WorksheetsNCLEX - Mock Test 2
Total questions: 100
Worksheet time: 2hrs 40mins
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
b)
a client who had a bowel resection 1 day ago and a client with asthma exacerbation
c)
a client who had a total hip arthroplasty 2 days ago and a client with influenza
d)
a client with iron-deficiency anemia and a client with intractable diarrhea
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.
b)
I plan to attend my grandchild's graduation next month.
c)
I will sign a 'no-suicide' contract at today's appointment.
d)
I seem to have a lot more energy since I started therapy.
e)
-
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.
b)
Activate the emergency response team and initiate CPR.
c)
Request the presence of the client's health care proxy.
d)
Explain the DNAR directive to the client's child.
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
b)
family history of osteoporosis
c)
history of peripheral artery disease
d)
consumes one glass of wine per day
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
b)
insert a peripheral venous access device and administer the amphotericin B
c)
interrupt the transfusion and administer the amphotericin B
d)
wait 1 hour after the transfusion is complete before administering amphotericin B
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!
e)
It breaks my heart that our client with paraplegia was so neglected by the family.
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.
b)
I may become shaky and restless when I am agitated.
c)
I may sleep more often when taking this medicine.
d)
I will try to change positions slowly.
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.
b)
Follow facility protocol for completing an incident report.
c)
Instruct the staff member to document the incident and notify the unit manager.
d)
Instruct the staff member to notify the health care provider about the client's uncontrolled pain.
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
b)
transient ischemic attack 2 days ago and is scheduled to receive aspirin
c)
stroke, is receiving t-PA therapy, and a Glasgow Coma Scale score that has changed from 9 to 13
d)
bowel resection, is receiving parenteral nutrition, and had 4800 mL of urine output over the past 12 hours
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
b)
acetaminophen
c)
sulfadiazine
d)
metformin
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
b)
asks the parent to remain at the bedside to provide comfort
c)
holds the client's hand as a soothing measure
d)
limits the number of staff members in the room to ease the client's anxiety
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
b)
a colonoscopy with polypectomy 1 day ago and is reporting a small amount of rectal bleeding
c)
an arteriovenous graft inserted 2 days ago and is reporting a temperature of 100.9 F (38.3 C)
d)
a laparoscopic inguinal hernia repair 1 day ago and is reporting difficulty with urination
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.
e)
Remove nits from pubic hair with a fine-toothed nit comb.
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
b)
furosemide
c)
guaifenesin
d)
methylprednisolone
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
b)
palms of the hands and soles of the feet
c)
skin over the sacrum and the heels
d)
nail beds of the fingers and toes
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
b)
the house is heated by a wood-burning stove
c)
the house was built in 1983
d)
the client's parents are unemployed and have limited financial resources
e)
-
17.
The nurse is caring for a client with a history of chronic obstructive pulmonary disease (COPD) who is receiving oxygen via nasal cannula. Which of the following findings would require immediate follow-up?
a)
The client is using pursed-lip breathing during ambulation
b)
The client has a respiratory rate of 24/min
c)
The client is receiving oxygen at 6 L/min
d)
The client has bilateral crackles in the lung bases
e)
-
18.
The nurse is reviewing the laboratory results of a client who is receiving warfarin therapy. Which of the following findings would require immediate intervention?
a)
International normalized ratio (INR) of 5.2
b)
Platelet count of 150,000/mm3
c)
Hemoglobin level of 13.0 g/dL
d)
White blood cell count of 9,000/mm3
e)
-
19.
The nurse is caring for a client who has a chest tube connected to suction. Which of the following findings would require immediate intervention?
a)
Continuous bubbling in the suction control chamber
b)
Fluctuation of water level in the water seal chamber
c)
Drainage of 150 mL in the past hour
d)
Occlusive dressing at the insertion site
e)
-
20.
The nurse is caring for a client who has a nasogastric (NG) tube connected to low intermittent suction. Which of the following findings would require immediate intervention?
a)
The client reports nausea and abdominal distension
b)
The NG tube drainage is green
c)
The suction is set to 80 mm Hg
d)
The client's potassium level is 3.4 mEq/L
e)
-
21.
