تبليغاتX
وبلاگ پرستاری ایران - NCLEX-RN Questions 1-125

وبلاگ پرستاری ایران

NCLEX-RN Questions 1-125

  1. A 43-year-old African American male is admitted with sickle cell anemia. The nurse plans to assess circulation in the lower extremities every 2 hours. Which of the following outcome criteria would the nurse use?

    1. Body temperature of 99°F or less

    2. Toes moved in active range of motion

    3. Sensation reported when soles of feet are touched

    4. Capillary refill of < 3 seconds

  2. A 30-year-old male from Haiti is brought to the emergency department in sickle cell crisis. What is the best position for this client?

    1. Side-lying with knees flexed

    2. Knee-chest

    3. High Fowler's with knees flexed

    4. Semi-Fowler's with legs extended on the bed

  3. A 25-year-old male is admitted in sickle cell crisis. Which of the following interventions would be of highest priority for this client?

    1. Taking hourly blood pressures with mechanical cuff

    2. Encouraging fluid intake of at least 200mL per hour

    3. Position in high Fowler's with knee gatch raised

    4. Administering Tylenol as ordered

  4. Which of the following foods would the nurse encourage the client in sickle cell crisis to eat?

    1. Peaches

    2. Cottage cheese

    3. Popsicle

    4. Lima beans

  5. A newly admitted client has sickle cell crisis. The nurse is planning care based on assessment of the client. The client is complaining of severe pain in his feet and hands. The pulse oximetry is 92. Which of the following interventions would be implemented first? Assume that there are orders for each intervention.

    1. Adjust the room temperature

    2. Give a bolus of IV fluids

    3. Start O2

    4. Administer meperidine (Demerol) 75mg IV push

  6. The nurse is instructing a client with iron-deficiency anemia. Which of the following meal plans would the nurse expect the client to select?

    1. Roast beef, gelatin salad, green beans, and peach pie

    2. Chicken salad sandwich, coleslaw, French fries, ice cream

    3. Egg salad on wheat bread, carrot sticks, lettuce salad, raisin pie

    4. Pork chop, creamed potatoes, corn, and coconut cake

  7. Clients with sickle cell anemia are taught to avoid activities that cause hypoxia and hypoxemia. Which of the following activities would the nurse recommend?

    1. A family vacation in the Rocky Mountains

    2. Chaperoning the local boys club on a snow-skiing trip

    3. Traveling by airplane for business trips

    4. A bus trip to the Museum of Natural History

  8. The nurse is conducting an admission assessment of a client with vitamin B12 deficiency. Which of the following would the nurse include in the physical assessment?

    1. Palpate the spleen

    2. Take the blood pressure

    3. Examine the feet for petechiae

    4. Examine the tongue

  9. An African American female comes to the outpatient clinic. The physician suspects vitamin B12 deficiency anemia. Because jaundice is often a clinical manifestation of this type of anemia, what body part would be the best indicator?

    1. Conjunctiva of the eye

    2. Soles of the feet

    3. Roof of the mouth

    4. Shins

  10. The nurse is conducting a physical assessment on a client with anemia. Which of the following clinical manifestations would be most indicative of the anemia?

    1. BP 146/88

    2. Respirations 28 shallow

    3. Weight gain of 10 pounds in 6 months

    4. Pink complexion

  11. The nurse is teaching the client with polycythemia vera about prevention of complications of the disease. Which of the following statements by the client indicates a need for further teaching?

    1. "I will drink 500mL of fluid or less each day."

    2. "I will wear support hose when I am up."

    3. "I will use an electric razor for shaving."

    4. "I will eat foods low in iron."

  12. A 33-year-old male is being evaluated for possible acute leukemia. Which of the following would the nurse inquire about as a part of the assessment?

    1. The client collects stamps as a hobby.

    2. The client recently lost his job as a postal worker.

    3. The client had radiation for treatment of Hodgkin's disease as a teenager.

    4. The client's brother had leukemia as a child.

  13. An African American client is admitted with acute leukemia. The nurse is assessing for signs and symptoms of bleeding. Where is the best site for examining for the presence of petechiae?

    1. The abdomen

    2. The thorax

    3. The earlobes

    4. The soles of the feet

  14. A client with acute leukemia is admitted to the oncology unit. Which of the following would be most important for the nurse to inquire?

    1. "Have you noticed a change in sleeping habits recently?"

    2. "Have you had a respiratory infection in the last 6 months?"

    3. "Have you lost weight recently?"

    4. "Have you noticed changes in your alertness?"

