse should first assess the client who had a
a)
subdural hematoma 36 hours ago and is requesting breakfast (9%)
b)
transient ischemic attack 2 days ago and is scheduled to receive aspirin (8%)
c)
stroke, is receiving t-PA therapy, and a Glasgow Coma Scale score that has changed from 9 to 13 (16%)
d)
bowel resection, is receiving parenteral nutrition, and had 4800 mL of urine output over the past 12 hours (65%)
e)
-
10.
The nurse is preparing to administer lithium to a client. Which of the following medications should the nurse hold for clarification prior to administering?
a)
hydrochlorothiazide (60%)
b)
acetaminophen (6%)
c)
sulfadiazine (16%)
d)
metformin (16%)
e)
-
11.
The nurse is caring for a 6-year-old client with autism spectrum disorder who is scheduled for a procedure. It would require follow-up if the nurse
a)
explains the procedure using pictures (23%)
b)
asks the parent to remain at the bedside to provide comfort (5%)
c)
holds the client's hand as a soothing measure (64%)
d)
limits the number of staff members in the room to ease the client's anxiety (6%)
e)
-
12.
The nurse in the clinic is reviewing telephone messages from clients previously seen at the facility. The nurse should first telephone the client who had
a)
a lumbar laminectomy with spinal fusion 2 days ago and is reporting straining with bowel movements (12%)
b)
a colonoscopy with polypectomy 1 day ago and is reporting a small amount of rectal bleeding (8%)
c)
an arteriovenous graft inserted 2 days ago and is reporting a temperature of 100.9 F (38.3 C) (60%)
d)
a laparoscopic inguinal hernia repair 1 day ago and is reporting difficulty with urination (19%)
e)
-
13.
The nurse is teaching clients at a community health clinic about pubic lice. Which of the following statements should the nurse include? Select all that apply.
a)
Wash clothes and linens in hot water.
b)
Wash pubic hair with lice treatment shampoo.
c)
Pubic lice are only spread through sexual contact.
d)
Sexual partners should also receive lice treatment. and "Remove nits from pubic hair with a fine-toothed nit comb."
e)
-
14.
The nurse is auscultating the breath sounds of a client who is short of breath and notes coarse crackles. Which of the following medications should the nurse anticipate will be prescribed for the client?
a)
albuterol (42%)
b)
furosemide (32%)
c)
guaifenesin (13%)
d)
methylprednisolone (10%)
e)
-
15.
The nurse is assessing a client with dark skin who has disseminated intravascular coagulation. Which of the following locations would be best to assess for the presence of petechiae?
a)
buccal mucosa and conjunctivae of the eye (43%)
b)
palms of the hands and soles of the feet (27%)
c)
skin over the sacrum and the heels (21%)
d)
nail beds of the fingers and toes (7%)
e)
-
16.
The home-health nurse is assessing the safety of the home environment for a pediatric client. It would require follow-up if
a)
the family lives in a rural area (0%)
b)
the house is heated by a wood-burning stove (69%)
c)
the house was built in 1983 (13%)
d)
the client's parents are unemployed and have limited financial resources (15%)
e)
-
17.
The nurse is caring for assigned clients. The nurse should first assess the client who has
a)
gestational diabetes mellitus and dysuria (1%)
b)
oligohydramnios and a reactive fetal nonstress test (14%)
c)
preeclampsia and 3+ reflexes with 2 beats of clonus (59%)
d)
hyperemesis gravidarum and a blood pressure of 95/58 mm Hg (23%)
e)
-
18.
The nurse is teaching female high school students about human papillomavirus (HPV) and genital warts. Which of the following statements by a student would indicate a correct understanding of the teaching? Select all that apply.
a)
Infection with HPV increases the risk of cervical cancer.
b)
Genital warts may come back again, even after receiving treatment.
c)
I need a Pap test as soon as I am sexually active, regardless of my age.
d)
I should receive the HPV vaccine series even though I am not sexually active and "Using condoms during sexual intercourse eliminates the risk of spreading the virus."
e)
-
19.
The charge nurse is making client care assignments for the oncoming shift. The most appropriate assignment for the nurse who is pregnant would be the client
a)
with endometrial cancer who is receiving brachytherapy (24%)
b)
who has pneumonia and was recently exposed to the Zika virus (12%)
c)
with disseminated herpes zoster who has vesicles on the face and scalp (10%)
d)
who has a wound infected with methicillin-resistant Staphylococcus aureus (52%)
e)
-
20.