The nurse is caring for a client who has a history of chronic kidney disease and is scheduled for a contrast-enhanced CT scan. Which of the following actions should the nurse take?
a)
Ensure the client has received adequate oral hydration
b)
Verify the client’s creatinine level before the scan
c)
Administer acetylcysteine prior to the scan
d)
Assess for iodine allergy
e)
-
22.
The nurse is caring for a client who has a peripherally inserted central catheter (PICC). Which of the following actions should the nurse take when obtaining a blood sample?
a)
Use a syringe to withdraw blood from the PICC
b)
Flush the PICC with heparin before drawing blood
c)
Apply a tourniquet above the PICC site
d)
Use the distal lumen of the PICC for blood sampling
e)
-
23.
The nurse is caring for a client with a history of heart failure who is receiving furosemide. Which of the following findings would require immediate intervention?
a)
Blood pressure of 100/60 mm Hg
b)
Potassium level of 3.2 mEq/L
c)
Weight loss of 2 lb in 24 hours
d)
Crackles in the lung bases
e)
-
24.
The nurse is caring for a client who has a new tracheostomy. Which of the following findings would require immediate intervention?
a)
Small amount of serosanguineous drainage around the stoma
b)
Tracheostomy ties are secured and clean
c)
Client is alert and oriented with oxygen saturation of 94%
d)
Tracheostomy tube cuff is deflated
e)
-
25.
The nurse is caring for a client who has a chest tube. Which of the following findings would require immediate intervention?
a)
Fluctuation of water level in the water seal chamber
b)
Drainage of 80 mL in the past hour
c)
Continuous bubbling in the water seal chamber
d)
Occlusive dressing at the insertion site
e)
-
26.
The nurse is teaching a client with a new diagnosis of type 2 diabetes mellitus. Which of the following statements by the client would require follow-up?
a)
I will check my blood sugar before meals and at bedtime.
b)
I will carry a snack in case my blood sugar drops.
c)
I will avoid fruit because it has sugar.
d)
I will walk for 30 minutes most days.
e)
-
27.
The nurse is caring for a client who has a prescription for enoxaparin. Which of the following actions should the nurse take?
a)
Administer the medication into the deltoid muscle
b)
Monitor activated partial thromboplastin time (aPTT)
c)
Inject the medication into the abdomen
d)
Assess for signs of bleeding
e)
-
28.
The nurse is caring for a client who is receiving vancomycin. Which of the following findings would require immediate intervention?
a)
Serum creatinine of 2.1 mg/dL
b)
Redness and itching of the face and neck
c)
Tinnitus and hearing loss
d)
Infusion rate of 1 g over 60 minutes
e)
-
29.
The nurse is caring for a client who is receiving digoxin. Which of the following findings would require immediate intervention?
a)
Apical pulse of 58/min
b)
Serum potassium of 3.6 mEq/L
c)
Nausea and vomiting
d)
Serum digoxin level of 1.0 ng/mL
e)
-
30.
The nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following findings would require immediate intervention?
a)
Temperature of 100.9 F (38.3 C)
b)
Weight gain of 1 lb in 24 hours
c)
Serum glucose of 110 mg/dL
d)
Serum sodium of 138 mEq/L
e)
-
31.
The nurse is caring for a client who has a prescription for methotrexate to treat rheumatoid arthritis. Which of the following statements by the client would require further teaching?
a)
I will increase my fluid intake while taking this medication.
b)
I will avoid drinking alcohol while taking methotrexate.
c)
I will take a folic acid supplement every day.
d)
I will continue taking my birth control pills.
e)
-
32.
The nurse is caring for a client with suspected bacterial meningitis. Which of the following findings would require immediate intervention?
a)
Positive Kernig sign
b)
Glasgow Coma Scale score of 12
c)
Temperature of 102.2 F (39.0 C)
d)
Reported inability to move the legs
e)
-
33.
The nurse is caring for a client who has a prescription for clozapine. Which of the following findings would require immediate intervention?
a)
White blood cell count of 2,500/mm3
b)
Weight gain of 4 lb in 1 month
c)
Dry mouth and constipation
d)
Drowsiness and fatigue
e)
-
34.
The nurse is caring for a client who has a prescription for phenytoin. Which of the following findings would require immediate intervention?
a)
Serum phenytoin level of 25 mcg/mL
b)
Reports of mild gingival hyperplasia
c)
History of tonic-clonic seizures
d)
Serum calcium level of 9.2 mg/dL
e)
-
35.