  15. Which of the following would be the priority nursing diagnosis for the adult client with acute leukemia?

    1. Oral mucous membrane, altered related to chemotherapy

    2. Risk for injury related to thrombocytopenia

    3. Fatigue related to the disease process

    4. Interrupted family processes related to life-threatening illness of a family member

  16. A 21-year-old male with Hodgkin's lymphoma is a senior at the local university. He is engaged to be married and is to begin a new job upon graduation. Which of the following diagnoses would be a priority for this client?

    1. Sexual dysfunction related to radiation therapy

    2. Anticipatory grieving related to terminal illness

    3. Tissue integrity related to prolonged bed rest

    4. Fatigue related to chemotherapy

  17. A client has autoimmune thrombocytopenic purpura. To determine the client's response to treatment, the nurse would monitor:

    1. Platelet count

    2. White blood cell count

    3. Potassium levels

    4. Partial prothrombin time (PTT)

  18. The home health nurse is visiting a client with autoimmune thrombocytopenic purpura (ATP). The client's platelet count currently is 80, It will be most important to teach the client and family about:

    1. Bleeding precautions

    2. Prevention of falls

    3. Oxygen therapy

    4. Conservation of energy

  19. A client with a pituitary tumor has had a transphenoidal hyposphectomy. Which of the following interventions would be appropriate for this client?

    1. Place the client in Trendelenburg position for postural drainage

    2. Encourage coughing and deep breathing every 2 hours

    3. Elevate the head of the bed 30°

    4. Encourage the Valsalva maneuver for bowel movements

  20. The client with a history of diabetes insipidus is admitted with polyuria, polydipsia, and mental confusion. The priority intervention for this client is:

    1. Measure the urinary output

    2. Check the vital signs

    3. Encourage increased fluid intake

    4. Weigh the client

  21. A client with hemophilia has a nosebleed. Which nursing action is most appropriate to control the bleeding?

    1. Place the client in a sitting position with the head hyperextended

    2. Pack the nares tightly with gauze to apply pressure to the source of bleeding

    3. Pinch the soft lower part of the nose for a minimum of 5 minutes

    4. Apply ice packs to the forehead and back of the neck

  22. A client has had a unilateral adrenalectomy to remove a tumor. To prevent complications, the most important measurement in the immediate post-operative period for the nurse to take is:

    1. Blood pressure

    2. Temperature

    3. Output

    4. Specific gravity

  23. A client with Addison's disease has been admitted with a history of nausea and vomiting for the past 3 days. The client is receiving IV glucocorticoids (Solu-Medrol). Which of the following interventions would the nurse implement?

    1. Glucometer readings as ordered

    2. Intake/output measurements

    3. Sodium and potassium levels monitored

    4. Daily weights

  24. A client had a total thyroidectomy yesterday. The client is complaining of tingling around the mouth and in the fingers and toes. What would the nurses' next action be?

    1. Obtain a crash cart

    2. Check the calcium level

    3. Assess the dressing for drainage

    4. Assess the blood pressure for hypertension

  25. A 32-year-old mother of three is brought to the clinic. Her pulse is 52, there is a weight gain of 30 pounds in 4 months, and the client is wearing two sweaters. The client is diagnosed with hypothyroidism. Which of the following nursing diagnoses is of highest priority?

    1. Impaired physical mobility related to decreased endurance

    2. Hypothermia r/t decreased metabolic rate

    3. Disturbed thought processes r/t interstitial edema

    4. Decreased cardiac output r/t bradycardia

  26. The client presents to the clinic with a serum cholesterol of 275mg/dL and is placed on rosuvastatin (Crestor). Which instruction should be given to the client?

    1. Report muscle weakness to the physician.

    2. Allow six months for the drug to take effect.

    3. Take the medication with fruit juice.

    4. Ask the doctor to perform a complete blood count before starting the medication.

  27. The client is admitted to the hospital with hypertensive crises. Diazoxide (Hyperstat) is ordered. During administration, the nurse should:

    1. Utilize an infusion pump

    2. Check the blood glucose level

    3. Place the client in Trendelenburg position

    4. Cover the solution with foil

  28. The 6-month-old client with a ventral septal defect is receiving Digitalis for regulation of his heart rate. Which finding should be reported to the doctor?

    1. Blood pressure of 126/80

    2. Blood glucose of 110mg/dL

    3. Heart rate of 60bpm

    4. Respiratory rate of 30 per minute

  29. The client admitted with angina is given a prescription for nitroglycerine. The client should be instructed to:

    1. Replenish his supply every 3 months

    2. Take one every 15 minutes if pain occurs

    3. Leave the medication in the brown bottle

    4. Crush the medication and take with water

  30. The client is instructed regarding foods that are low in fat and cholesterol. Which diet selection is lowest in saturated fats?