The nurse is caring for a client with unstable angina who is receiving IV nitroglycerin and reports the onset of a dull, throbbing headache. Which of the following actions should the nurse take?
a)
Decrease the infusion rate and reassess the client. (29%)
b)
Document the finding and administer acetaminophen. (37%)
c)
Stop the infusion immediately and notify the health care provider. (19%)
d)
Notify the health care provider and request a CT scan of the head. (12%)
e)
-
21.
The nurse is caring for a client with suspected meningococcal meningitis. Which of the following nursing interventions is the priority?
a)
Implement seizure precautions. (18%)
b)
Place the client on droplet precautions. (62%)
c)
Administer acetaminophen for fever. (9%)
d)
Obtain a urine specimen for culture. (7%)
e)
-
22.
The nurse is caring for a client who had a thyroidectomy 12 hours ago. Which finding requires immediate intervention?
a)
Serum calcium of 8.0 mg/dL (2.0 mmol/L) (14%)
b)
Respiratory rate of 26/min (12%)
c)
Stridor and difficulty breathing (67%)
d)
Incisional pain rated 7/10 (6%)
e)
-
23.
The nurse is caring for a client with a chest tube connected to suction. Which finding should the nurse report to the health care provider immediately?
a)
Continuous bubbling in the water seal chamber (62%)
b)
Fluctuation of fluid level in the water seal chamber (12%)
c)
Drainage of 75 mL/hr of bright red blood (20%)
d)
Drainage of 25 mL/hr of serosanguineous fluid (5%)
e)
-
24.
The nurse is providing discharge teaching to a client with newly diagnosed celiac disease. Which statement by the client indicates a correct understanding of the teaching?
a)
I can eat wheat bread as long as it is toasted. (5%)
b)
I will avoid barley, rye, and oats. (68%)
c)
I can have ice cream and pudding made with wheat starch. (12%)
d)
I will start a high-fiber diet with whole wheat cereals. (10%)
e)
-
25.
The nurse is caring for a client with a tracheostomy who is receiving mechanical ventilation. The high-pressure alarm sounds. Which of the following should the nurse do first?
a)
Look for kinks in the ventilator tubing. (55%)
b)
Assess for decreased lung compliance. (12%)
c)
Empty water from the ventilator tubing. (20%)
d)
Suction the tracheostomy tube. (10%)
e)
-
26.
The nurse is caring for a client with suspected tuberculosis (TB). Which of the following interventions is most important for the nurse to implement?
a)
Initiate airborne precautions. (71%)
b)
Obtain a sputum culture for acid-fast bacilli. (14%)
c)
Administer isoniazid as prescribed. (8%)
d)
Place the client in a semi-Fowler position. (5%)
e)
-
27.
The nurse is providing discharge teaching to a client with newly prescribed warfarin. Which statement by the client indicates a need for further teaching?
a)
I will avoid eating spinach and broccoli. (12%)
b)
I will have my blood tested regularly. (9%)
c)
I will take the medication at the same time each day. (8%)
d)
I will use a soft-bristle toothbrush. (68%)
e)
-
28.
The nurse is caring for a client with a chest tube following thoracic surgery. Which finding requires immediate intervention?
a)
Drainage of 120 mL/hr of bright red blood (65%)
b)
Serosanguineous drainage of 30 mL/hr (10%)
c)
No fluctuation in the water seal chamber (15%)
d)
Intermittent bubbling in the suction control chamber (8%)
e)
-
29.
The nurse is caring for a client with cirrhosis and ascites. Which dietary instruction should the nurse provide?
a)
Increase protein intake. (12%)
b)
Restrict sodium intake. (70%)
c)
Increase fluid intake. (10%)
d)
Restrict carbohydrate intake. (6%)
e)
-
30.
The nurse is caring for a client with a central venous catheter (CVC). Which action by the nurse requires intervention?
a)
Flushing the CVC with 10 mL of normal saline using a 10-mL syringe. (12%)
b)
Using sterile technique when changing the CVC dressing. (9%)
c)
Checking for blood return before administering IV medications. (8%)
d)
Using the CVC for blood pressure measurement. (68%)
e)
-
31.
The nurse is caring for a client with a chest tube following lobectomy. Which finding requires immediate intervention?
a)
Drainage of 100 mL/hr of bright red blood (65%)
b)
Serosanguineous drainage of 30 mL/hr (10%)
c)
No fluctuation in the water seal chamber (15%)
d)
Intermittent bubbling in the suction control chamber (8%)
e)
-
32.