The nurse is caring for a client who has a prescription for metoclopramide. Which of the following findings would require immediate intervention?
a)
Excessive blinking of the eyes
b)
Loss of appetite and nausea
c)
Dry mouth and constipation
d)
Feeling tired and sleepy
e)
-
36.
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.
b)
Turn the client onto the nonoperative side using the log-rolling technique.
c)
Cleanse the incision site with normal saline and apply a new, sterile dressing.
d)
Mark the edges of the drainage on the dressing and continue to monitor the dressing.
e)
-
37.
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.
b)
Obtain a Doppler ultrasound of the right pedal pulse.
c)
Document the right pedal pulse strength as "0".
d)
Notify the health care provider.
e)
-
38.
The nurse is caring for assigned clients. The nurse should first assess the client who
a)
is receiving a continuous infusion of 0.9% sodium chloride at 250 mL/hr and reports swollen legs and a cough.
b)
had a hip replacement 2 days ago and is reporting intense itching at the incision site.
c)
was scheduled to be discharged 2 hours ago and reports increasing frustration regarding the delay.
d)
is receiving 0.9% sodium chloride with 20 mEq/L potassium chloride and has a potassium level of 5.0 mEq/L.
e)
-
39.
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.
b)
I can use a hair removal cream for excess hair growth.
c)
I am going to a concert with my friends this weekend.
d)
I will stop drinking grapefruit juice every morning.
e)
-
40.
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?
b)
Have you experienced any unintentional weight loss?
c)
When was your last visit with your health care provider?
d)
What time of day do you take each of your medications?
e)
-
41.
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.
b)
Scrub the wound with povidone-iodine solution or soap and water.
c)
Inject human rabies immunoglobulin into the proximal wound area.
d)
Administer the tetanus toxoid vaccine if unable to confirm client vaccination history.
e)
-
42.
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.
b)
Placing a donut pillow under the client's head.
c)
Rotating the site used for the pulse oximeter.
d)
Elevating the head of the bed 30 degrees.
e)
-
43.
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.
b)
You seem to be thinking the worst. We are doing everything we can.
c)
Organ donation often provides comfort to family members who are grieving.
d)
A specialized team will review your spouse's medical history to determine eligibility.
e)
-
44.
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?
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.
45.
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.
b)
has hypertension.
c)
has a history of smoking.
d)
is receiving treatment for hyperlipidemia.
e)
-
46.
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?
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.
47.
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?
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.
48.
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.
b)
had a bowel obstruction that resolved 2 days ago and reports moderate flatulence.
c)
has ulcerative colitis and reports 3 loose, bloody stools per day for the past 2 days.
d)
has irritable bowel syndrome and reports 4 loose stools per day for the past 3 days.
e)
-
49.
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?
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.
50.
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.
b)
Scrubbing underneath artificial fingernails while performing hand hygiene.
c)
Using alcohol-based hand rub when entering a client's room.
d)
Washing the hands with soap and water for 20 seconds.
e)
-
51.
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?
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.
52.
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?
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.
53.
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.
b)
had a bowel obstruction that resolved 2 days ago and reports moderate flatulence.
c)
has ulcerative colitis and reports 3 loose, bloody stools per day for the past 2 days.
d)
has irritable bowel syndrome and reports 4 loose stools per day for the past 3 days.
e)
-
54.
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?
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.
55.
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.
b)
Scrubbing underneath artificial fingernails while performing hand hygiene.
c)
Using alcohol-based hand rub when entering a client's room.
d)
Washing the hands with soap and water for 20 seconds.
e)
-
56.
The nurse is teaching a client with chronic insomnia about sleep hygiene. Which of the following information should the nurse include?
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.
57.
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?
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 I put my baby in it.
d)
I always check the bath water temperature with my hand before placing my baby in the tub.
e)
I keep small toys and objects out of reach to prevent choking.
58.
The nurse is caring for a client with a history of alcohol use disorder who is receiving IV lorazepam. Which of the following findings would require immediate intervention?
a)
Confusion and agitation.
b)
Blood pressure 160/90 mm Hg.
c)
Hand tremors and insomnia.
d)
Serum potassium level of 3.4 mEq/L.
e)
-
59.