    1. Macaroni and cheese

    2. Shrimp with rice

    3. Turkey breast

    4. Spaghetti

  31. The client is admitted with left-sided congestive heart failure. In assessing the client for edema, the nurse should check the:

    1. Feet

    2. Neck

    3. Hands

    4. Sacrum

  32. The nurse is checking the client's central venous pressure. The nurse should place the zero of the manometer at the:

    1. Phlebostatic axis

    2. PMI

    3. Erb's point

    4. Tail of Spence

  33. The physician orders lisinopril (Zestril) and furosemide (Lasix) to be administered concomitantly to the client with hypertension. The nurse should:

    1. Question the order

    2. Administer the medications

    3. Administer separately

    4. Contact the pharmacy

  34. The best method of evaluating the amount of peripheral edema is:

    1. Weighing the client daily

    2. Measuring the extremity

    3. Measuring the intake and output

    4. Checking for pitting

  35. A client with vaginal cancer is being treated with a radioactive vaginal implant. The client's husband asks the nurse if he can spend the night with his wife. The nurse should explain that:

    1. Overnight stays by family members is against hospital policy.

    2. There is no need for him to stay because staffing is adequate.

    3. His wife will rest much better knowing that he is at home.

    4. Visitation is limited to 30 minutes when the implant is in place.

  36. The nurse is caring for a client hospitalized with a facial stroke. Which diet selection would be suited to the client?

    1. Roast beef sandwich, potato chips, pickle spear, iced tea

    2. Split pea soup, mashed potatoes, pudding, milk

    3. Tomato soup, cheese toast, Jello, coffee

    4. Hamburger, baked beans, fruit cup, iced tea

  37. The physician has prescribed Novalog insulin for a client with diabetes mellitus. Which statement indicates that the client knows when the peak action of the insulin occurs?

    1. "I will make sure I eat breakfast within 10 minutes of taking my insulin."

    2. "I will need to carry candy or some form of sugar with me all the time."

    3. "I will eat a snack around three o'clock each afternoon."

    4. "I can save my dessert from supper for a bedtime snack."

  38. The nurse is teaching basic infant care to a group of first-time parents. The nurse should explain that a sponge bath is recommended for the first 2 weeks of life because:

    1. New parents need time to learn how to hold the baby.

    2. The umbilical cord needs time to separate.

    3. Newborn skin is easily traumatized by washing.

    4. The chance of chilling the baby outweighs the benefits of bathing.

  39. A client with leukemia is receiving Trimetrexate. After reviewing the client's chart, the physician orders Wellcovorin (leucovorin calcium). The rationale for administering leucovorin calcium to a client receiving Trimetrexate is to:

    1. Treat iron-deficiency anemia caused by chemotherapeutic agents

    2. Create a synergistic effect that shortens treatment time

    3. Increase the number of circulating neutrophils

    4. Reverse drug toxicity and prevent tissue damage

  40. A 4-month-old is brought to the well-baby clinic for immunization. In addition to the DPT and polio vaccines, the baby should receive:

    1. Hib titer

    2. Mumps vaccine

    3. Hepatitis B vaccine

    4. MMR

  41. The physician has prescribed Nexium (esomeprazole) for a client with erosive gastritis. The nurse should administer the medication:

    1. 30 minutes before meals

    2. With each meal

    3. In a single dose at bedtime

    4. 30 minutes after meals

  42. A client on the psychiatric unit is in an uncontrolled rage and is threatening other clients and staff. What is the most appropriate action for the nurse to take?

    1. Call security for assistance and prepare to sedate the client.

    2. Tell the client to calm down and ask him if he would like to play cards.

    3. Tell the client that if he continues his behavior he will be punished.

    4. Leave the client alone until he calms down.

  43. When the nurse checks the fundus of a client on the first postpartum day, she notes that the fundus is firm, is at the level of the umbilicus, and is displaced to the right. The next action the nurse should take is to:

    1. Check the client for bladder distention

    2. Assess the blood pressure for hypotension

    3. Determine whether an oxytocic drug was given

    4. Check for the expulsion of small clots

  44. A client is admitted to the hospital with a temperature of 99.8°F, complaints of blood-tinged hemoptysis, fatigue, and night sweats. The client's symptoms are consistent with a diagnosis of:

    1. Pneumonia

    2. Reaction to antiviral medication

    3. Tuberculosis

    4. Superinfection due to low CD4 count

  45. The client is seen in the clinic for treatment of migraine headaches. The drug Imitrex (sumatriptan succinate) is prescribed for the client. Which of the following in the client's history should be reported to the doctor?