The nurse is providing teaching to a client with newly diagnosed type 1 diabetes mellitus. Which statement by the client indicates a correct understanding of the teaching?
a)
I will rotate insulin injection sites within the same anatomical area. (68%)
b)
I will inject insulin into my thigh before exercising. (12%)
c)
I will store all opened insulin vials in the refrigerator. (10%)
d)
I will mix long-acting insulin with regular insulin in the same syringe. (7%)
e)
-
33.
The nurse is caring for a client with a percutaneous endoscopic gastrostomy (PEG) tube. Which action by the nurse is appropriate?
a)
Flush the tube with 30 mL of water before and after medication administration. (72%)
b)
Clamp the tube for 60 minutes after medication administration. (10%)
c)
Crush enteric-coated medications before administration. (8%)
d)
Administer all medications together to save time. (7%)
e)
-
34.
The nurse is caring for a client with chronic kidney disease (CKD). Which dietary instruction should the nurse provide?
a)
Increase potassium intake. (8%)
b)
Restrict sodium, potassium, and phosphorus intake. (70%)
c)
Increase protein intake. (12%)
d)
Restrict carbohydrate intake. (7%)
e)
-
35.
The nurse is caring for a client with a newly created colostomy. Which statement by the client indicates a need for further teaching?
a)
I will empty my pouch when it is one-third full. (10%)
b)
I will use warm water to clean around the stoma. (12%)
c)
I will apply a skin barrier to protect the skin. (8%)
d)
I will use alcohol to clean around the stoma. (68%)
e)
-
36.
The nurse is caring for a client with suspected pulmonary embolism (PE). Which intervention should the nurse implement first?
a)
Administer anticoagulant therapy as prescribed. (12%)
b)
Apply oxygen via nasal cannula. (68%)
c)
Prepare the client for CT pulmonary angiography. (10%)
d)
Place the client in Trendelenburg position. (7%)
e)
-
37.
The nurse is providing teaching to a client with newly prescribed digoxin. Which statement by the client indicates a need for further teaching?
a)
I will check my pulse before taking the medication. (10%)
b)
I will take the medication if my pulse is below 60/min. (68%)
c)
I will report nausea and vision changes to my provider. (12%)
d)
I will take the medication at the same time each day. (8%)
e)
-
38.
The nurse is caring for a client with a nasogastric (NG) tube connected to low intermittent suction. Which finding requires immediate intervention?
a)
Small amount of gastric drainage in the tubing (10%)
b)
Absent bowel sounds for 2 hours after surgery (12%)
c)
Abdominal distension and absent bowel sounds (68%)
d)
Occasional nausea (8%)
e)
-
39.
The nurse is providing discharge teaching to a client with heart failure who is prescribed furosemide. Which statement by the client indicates a correct understanding of the teaching?
a)
I will weigh myself daily at the same time. (70%)
b)
I will eat foods high in sodium to replace losses. (10%)
c)
I will avoid potassium-rich foods. (8%)
d)
I will take the medication only if I feel short of breath. (7%)
e)
-
40.
The nurse is caring for a client with a newly placed peritoneal dialysis catheter. Which action by the nurse is appropriate?
a)
Flush the catheter with heparinized saline. (8%)
b)
Keep the catheter exit site clean and dry. (70%)
c)
Apply an occlusive dressing over the catheter. (12%)
d)
Clamp the catheter when not in use. (7%)
e)
-
41.
The nurse is providing teaching to a client with newly prescribed levothyroxine. Which statement by the client indicates a need for further teaching?
a)
I will take this medication every morning on an empty stomach. (10%)
b)
I will take this medication with calcium supplements. (68%)
c)
I will expect to take this medication for the rest of my life. (12%)
d)
I will notify my provider if I experience chest pain. (8%)
e)
-
42.
The nurse is caring for a client with a chest tube following thoracotomy. Which finding requires immediate intervention?
a)
Drainage of 150 mL/hr of bright red blood (65%)
b)
Serosanguineous drainage of 30 mL/hr (10%)
c)
No fluctuation in the water seal chamber (15%)
d)
Intermittent bubbling in the suction control chamber (8%)
e)
-
43.
The nurse is providing discharge teaching to a client with newly prescribed phenytoin. Which statement by the client indicates a correct understanding of the teaching?
a)
I will stop taking the medication if I develop a rash. (68%)
b)
I will take the medication only when I have a seizure. (10%)
c)
I will stop the medication if I feel better. (12%)
d)
I will take the medication with antacids to prevent stomach upset. (8%)
e)
-
44.