The nurse is caring for a client who has a prescription for a unit of packed red blood cells. Which of the following actions by the nurse would require follow-up?
a)
Obtaining baseline vital signs before starting the transfusion.
b)
Starting the transfusion within 30 minutes of receiving the blood.
c)
Infusing the blood over 4 hours.
d)
Checking the client's identification using 2 identifiers.
e)
-
60.
The nurse is caring for a client who has a chest tube connected to suction. Which of the following findings would require immediate intervention?
a)
Continuous bubbling in the suction control chamber.
b)
Drainage of 75 mL in the collection chamber over the past hour.
c)
Crackling sensation under the skin around the insertion site.
d)
Water level of 2 cm in the water seal chamber.
e)
-
61.
The nurse is caring for a client who has a prescription for warfarin. Which of the following findings would require immediate intervention?
a)
Bruising on the arms and legs.
b)
International normalized ratio (INR) of 4.5.
c)
Black tarry stools.
d)
Occasional nosebleeds.
e)
-
62.
The nurse is caring for a client with a history of chronic obstructive pulmonary disease (COPD). Which of the following findings would require immediate intervention?
a)
Use of accessory muscles during respiration.
b)
Respiratory rate of 24/min.
c)
PaCO₂ of 55 mm Hg.
d)
New-onset confusion.
e)
-
63.
The nurse is caring for a client who has a prescription for a unit of packed red blood cells. Which of the following actions by the nurse would require follow-up?
a)
Obtaining baseline vital signs before starting the transfusion.
b)
Starting the transfusion within 30 minutes of receiving the blood.
c)
Infusing the blood over 4 hours.
d)
Checking the client's identification using 2 identifiers.
e)
-
64.
The nurse is caring for a client who has a chest tube connected to suction. Which of the following findings would require immediate intervention?
a)
Continuous bubbling in the suction control chamber.
b)
Drainage of 75 mL in the collection chamber over the past hour.
c)
Crackling sensation under the skin around the insertion site.
d)
Water level of 2 cm in the water seal chamber.
e)
-
65.
The nurse is caring for a client who has a prescription for a unit of packed red blood cells. Which of the following actions by the nurse would require follow-up?
a)
Obtaining baseline vital signs before starting the transfusion.
b)
Starting the transfusion within 30 minutes of receiving the blood.
c)
Infusing the blood over 4 hours.
d)
Checking the client's identification using 2 identifiers.
e)
-
66.
The nurse is caring for a client who has a prescription for warfarin. Which of the following findings would require immediate intervention?
a)
Bruising on the arms and legs.
b)
International normalized ratio (INR) of 4.5.
c)
Black tarry stools.
d)
Occasional nosebleeds.
e)
-
67.
The nurse is caring for a client with a history of chronic obstructive pulmonary disease (COPD). Which of the following findings would require immediate intervention?
a)
Use of accessory muscles during respiration.
b)
Respiratory rate of 24/min.
c)
PaCO₂ of 55 mm Hg.
d)
New-onset confusion.
e)
-
68.
The nurse is caring for a client who has a prescription for a unit of packed red blood cells. Which of the following actions by the nurse would require follow-up?
a)
Obtaining baseline vital signs before starting the transfusion.
b)
Starting the transfusion within 30 minutes of receiving the blood.
c)
Infusing the blood over 4 hours.
d)
Checking the client's identification using 2 identifiers.
e)
-
69.
The nurse is caring for a client who has a chest tube connected to suction. Which of the following findings would require immediate intervention?
a)
Continuous bubbling in the suction control chamber.
b)
Drainage of 75 mL in the collection chamber over the past hour.
c)
Crackling sensation under the skin around the insertion site.
d)
Water level of 2 cm in the water seal chamber.
e)
-
70.
The nurse is caring for a client who has a prescription for a unit of packed red blood cells. Which of the following actions by the nurse would require follow-up?
a)
Obtaining baseline vital signs before starting the transfusion.
b)
Starting the transfusion within 30 minutes of receiving the blood.
c)
Infusing the blood over 4 hours.
d)
Checking the client's identification using 2 identifiers.
e)
-
71.