    1. Diabetes

    2. Prinzmetal's angina

    3. Cancer

    4. Cluster headaches

  46. The client with suspected meningitis is admitted to the unit. The doctor is performing an assessment to determine meningeal irritation and spinal nerve root inflammation. A positive Kernig's sign is charted if the nurse notes:

    1. Pain on flexion of the hip and knee

    2. Nuchal rigidity on flexion of the neck

    3. Pain when the head is turned to the left side

    4. Dizziness when changing positions

  47. The client with Alzheimer's disease is being assisted with activities of daily living when the nurse notes that the client uses her toothbrush to brush her hair. The nurse is aware that the client is exhibiting:

    1. Agnosia

    2. Apraxia

    3. Anomia

    4. Aphasia

  48. The client with dementia is experiencing confusion late in the afternoon and before bedtime. The nurse is aware that the client is experiencing what is known as:

    1. Chronic fatigue syndrome

    2. Normal aging

    3. Sundowning

    4. Delusions

  49. The client with confusion says to the nurse, "I haven't had anything to eat all day long. When are they going to bring breakfast?" The nurse saw the client in the day room eating breakfast with other clients 30 minutes before this conversation. Which response would be best for the nurse to make?

    1. "You know you had breakfast 30 minutes ago."

    2. "I am so sorry that they didn't get you breakfast. I'll report it to the charge nurse."

    3. "I'll get you some juice and toast. Would you like something else?"

    4. "You will have to wait a while; lunch will be here in a little while."

  50. The doctor has prescribed Exelon (rivastigmine) for the client with Alzheimer's disease. Which side effect is most often associated with this drug?

    1. Urinary incontinence

    2. Headaches

    3. Confusion

    4. Nausea

  51. A client is admitted to the labor and delivery unit in active labor. During examination, the nurse notes a papular lesion on the perineum. Which initial action is most appropriate?

    1. Document the finding

    2. Report the finding to the doctor

    3. Prepare the client for a C-section

    4. Continue primary care as prescribed

  52. A client with a diagnosis of HPV is at risk for which of the following?

    1. Hodgkin's lymphoma

    2. Cervical cancer

    3. Multiple myeloma

    4. Ovarian cancer

  53. During the initial interview, the client reports that she has a lesion on the perineum. Further investigation reveals a small blister on the vulva that is painful to touch. The nurse is aware that the most likely source of the lesion is:

    1. Syphilis

    2. Herpes

    3. Gonorrhea

    4. Condylomata

  54. A client visiting a family planning clinic is suspected of having an STI. The best diagnostic test for treponema pallidum is:

    1. Venereal Disease Research Lab (VDRL)

    2. Rapid plasma reagin (RPR)

    3. Florescent treponemal antibody (FTA)

    4. Thayer-Martin culture (TMC)

  55. A 15-year-old primigravida is admitted with a tentative diagnosis of HELLP syndrome. Which laboratory finding is associated with HELLP syndrome?

    1. Elevated blood glucose

    2. Elevated platelet count

    3. Elevated creatinine clearance

    4. Elevated hepatic enzymes

  56. The nurse is assessing the deep tendon reflexes of a client with preeclampsia. Which method is used to elicit the biceps reflex?

    1. The nurse places her thumb on the muscle inset in the antecubital space and taps the thumb briskly with the reflex hammer.

    2. The nurse loosely suspends the client's arm in an open hand while tapping the back of the client's elbow.

    3. The nurse instructs the client to dangle her legs as the nurse strikes the area below the patella with the blunt side of the reflex hammer.

    4. The nurse instructs the client to place her arms loosely at her side as the nurse strikes the muscle insert just above the wrist.

  57. A primigravida with diabetes is admitted to the labor and delivery unit at 34 weeks gestation. Which doctor's order should the nurse question?

    1. Magnesium sulfate 4gm (25%) IV

    2. Brethine 10mcg IV

    3. Stadol 1mg IV push every 4 hours as needed prn for pain

    4. Ancef 2gm IVPB every 6 hours

  58. A diabetic multigravida is scheduled for an amniocentesis at 32 weeks gestation to determine the L/S ratio and phosphatidyl glycerol level. The L/S ratio is 1:1 and the presence of phosphatidylglycerol is noted. The nurse's assessment of this data is:

    1. The infant is at low risk for congenital anomalies.

    2. The infant is at high risk for intrauterine growth retardation.

    3. The infant is at high risk for respiratory distress syndrome.

    4. The infant is at high risk for birth trauma.

  59. Which observation in the newborn of a diabetic mother would require immediate nursing intervention?

    1. Crying

    2. Wakefulness

    3. Jitteriness

    4. Yawning

  60. The nurse caring for a client receiving intravenous magnesium sulfate must closely observe for side effects associated with drug therapy. An expected side effect of magnesium sulfate is:

    1. Decreased urinary output

    2. Hypersomnolence

    3. Absence of knee jerk reflex

    4. Decreased respiratory rate

  61. The client has elected to have epidural anesthesia to relieve labor pain. If the client experiences hypotension, the nurse would:

    1. Place her in Trendelenburg position

    2. Decrease the rate of IV infusion

    3. Administer oxygen per nasal cannula

    4. Increase the rate of the IV infusion

  62. A client has cancer of the pancreas. The nurse should be most concerned about which nursing diagnosis?

    1. Alteration in nutrition

    2. Alteration in bowel elimination

    3. Alteration in skin integrity

    4. Ineffective individual coping

  63. The nurse is caring for a client with ascites. Which is the best method to use for determining early ascites?

    1. Inspection of the abdomen for enlargement

    2. Bimanual palpation for hepatomegaly

    3. Daily measurement of abdominal girth

    4. Assessment for a fluid wave

  64. The client arrives in the emergency department after a motor vehicle accident. Nursing assessment findings include BP 80/34, pulse rate 120, and respirations 20. Which is the client's most appropriate priority nursing diagnosis?

    1. Alteration in cerebral tissue perfusion

    2. Fluid volume deficit

    3. Ineffective airway clearance

    4. Alteration in sensory perception

  65. The home health nurse is visiting an 18-year-old with osteogenesis imperfecta. Which information obtained on the visit would cause the most concern? The client:

    1. Likes to play football

    2. Drinks several carbonated drinks per day

    3. Has two sisters with sickle cell tract

    4. Is taking acetaminophen to control pain

  66. The nurse working the organ transplant unit is caring for a client with a white blood cell count of During evening visitation, a visitor brings a basket of fruit. What action should the nurse take?

    1. Allow the client to keep the fruit

    2. Place the fruit next to the bed for easy access by the client

    3. Offer to wash the fruit for the client

    4. Tell the family members to take the fruit home

  67. The nurse is caring for the client following a laryngectomy when suddenly the client becomes nonresponsive and pale, with a BP of 90/40 systolic. The initial nurse's action should be to:

    1. Place the client in Trendelenburg position

    2. Increase the infusion of Dextrose in normal saline

    3. Administer atropine intravenously

    4. Move the emergency cart to the bedside

  68. The client admitted 2 days earlier with a lung resection accidentally pulls out the chest tube. Which action by the nurse indicates understanding of the management of chest tubes?

    1. Order a chest x-ray

    2. Reinsert the tube

    3. Cover the insertion site with a Vaseline gauze

    4. Call the doctor

  69. A client being treated with sodium warfarin has a Protime of 120 seconds. Which intervention would be most important to include in the nursing care plan?

    1. Assess for signs of abnormal bleeding

    2. Anticipate an increase in the Coumadin dosage

    3. Instruct the client regarding the drug therapy

    4. Increase the frequency of neurological assessments

  70. Which selection would provide the most calcium for the client who is 4 months pregnant?

    1. A granola bar

    2. A bran muffin

    3. A cup of yogurt

    4. A glass of fruit juice

  71. The client with preeclampsia is admitted to the unit with an order for magnesium sulfate. Which action by the nurse indicates understanding of the possible side effects of magnesium sulfate?

    1. The nurse places a sign over the bed not to check blood pressure in the right arm.

    2. The nurse places a padded tongue blade at the bedside.

    3. The nurse inserts a Foley catheter.

    4. The nurse darkens the room.

  72. A 6-year-old client is admitted to the unit with a hemoglobin of 6g/dL. The physician has written an order to transfuse 2 units of whole blood. When discussing the treatment, the child's mother tells the nurse that she does not believe in having blood transfusions and that she will not allow her child to have the treatment. What nursing action is most appropriate?

    1. Ask the mother to leave while the blood transfusion is in progress

    2. Encourage the mother to reconsider

    3. Explain the consequences without treatment

    4. Notify the physician of the mother's refusal

  73. A client is admitted to the unit 2 hours after an explosion causes burns to the face. The nurse would be most concerned with the client developing which of the following?

    1. Hypovolemia

    2. Laryngeal edema

    3. Hypernatremia

    4. Hyperkalemia

  74. The nurse is evaluating nutritional outcomes for an elderly client with bulimia. Which data best indicates that the plan of care is effective?

    1. The client selects a balanced diet from the menu.

    2. The client's hemoglobin and hematocrit improve.

    3. The client's tissue turgor improves.

    4. The client gains weight.

  75. The client is admitted following repair of a fractured tibia and cast application. Which nursing assessment should be reported to the doctor?

    1. Pain beneath the cast

    2. Warm toes

    3. Pedal pulses weak and rapid

    4. Paresthesia of the toes

  76. The client is having an arteriogram. During the procedure, the client tells the nurse, "I'm feeing really hot." Which response would be best?

    1. "You are having an allergic reaction. I will get an order for Benadryl."

    2. "That feeling of warmth is normal when the dye is injected."

    3. "That feeling of warmth indicates that the clots in the coronary vessels are dissolving."