The nurse is caring for a client with a peripherally inserted central catheter (PICC). Which action by the nurse requires intervention?
a)
Flushing the PICC with 10 mL of normal saline using a 10-mL syringe. (12%)
b)
Using sterile technique when changing the PICC dressing. (9%)
c)
Checking for blood return before administering IV medications. (8%)
d)
Using the PICC for blood pressure measurement. (68%)
e)
-
45.
The nurse is providing teaching to a client with newly prescribed prednisone. Which statement by the client indicates a need for further teaching?
a)
I will take this medication with food. (10%)
b)
I will stop taking the medication when I feel better. (68%)
c)
I will notify my provider if I develop signs of infection. (12%)
d)
I will monitor my blood sugar while taking this medication. (8%)
e)
-
46.
The nurse is providing teaching to a client with newly prescribed alendronate. Which statement by the client indicates a need for further teaching?
a)
I will take this medication with a full glass of water. (10%)
b)
I will remain upright for at least 30 minutes after taking it. (12%)
c)
I will take this medication at bedtime. (68%)
d)
I will take this medication on an empty stomach. (8%)
e)
-
47.
The nurse is caring for a client with a chest tube following pneumothorax. Which finding requires immediate intervention?
a)
Continuous bubbling in the water seal chamber. (68%)
b)
Fluctuation of fluid level in the water seal chamber. (12%)
c)
Drainage of 50 mL/hr of serosanguineous fluid. (10%)
d)
Intermittent bubbling in the suction control chamber. (8%)
e)
-
48.
The nurse is providing discharge teaching to a client with newly prescribed metronidazole. Which statement by the client indicates a need for further teaching?
a)
I will avoid drinking alcohol while taking this medication. (10%)
b)
I may notice my urine turning a dark color. (12%)
c)
I will stop the medication if I develop a metallic taste. (68%)
d)
I will take the medication as prescribed until it is finished. (8%)
e)
-
49.
The nurse is caring for a client with a newly placed arteriovenous (AV) fistula for hemodialysis. Which action by the nurse is appropriate?
a)
Assess for a bruit and thrill over the fistula site. (70%)
b)
Use the fistula for blood pressure measurement. (10%)
c)
Draw blood samples from the fistula. (8%)
d)
Apply a tourniquet above the fistula site. (7%)
e)
-
50.
The nurse is providing teaching to a client with newly prescribed nitroglycerin sublingual tablets. Which statement by the client indicates a correct understanding of the teaching?
a)
I will take up to 3 tablets in 15 minutes if I still have chest pain. (70%)
b)
I will swallow the tablets with water. (10%)
c)
I will store the tablets in a plastic pillbox. (8%)
d)
I will take the tablets 30 minutes before exercise. (7%)
e)
-
51.
The nurse is caring for a client who had a craniotomy with bone flap removal 2 days ago. The nurse notes clear drainage saturating the surgical dressing. Which of the following actions should the nurse take?
a)
Notify the health care provider of the color and amount of drainage. (71%)
b)
Turn the client onto the nonoperative side using the log-rolling technique. (8%)
c)
Cleanse the incision site with normal saline and apply a new, sterile dressing. (8%)
d)
Mark the edges of the drainage on the dressing and continue to monitor the dressing. (12%)
e)
-
52.
The nurse is unable to palpate the right pedal pulse of a client who had cardiac catheterization 1 hour ago through the right femoral artery. Which of the following actions should the nurse take next?
a)
Apply a heating pad to the right foot to increase circulation. (2%)
b)
Obtain a Doppler ultrasound of the right pedal pulse. (69%)
c)
Document the right pedal pulse strength as "0". (1%)
d)
Notify the health care provider. (25%)
e)
-
53.
The nurse is caring for assigned clients. The nurse should first assess the client who
a)
had a hip replacement 2 days ago and is reporting intense itching at the incision site (1%)
b)
was scheduled to be discharged 2 hours ago and reports increasing frustration regarding the delay (0%)
c)
is receiving a continuous infusion of 0.9% sodium chloride at 250 mL/hr and reports swollen legs and a cough (64%)
d)
is receiving 0.9% sodium chloride with 20 mEq/L (20 mmol/L) potassium chloride and has a potassium level of 5.0 (32%) mEq/L (5.0 mmol/L) (normal: 3.5-5 mEq/L [3.5-5 mmol/L])
e)
-
54.