The nurse is caring for a client who has a prescription for warfarin. Which of the following findings would require immediate intervention?
a)
Bruising on the arms and legs.
b)
International normalized ratio (INR) of 4.5.
c)
Black tarry stools.
d)
Occasional nosebleeds.
e)
-
72.
The nurse is caring for a client with a history of chronic obstructive pulmonary disease (COPD). Which of the following findings would require immediate intervention?
a)
Use of accessory muscles during respiration.
b)
Respiratory rate of 24/min.
c)
PaCO₂ of 55 mm Hg.
d)
New-onset confusion.
e)
-
73.
The nurse is caring for a client who has a prescription for a unit of packed red blood cells. Which of the following actions by the nurse would require follow-up?
a)
Obtaining baseline vital signs before starting the transfusion.
b)
Starting the transfusion within 30 minutes of receiving the blood.
c)
Infusing the blood over 4 hours.
d)
Checking the client's identification using 2 identifiers.
e)
-
74.
The nurse is caring for a client who has a chest tube connected to suction. Which of the following findings would require immediate intervention?
a)
Continuous bubbling in the suction control chamber.
b)
Drainage of 75 mL in the collection chamber over the past hour.
c)
Crackling sensation under the skin around the insertion site.
d)
Water level of 2 cm in the water seal chamber.
e)
-
75.
The nurse is caring for a client who has a prescription for a unit of packed red blood cells. Which of the following actions by the nurse would require follow-up?
a)
Obtaining baseline vital signs before starting the transfusion.
b)
Starting the transfusion within 30 minutes of receiving the blood.
c)
Infusing the blood over 4 hours.
d)
Checking the client's identification using 2 identifiers.
e)
-
76.
The nurse is caring for a client who has a prescription for warfarin. Which of the following findings would require immediate intervention?
a)
Bruising on the arms and legs.
b)
International normalized ratio (INR) of 4.5.
c)
Black tarry stools.
d)
Occasional nosebleeds.
e)
-
77.
The nurse is caring for a client with a history of chronic obstructive pulmonary disease (COPD). Which of the following findings would require immediate intervention?
a)
Use of accessory muscles during respiration.
b)
Respiratory rate of 24/min.
c)
PaCO₂ of 55 mm Hg.
d)
New-onset confusion.
e)
-
78.
The nurse is caring for a client who has a prescription for a unit of packed red blood cells. Which of the following actions by the nurse would require follow-up?
a)
Obtaining baseline vital signs before starting the transfusion.
b)
Starting the transfusion within 30 minutes of receiving the blood.
c)
Infusing the blood over 4 hours.
d)
Checking the client's identification using 2 identifiers.
e)
-
79.
The nurse is caring for a client who has a chest tube connected to suction. Which of the following findings would require immediate intervention?
a)
Continuous bubbling in the suction control chamber.
b)
Drainage of 75 mL in the collection chamber over the past hour.
c)
Crackling sensation under the skin around the insertion site.
d)
Water level of 2 cm in the water seal chamber.
e)
-
80.
The nurse is caring for a client who has a prescription for a unit of packed red blood cells. Which of the following actions by the nurse would require follow-up?
a)
Obtaining baseline vital signs before starting the transfusion.
b)
Starting the transfusion within 30 minutes of receiving the blood.
c)
Infusing the blood over 4 hours.
d)
Checking the client's identification using 2 identifiers.
e)
-
81.
The nurse is caring for a client who has a prescription for warfarin. Which of the following findings would require immediate intervention?
a)
Bruising on the arms and legs.
b)
International normalized ratio (INR) of 4.5.
c)
Black tarry stools.
d)
Occasional nosebleeds.
e)
-
82.
The nurse is caring for a client with a history of chronic obstructive pulmonary disease (COPD). Which of the following findings would require immediate intervention?
a)
Use of accessory muscles during respiration.
b)
Respiratory rate of 24/min.
c)
PaCO₂ of 55 mm Hg.
d)
New-onset confusion.
e)
-
83.
The nurse is caring for a client who has a prescription for a unit of packed red blood cells. Which of the following actions by the nurse would require follow-up?
a)
Obtaining baseline vital signs before starting the transfusion.
b)
Starting the transfusion within 30 minutes of receiving the blood.
c)
Infusing the blood over 4 hours.
d)
Checking the client's identification using 2 identifiers.
e)
-
84.