    4. "I will tell your doctor and let him explain to you the reason for the hot feeling that you are experiencing."

  77. The nurse is observing several healthcare workers providing care. Which action by the healthcare worker indicates a need for further teaching?

    1. The nursing assistant wears gloves while giving the client a bath.

    2. The nurse wears goggles while drawing blood from the client.

    3. The doctor washes his hands before examining the client.

    4. The nurse wears gloves to take the client's vital signs.

  78. The client is having electroconvulsive therapy for treatment of severe depression. Which of the following indicates that the client's ECT has been effective?

    1. The client loses consciousness.

    2. The client vomits.

    3. The client's ECG indicates tachycardia.

    4. The client has a grand mal seizure.

  79. The 5-year-old is being tested for enterobiasis (pinworms). To collect a specimen for assessment of pinworms, the nurse should teach the mother to:

    1. Examine the perianal area with a flashlight 2 or 3 hours after the child is asleep

    2. Scrape the skin with a piece of cardboard and bring it to the clinic

    3. Obtain a stool specimen in the afternoon

    4. Bring a hair sample to the clinic for evaluation

  80. The nurse is teaching the mother regarding treatment for enterobiasis. Which instruction should be given regarding the medication?

    1. Treatment is not recommended for children less than 10 years of age.

    2. The entire family should be treated.

    3. Medication therapy will continue for 1 year.

    4. Intravenous antibiotic therapy will be ordered.

  81. The registered nurse is making assignments for the day. Which client should be assigned to the pregnant nurse?

    1. The client receiving linear accelerator radiation therapy for lung cancer

    2. The client with a radium implant for cervical cancer

    3. The client who has just been administered soluble brachytherapy for thyroid cancer

    4. The client who returned from placement of iridium seeds for prostate cancer

  82. The nurse is planning room assignments for the day. Which client should be assigned to a private room if only one is available?

    1. The client with Cushing's disease

    2. The client with diabetes

    3. The client with acromegaly

    4. The client with myxedema

  83. The nurse caring for a client in the neonatal intensive care unit administers adult-strength Digitalis to the 3-pound infant. As a result of her actions, the baby suffers permanent heart and brain damage. The nurse can be charged with:

    1. Negligence

    2. Tort

    3. Assault

    4. Malpractice

  84. Which assignment should not be performed by the licensed practical nurse?

    1. Inserting a Foley catheter

    2. Discontinuing a nasogastric tube

    3. Obtaining a sputum specimen

    4. Starting a blood transfusion

  85. The client returns to the unit from surgery with a blood pressure of 90/50, pulse 132, and respirations 30. Which action by the nurse should receive priority?

    1. Continuing to monitor the vital signs

    2. Contacting the physician

    3. Asking the client how he feels

    4. Asking the LPN to continue the post-op care

  86. Which nurse should be assigned to care for the postpartal client with preeclampsia?

    1. The RN with 2 weeks of experience in postpartum

    2. The RN with 3 years of experience in labor and delivery

    3. The RN with 10 years of experience in surgery

    4. The RN with 1 year of experience in the neonatal intensive care unit

  87. Which information should be reported to the state Board of Nursing?

    1. The facility fails to provide literature in both Spanish and English.

    2. The narcotic count has been incorrect on the unit for the past 3 days.

    3. The client fails to receive an itemized account of his bills and services received during his hospital stay.

    4. The nursing assistant assigned to the client with hepatitis fails to feed the client and give the bath.

  88. The nurse is suspected of charting medication administration that he did not give. After talking to the nurse, the charge nurse should:

    1. Call the Board of Nursing

    2. File a formal reprimand

    3. Terminate the nurse

    4. Charge the nurse with a tort

  89. The home health nurse is planning for the day's visits. Which client should be seen first?

    1. The 78-year-old who had a gastrectomy 3 weeks ago and has a PEG tube

    2. The 5-month-old discharged 1 week ago with pneumonia who is being treated with amoxicillin liquid suspension

    3. The 50-year-old with MRSA being treated with Vancomycin via a PICC line

    4. The 30-year-old with an exacerbation of multiple sclerosis being treated with cortisone via a centrally placed venous catheter

  90. The emergency room is flooded with clients injured in a tornado. Which clients can be assigned to share a room in the emergency department during the disaster?

    1. A schizophrenic client having visual and auditory hallucinations and the client with ulcerative colitis

    2. The client who is 6 months pregnant with abdominal pain and the client with facial lacerations and a broken arm

    3. A child whose pupils are fixed and dilated and his parents, and a client with a frontal head injury

    4. The client who arrives with a large puncture wound to the abdomen and the client with chest pain

  91. The nurse is caring for a 6-year-old client admitted with a diagnosis of conjunctivitis. Before administering eyedrops, the nurse should recognize that it is essential to consider which of the following?