The nurse is teaching a client who has a new prescription for cyclosporine. Which of the following statements by the client would require follow-up?
a)
I will need to regularly check my blood pressure at home. (4%)
b)
I can use a hair removal cream for excess hair growth. (11%)
c)
I am going to a concert with my friends this weekend. (77%)
d)
I will stop drinking grapefruit juice every morning. (6%)
e)
-
55.
The nurse is talking with a client who has acute decompensated heart failure and is taking furosemide, digoxin, and sucralfate. Which of the following questions would be a priority for the nurse to ask the client?
a)
Do you exercise regularly at home? (2%)
b)
Have you experienced any unintentional weight loss? (22%)
c)
When was your last visit with your health care provider? (14%)
d)
What time of day do you take each of your medications? (60%)
e)
-
56.
The nurse in the emergency department is caring for a client who has been bitten by a bat and has 2 puncture wounds on the fingertip. Which of the following actions should the nurse take first?
a)
Administer the human rabies vaccine. (17%)
b)
Scrub the wound with povidone-iodine solution or soap and water. (64%)
c)
Inject human rabies immunoglobulin into the proximal wound area. (9%)
d)
Administer the tetanus toxoid vaccine if unable to confirm client vaccination history. (8%)
e)
-
57.
The nurse is caring for a 10-month-old client who is sedated and at risk for skin breakdown. It would require follow-up if the nurse is observed
a)
Applying barrier cream when changing the client's diaper (7%)
b)
Placing a donut pillow under the client's head (59%)
c)
Rotating the site used for the pulse oximeter (13%)
d)
Elevating the head of the bed 30 degrees (19%)
e)
-
58.
The nurse is caring for a client with brain death who is receiving mechanical ventilation. The client's spouse asks about organ donation. Which of the following responses would be appropriate for the nurse to make?
a)
Our facility's ethics committee will determine how to proceed. (5%)
b)
You seem to be thinking the worst. We are doing everything we can. (11%)
c)
Organ donation often provides comfort to family members who are grieving. (9%)
d)
A specialized team will review your spouse's medical history to determine eligibility. (73%)
e)
-
59.
The nurse has attended a staff education program about end-of-life care. Which of the following statements by the nurse would indicate a correct understanding of the program? Select all that apply.
a)
Agitation can indicate the client is experiencing pain.
b)
I should ask the family to leave the room if the client becomes restless.
c)
I will explain interventions to the client even if the client is unresponsive.
d)
Pain management rather than treatment of the client's condition is the goal.
e)
I will encourage the client's family to hold the client's hand while I administer pain medication.
60.
The nurse is screening for clients at risk for myocardial infarction. The nurse should recognize the client at highest risk for atypical presentation of myocardial infarction is a client who
a)
Is female (61%)
b)
Has hypertension (16%)
c)
Has a history of smoking (13%)
d)
Is receiving treatment for hyperlipidemia (8%)
e)
-
61.
The nurse is evaluating the effectiveness of the treatment regimen for a client with major depressive disorder. Which of the following statements by the client would indicate that the treatment regimen has been effective? Select all that apply.
a)
I am trying to eat larger meals, but I still have lost 5 lb (2.27 kg).
b)
I have been getting about 13 hours of sleep at night, but I still feel tired.
c)
I do not have the same interest in physical intimacy that I used to, but my spouse is patient.
d)
I joined a book club with some of the other parents from my children's school.
e)
I like the look of my new haircut and color even though it is very different.
62.
The nurse is teaching the parent of a 6-month-old client who has a new prescription for a liquid iron supplement. Which of the following statements by the parent would require follow-up? Select all that apply.
a)
My child may become constipated.
b)
My child's stools may become black and tarry.
c)
I will administer the medication with meals to increase absorption.
d)
I will administer the medication toward the back of my child's cheek.
e)
I can administer the medication with milk to prevent stomach irritation.
63.
The nurse at an outpatient clinic is reviewing telephone messages from clients previously seen at the clinic. The nurse should first telephone the client who
a)
Had a barium enema 3 days ago and reports constipation (38%)
b)
Had a bowel obstruction that resolved 2 days ago and reports moderate flatulence (2%)
c)
Has ulcerative colitis and reports 3 loose, bloody stools per day for the past 2 days (35%)
d)
Has irritable bowel syndrome and reports 4 loose stools per day for the past 3 days (22%)
e)
-
64.