The nurse is caring for a client who has a chest tube connected to suction. Which of the following findings would require immediate intervention?
a)
Continuous bubbling in the suction control chamber.
b)
Drainage of 75 mL in the collection chamber over the past hour.
c)
Crackling sensation under the skin around the insertion site.
d)
Water level of 2 cm in the water seal chamber.
e)
-
85.
The nurse is caring for a client who has a prescription for a unit of packed red blood cells. Which of the following actions by the nurse would require follow-up?
a)
Obtaining baseline vital signs before starting the transfusion.
b)
Starting the transfusion within 30 minutes of receiving the blood.
c)
Infusing the blood over 4 hours.
d)
Checking the client's identification using 2 identifiers.
e)
-
86.
The nurse is caring for a client who has a prescription for warfarin. Which of the following findings would require immediate intervention?
a)
Bruising on the arms and legs.
b)
International normalized ratio (INR) of 4.5.
c)
Black tarry stools.
d)
Occasional nosebleeds.
e)
-
87.
The nurse is caring for a client with a history of chronic obstructive pulmonary disease (COPD). Which of the following findings would require immediate intervention?
a)
Use of accessory muscles during respiration.
b)
Respiratory rate of 24/min.
c)
PaCO₂ of 55 mm Hg.
d)
New-onset confusion.
e)
-
88.
The nurse is caring for a client who has a prescription for a unit of packed red blood cells. Which of the following actions by the nurse would require follow-up?
a)
Obtaining baseline vital signs before starting the transfusion.
b)
Starting the transfusion within 30 minutes of receiving the blood.
c)
Infusing the blood over 4 hours.
d)
Checking the client's identification using 2 identifiers.
e)
-
89.
The nurse is caring for a client who has a chest tube connected to suction. Which of the following findings would require immediate intervention?
a)
Continuous bubbling in the suction control chamber.
b)
Drainage of 75 mL in the collection chamber over the past hour.
c)
Crackling sensation under the skin around the insertion site.
d)
Water level of 2 cm in the water seal chamber.
e)
-
90.
The nurse is caring for a client who has a prescription for a unit of packed red blood cells. Which of the following actions by the nurse would require follow-up?
a)
Obtaining baseline vital signs before starting the transfusion.
b)
Starting the transfusion within 30 minutes of receiving the blood.
c)
Infusing the blood over 4 hours.
d)
Checking the client's identification using 2 identifiers.
e)
-
91.
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.
b)
Obtain a Doppler ultrasound of the right pedal pulse.
c)
Document the right pedal pulse strength as "0".
d)
Notify the health care provider.
e)
-
92.
The nurse is caring for assigned clients. The nurse should first assess the client who
a)
is receiving a continuous infusion of 0.9% sodium chloride at 250 mL/hr and reports swollen legs and a cough.
b)
had a hip replacement 2 days ago and is reporting intense itching at the incision site.
c)
was scheduled to be discharged 2 hours ago and reports increasing frustration regarding the delay.
d)
is receiving 0.9% sodium chloride with 20 mEq/L potassium chloride and has a potassium level of 5.0 mEq/L.
e)
-
93.
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.
b)
I can use a hair removal cream for excess hair growth.
c)
I am going to a concert with my friends this weekend.
d)
I will stop drinking grapefruit juice every morning.
e)
-
94.
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?
b)
Have you experienced any unintentional weight loss?
c)
When was your last visit with your health care provider?
d)
What time of day do you take each of your medications?
e)
-
95.
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.
b)
Scrub the wound with povidone-iodine solution or soap and water.
c)
Inject human rabies immunoglobulin into the proximal wound area.
d)
Administer the tetanus toxoid vaccine if unable to confirm client vaccination history.
e)
-
96.
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.
b)
Placing a donut pillow under the client's head.
c)
Rotating the site used for the pulse oximeter.
d)
Elevating the head of the bed 30 degrees.
e)
-
97.
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.
b)
You seem to be thinking the worst. We are doing everything we can.
c)
Organ donation often provides comfort to family members who are grieving.
d)
A specialized team will review your spouse's medical history to determine eligibility.
e)
-
98.
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?
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.
99.
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.
b)
has hypertension.
c)
has a history of smoking.
d)
is receiving treatment for hyperlipidemia.
e)
-
100.
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?
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.
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