    1. The eye should be cleansed with warm water, removing any exudate, before instilling the eyedrops.

    2. The child should be allowed to instill his own eyedrops.

    3. The mother should be allowed to instill the eyedrops.

    4. If the eye is clear from any redness or edema, the eyedrops should be held.

  92. The nurse is discussing meal planning with the mother of a 2-year-old toddler. Which of the following statements, if made by the mother, would require a need for further instruction?

    1. "It is okay to give my child white grape juice for breakfast."

    2. "My child can have a grilled cheese sandwich for lunch."

    3. "We are going on a camping trip this weekend, and I have bought hot dogs to grill for his lunch."

    4. "For a snack, my child can have ice cream."

  93. A 2-year-old toddler is admitted to the hospital. Which of the following nursing interventions would you expect?

    1. Ask the parent/guardian to leave the room when assessments are being performed.

    2. Ask the parent/guardian to take the child's favorite blanket home because anything from the outside should not be brought into the hospital.

    3. Ask the parent/guardian to room-in with the child.

    4. If the child is screaming, tell him this is inappropriate behavior.

  94. Which instruction should be given to the client who is fitted for a behind-the-ear hearing aid?

    1. Remove the mold and clean every week.

    2. Store the hearing aid in a warm place.

    3. Clean the lint from the hearing aid with a toothpick.

    4. Change the batteries weekly.

  95. A priority nursing diagnosis for a child being admitted from surgery following a tonsillectomy is:

    1. Body image disturbance

    2. Impaired verbal communication

    3. Risk for aspiration

    4. Pain

  96. A client with bacterial pneumonia is admitted to the pediatric unit. What would the nurse expect the admitting assessment to reveal?

    1. High fever

    2. Nonproductive cough

    3. Rhinitis

    4. Vomiting and diarrhea

  97. The nurse is caring for a client admitted with epiglottis. Because of the possibility of complete obstruction of the airway, which of the following should the nurse have available?

    1. Intravenous access supplies

    2. A tracheostomy set

    3. Intravenous fluid administration pump

    4. Supplemental oxygen

  98. A 25-year-old client with Grave's disease is admitted to the unit. What would the nurse expect the admitting assessment to reveal?

    1. Bradycardia

    2. Decreased appetite

    3. Exophthalmos

    4. Weight gain

  99. The nurse is providing dietary instructions to the mother of an 8-year-old child diagnosed with celiac disease. Which of the following foods, if selected by the mother, would indicate her understanding of the dietary instructions?

    1. Ham sandwich on whole-wheat toast

    2. Spaghetti and meatballs

    3. Hamburger with ketchup

    4. Cheese omelet

  100. The nurse is caring for an 80-year-old with chronic bronchitis. Upon the morning rounds, the nurse finds an O2 sat of 76%. Which of the following actions should the nurse take first?

    1. Notify the physician

    2. Recheck the O2 saturation level in 15 minutes

    3. Apply oxygen by mask

    4. Assess the child's pulse

  101. A gravida III para 0 is admitted to the labor and delivery unit. The doctor performs an amniotomy. Which observation would the nurse be expected to make after the amniotomy?

    1. Fetal heart tones 160bpm

    2. A moderate amount of straw-colored fluid

    3. A small amount of greenish fluid

    4. A small segment of the umbilical cord

  102. The client is admitted to the unit. A vaginal exam reveals that she is 2cm dilated. Which of the following statements would the nurse expect her to make?

    1. "We have a name picked out for the baby."

    2. "I need to push when I have a contraction."

    3. "I can't concentrate if anyone is touching me."

    4. "When can I get my epidural?"

  103. The client is having fetal heart rates of 90–110bpm during the contractions. The first action the nurse should take is:

    1. Reposition the monitor

    2. Turn the client to her left side

    3. Ask the client to ambulate

    4. Prepare the client for delivery

  104. In evaluating the effectiveness of IV Pitocin for a client with secondary dystocia, the nurse should expect:

    1. A painless delivery

    2. Cervical effacement

    3. Infrequent contractions

    4. Progressive cervical dilation

  105. A vaginal exam reveals a footling breech presentation. The nurse should take which of the following actions at this time?

    1. Anticipate the need for a Caesarean section

    2. Apply the fetal heart monitor

    3. Place the client in Genu Pectoral position

    4. Perform an ultrasound exam

  106. A vaginal exam reveals that the cervix is 4cm dilated, with intact membranes and a fetal heart tone rate of 160–170bpm. The nurse decides to apply an external fetal monitor. The rationale for this implementation is:

    1. The cervix is closed.

    2. The membranes are still intact.

    3. The fetal heart tones are within normal limits.

    4. The contractions are intense enough for insertion of an internal monitor.

  107. The following are all nursing diagnoses appropriate for a gravida 1 para 0 in labor. Which one would be most appropriate for the primagravida as she completes the early phase of labor?