The nurse is caring for a client who is receiving mechanical ventilation and hears the low-pressure alarm sounding. Which of the following situations would trigger the low-pressure alarm? Select all that apply.
a)
Coughing or gagging
b)
Disconnected ventilator tubing
c)
Cuff leak in the endotracheal tube
d)
Dislodgement of the endotracheal tube
e)
Buildup of secretions in the endotracheal tube
65.
The nurse is observing staff members caring for assigned clients. The nurse should intervene if a staff member is observed
a)
Removing the gloves prior to removing the surgical mask when exiting a client's room (23%)
b)
Scrubbing underneath artificial fingernails while performing hand hygiene (49%)
c)
Using alcohol-based hand rub when entering a client's room (8%)
d)
Washing the hands with soap and water for 20 seconds (18%)
e)
Option B
66.
The nurse is teaching a client with chronic insomnia about sleep hygiene. Which of the following information should the nurse include? Select all that apply.
a)
Drink a glass of red wine about 1 hour before going to bed.
b)
Avoid caffeinated beverages for at least 4 hours before bedtime.
c)
Keep a consistent sleep schedule, even on days that you do not work.
d)
Watch videos on your laptop in bed until you are tired enough to fall asleep.
e)
Get out of bed and read a book if you are still awake 20 minutes after laying down.
67.
The nurse has taught the parents of a 6-month-old client about injury prevention. Which of the following statements by a parent would indicate a correct understanding of the teaching? Select all that apply.
a)
I do not need a childproof gate by the stairs as my baby cannot walk yet.
b)
I can switch to a front-facing car seat as my baby is in the 99th percentile for height.
c)
I use the restraining belt on the high chair every time my baby is sitting in it.
d)
I always check the bathwater temperature before placing my baby in the tub.
e)
I keep all medications and cleaning supplies locked in a cabinet.
68.
The nurse is caring for a client who has chronic kidney disease and is scheduled for hemodialysis today. Which of the following laboratory values should the nurse report to the health care provider before dialysis?
a)
Serum potassium 6.8 mEq/L (6.8 mmol/L)
b)
Serum sodium 138 mEq/L (138 mmol/L)
c)
Serum creatinine 4.0 mg/dL (354 µmol/L)
d)
Blood urea nitrogen 60 mg/dL (21.4 mmol/L)
e)
-
69.
The nurse is caring for a client who had a thyroidectomy 12 hours ago. Which of the following findings would be most concerning?
a)
Serum calcium 8.0 mg/dL (2.0 mmol/L)
b)
Respiratory stridor
c)
Incisional pain rated 7/10
d)
Serosanguineous drainage on the dressing
e)
-
70.
The nurse is providing discharge teaching to a client with newly diagnosed celiac disease. Which of the following client statements indicate that teaching has been effective?
a)
I will avoid wheat, barley, and rye.
b)
I can eat oats as long as they are labeled gluten-free.
c)
I will need to follow this diet for the rest of my life.
d)
I can still enjoy corn, rice, and quinoa.
e)
-
71.
The nurse is providing discharge teaching to a client with chronic obstructive pulmonary disease (COPD). Which of the following client statements indicate that teaching has been effective?
a)
I will use my albuterol inhaler every morning to prevent symptoms.
b)
I will receive the pneumococcal and annual influenza vaccines.
c)
I will increase my oxygen flow rate if I feel short of breath.
d)
I will try to gain weight by eating high-calorie foods.
e)
-
72.
The nurse is caring for a client who had abdominal surgery 2 days ago. Which of the following findings would be most concerning?
a)
Temperature of 100.4 °F (38 °C)
b)
Incisional pain rated 6/10
c)
Serosanguineous drainage from the incision
d)
Abdominal rigidity and guarding
e)
-
73.
The nurse is teaching a client with newly diagnosed type 1 diabetes mellitus about insulin administration. Which of the following client statements indicate a need for further teaching?
a)
I will rotate injection sites within the same anatomical area.
b)
I will inject insulin into my thigh before running.
c)
I will store unopened insulin vials in the refrigerator.
d)
I will carry a source of fast-acting glucose with me.
e)
-
74.
The nurse is caring for a client with cirrhosis. Which of the following findings would require immediate intervention?
a)
Spider angiomas on the chest
b)
Ascites and peripheral edema
c)
Confusion and hand tremors
d)
Bruising on the extremities
e)
-
75.
The nurse is providing teaching to a client with newly diagnosed hypertension about lifestyle modifications. Which of the following client statements indicate that teaching has been effective?
a)
I will limit my sodium intake to less than 2 grams per day.
b)
I will exercise for at least 30 minutes most days of the week.
c)
I will avoid smoking and limit alcohol intake.
d)
I will monitor my blood pressure at home regularly.
e)
-
76.
The nurse is caring for a client with pneumonia who is receiving intravenous antibiotics. Which of the following findings would indicate that the treatment has been effective?
a)
White blood cell count decreased from 15,000/mm³ to 8,000/mm³
b)
Temperature increased from 100.8 °F (38.2 °C) to 102.2 °F (39 °C)
c)
Respiratory rate increased from 20/min to 28/min
d)
Oxygen saturation decreased from 95% to 90%
e)
-
77.
The nurse is providing teaching to a client with newly diagnosed osteoporosis. Which of the following client statements indicate that teaching has been effective?
a)
I will increase my intake of foods rich in calcium and vitamin D.
b)
I will begin weight-bearing exercises such as walking.
c)
I will avoid smoking and limit alcohol intake.
d)
I will take prescribed bisphosphonates as directed.
e)
-
78.
The nurse is caring for a client with a chest tube connected to a closed drainage system. Which of the following findings would require immediate intervention?
a)
Continuous bubbling in the water seal chamber
b)
Fluctuation (tidaling) of fluid in the water seal chamber
c)
Drainage of 50 mL of serosanguineous fluid in the past hour
d)
Drainage system positioned below the level of the chest
e)
-
79.
The nurse is providing discharge teaching to a client with a new prescription for warfarin. Which of the following client statements indicate a need for further teaching?
a)
I will avoid eating large amounts of leafy green vegetables.
b)
I will take my medication at the same time every day.
c)
I will use a soft-bristle toothbrush and electric razor.
d)
I will take aspirin for headaches.
e)
-
80.
The nurse is caring for a client with heart failure who is receiving furosemide. Which of the following findings would indicate that the medication is effective?
a)
Weight decreased from 82 kg to 79 kg in 2 days
b)
Blood pressure decreased from 140/90 mm Hg to 100/60 mm Hg
c)
Potassium level decreased from 4.2 mEq/L to 3.2 mEq/L
d)
Heart rate increased from 78/min to 96/min
e)
-
81.
The nurse is providing teaching to a client with gastroesophageal reflux disease (GERD). Which of the following client statements indicate that teaching has been effective?
a)
I will avoid coffee, chocolate, and spicy foods.
b)
I will eat small, frequent meals instead of large meals.
c)
I will avoid lying down for 2–3 hours after eating.
d)
I will elevate the head of my bed on blocks.
e)
-
82.
The nurse is caring for a client with a chest tube following thoracic surgery. Which of the following findings would require immediate intervention?
a)
Drainage of 100 mL of blood in the first hour
b)
No tidaling in the water seal chamber
c)
Drainage system positioned below the chest
d)
Serosanguineous drainage in the tubing
e)
-
83.
The nurse is providing teaching to a client with newly diagnosed peptic ulcer disease. Which of the following client statements indicate a need for further teaching?
a)
I will avoid NSAIDs such as ibuprofen.
b)
I will avoid alcohol and smoking.
c)
I will take my prescribed antibiotics until they are finished.
d)
I will continue to drink coffee every morning.
e)
-
84.
The nurse is caring for a client with a nasogastric tube connected to low intermittent suction. Which of the following findings would require immediate intervention?
a)
Small amounts of green drainage in the tubing
b)
Abdominal distension and absent bowel sounds
c)
Occasional nausea relieved by antiemetics
d)
Serosanguineous drainage at the insertion site
e)
-
85.
The nurse is providing teaching to a client with a new prescription for levothyroxine. Which of the following client statements indicate that teaching has been effective?
a)
I will take this medication every morning on an empty stomach.
b)
I will not stop taking this medication even if I feel better.
c)
I will expect to take this medication for the rest of my life.
d)
I will notify my health care provider if I experience chest pain or palpitations.
e)
-
86.
The nurse is providing teaching to a client with a new prescription for phenytoin. Which of the following client statements indicate a need for further teaching?
a)
I will not stop taking this medication abruptly.
b)
I will visit my dentist regularly for gum care.
c)
I will take my medication with antacids if I get heartburn.
d)
I will notify my health care provider if I develop a rash.
e)
-
87.
The nurse is caring for a client with a central venous catheter (CVC). Which of the following findings would require immediate intervention?
a)
Air bubbles visible in the tubing
b)
Redness and tenderness at the insertion site
c)
Difficulty flushing the catheter
d)
Transparent dressing intact over the site
e)
-
88.
The nurse is providing discharge teaching to a client with a new prescription for lithium. Which of the following client statements indicate that teaching has been effective?
a)
I will maintain a consistent intake of fluids and salt.
b)
I will have my blood levels checked regularly.
c)
I will notify my health care provider if I develop diarrhea or vomiting.
d)
I will avoid taking NSAIDs unless prescribed.
e)
-
89.
The nurse is caring for a client with a tracheostomy. Which of the following findings would require immediate intervention?
a)
Small amounts of thin, white secretions
b)
Crackling sensation under the skin around the tracheostomy site
c)
Tracheostomy ties secure and intact
d)
Inner cannula removed for cleaning
e)
-
90.
The nurse is providing teaching to a client with a new prescription for isoniazid (INH) for tuberculosis. Which of the following client statements indicate a need for further teaching?
a)
I will avoid drinking alcohol while taking this medication.
b)
I will take vitamin B6 to prevent side effects.
c)
I will stop taking the medication once I feel better.
d)
I will have my liver function monitored regularly.
e)
-
91.
The nurse is providing teaching to a client with a new prescription for metformin. Which of the following client statements indicate a need for further teaching?
a)
I will take this medication with meals.
b)
I will avoid drinking alcohol while taking this medication.
c)
I will stop the medication if I develop severe diarrhea.
d)
I will take the medication even if I am scheduled for a CT scan with contrast.
e)
-
92.
The nurse is caring for a client with a chest tube following lobectomy. Which of the following findings would require immediate intervention?
a)
Drainage of 200 mL of blood in the first hour
b)
Drainage system positioned below the chest
c)
Serosanguineous drainage in the tubing
d)
Fluctuation (tidaling) in the water seal chamber
e)
-
93.
The nurse is providing discharge teaching to a client with a new prescription for prednisone. Which of the following client statements indicate a need for further teaching?
a)
I will not stop taking this medication abruptly.
b)
I will avoid contact with people who are sick.
c)
I will take this medication on an empty stomach.
d)
I will monitor my blood sugar more closely.
e)
-
94.
The nurse is caring for a client with a new colostomy. Which of the following client statements indicate that teaching has been effective?
a)
I will empty my pouch when it is one-third full.
b)
I will cut the opening of the skin barrier 1/8 inch larger than my stoma.
c)
I will avoid foods that cause gas and odor, such as broccoli and beans.
d)
I will drink plenty of fluids to prevent constipation.
e)
-
95.
The nurse is providing teaching to a client with a new prescription for digoxin. Which of the following client statements indicate a need for further teaching?
a)
I will check my pulse before taking this medication.
b)
I will take an extra dose if I miss one.
c)
I will notify my health care provider if I experience nausea or vision changes.
d)
I will keep my medication in its original container.
e)
-
96.
The nurse is providing teaching to a client with a new prescription for nitroglycerin sublingual tablets. Which of the following client statements indicate that teaching has been effective?
a)
I will keep the tablets in their original dark container.
b)
I will take up to 3 tablets in 15 minutes if I have chest pain.
c)
I will call emergency services if the pain is not relieved after the first tablet.
d)
I may experience a headache after taking this medication.
e)
-
97.
The nurse is caring for a client with a peripherally inserted central catheter (PICC). Which of the following findings would require immediate intervention?
a)
Redness and swelling at the insertion site
b)
Difficulty flushing the catheter
c)
Transparent dressing intact over the site
d)
No blood return when aspirating
e)
-
98.
The nurse is providing discharge teaching to a client with a new prescription for hydrochlorothiazide. Which of the following client statements indicate a need for further teaching?
a)
I will take this medication in the morning.
b)
I will eat foods rich in potassium.
c)
I will rise slowly when getting out of bed.
d)
I will take this medication even if my blood pressure is normal.
e)
-
99.
The nurse is caring for a client with a new ileostomy. Which of the following findings would require immediate intervention?
a)
Stoma is pink and moist
b)
Stoma output is liquid and greenish-brown
c)
Stoma is dusky or bluish in color
d)
Peristomal skin is intact
e)
-
100.
The nurse is providing teaching to a client with a new prescription for warfarin. Which of the following foods should the client limit while taking this medication?
a)
Spinach
b)
Oranges
c)
Apples
d)
Potatoes
100 %
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