    1. Impaired gas exchange related to hyperventilation

    2. Alteration in placental perfusion related to maternal position

    3. Impaired physical mobility related to fetal-monitoring equipment

    4. Potential fluid volume deficit related to decreased fluid intake

  108. As the client reaches 8cm dilation, the nurse notes late decelerations on the fetal monitor. The FHR baseline is 165–175bpm with variability of 0–2bpm. What is the most likely explanation of this pattern?

    1. The baby is asleep.

    2. The umbilical cord is compressed.

    3. There is a vagal response.

    4. There is uteroplacental insufficiency.

  109. The nurse notes variable decelerations on the fetal monitor strip. The most appropriate initial action would be to:

    1. Notify her doctor

    2. Start an IV

    3. Reposition the client

    4. Readjust the monitor

  110. Which of the following is a characteristic of a reassuring fetal heart rate pattern?

    1. A fetal heart rate of 170–180bpm

    2. A baseline variability of 25–35bpm

    3. Ominous periodic changes

    4. Acceleration of FHR with fetal movements

  111. The rationale for inserting a French catheter every hour for the client with epidural anesthesia is:

    1. The bladder fills more rapidly because of the medication used for the epidural.

    2. Her level of consciousness is such that she is in a trancelike state.

    3. The sensation of the bladder filling is diminished or lost.

    4. She is embarrassed to ask for the bedpan that frequently.

  112. A client in the family planning clinic asks the nurse about the most likely time for her to conceive. The nurse explains that conception is most likely to occur when:

    1. Estrogen levels are low.

    2. Lutenizing hormone is high.

    3. The endometrial lining is thin.

    4. The progesterone level is low.

  113. A client tells the nurse that she plans to use the rhythm method of birth control. The nurse is aware that the success of the rhythm method depends on the:

    1. Age of the client

    2. Frequency of intercourse

    3. Regularity of the menses

    4. Range of the client's temperature

  114. A client with diabetes asks the nurse for advice regarding methods of birth control. Which method of birth control is most suitable for the client with diabetes?

    1. Intrauterine device

    2. Oral contraceptives

    3. Diaphragm

    4. Contraceptive sponge

  115. The doctor suspects that the client has an ectopic pregnancy. Which symptom is consistent with a diagnosis of ectopic pregnancy?

    1. Painless vaginal bleeding

    2. Abdominal cramping

    3. Throbbing pain in the upper quadrant

    4. Sudden, stabbing pain in the lower quadrant

  116. The nurse is teaching a pregnant client about nutritional needs during pregnancy. Which menu selection will best meet the nutritional needs of the pregnant client?

    1. Hamburger pattie, green beans, French fries, and iced tea

    2. Roast beef sandwich, potato chips, baked beans, and cola

    3. Baked chicken, fruit cup, potato salad, coleslaw, yogurt, and iced tea

    4. Fish sandwich, gelatin with fruit, and coffee

  117. The client with hyperemesis gravidarum is at risk for developing:

    1. Respiratory alkalosis without dehydration

    2. Metabolic acidosis with dehydration

    3. Respiratory acidosis without dehydration

    4. Metabolic alkalosis with dehydration

  118. A client tells the doctor that she is about 20 weeks pregnant. The most definitive sign of pregnancy is:

    1. Elevated human chorionic gonadatropin

    2. The presence of fetal heart tones

    3. Uterine enlargement

    4. Breast enlargement and tenderness

  119. The nurse is caring for a neonate whose mother is diabetic. The nurse will expect the neonate to be:

    1. Hypoglycemic, small for gestational age

    2. Hyperglycemic, large for gestational age

    3. Hypoglycemic, large for gestational age

    4. Hyperglycemic, small for gestational age

  120. Which of the following instructions should be included in the nurse's teaching regarding oral contraceptives?

    1. Weight gain should be reported to the physician.

    2. An alternate method of birth control is needed when taking antibiotics.

    3. If the client misses one or more pills, two pills should be taken per day for 1 week.

    4. Changes in the menstrual flow should be reported to the physician.

  121. The nurse is discussing breastfeeding with a postpartum client. Breastfeeding is contraindicated in the postpartum client with:

    1. Diabetes

    2. Positive HIV

    3. Hypertension

    4. Thyroid disease

  122. A client is admitted to the labor and delivery unit complaining of vaginal bleeding with very little discomfort. The nurse's first action should be to:

    1. Assess the fetal heart tones

    2. Check for cervical dilation

    3. Check for firmness of the uterus

    4. Obtain a detailed history

  123. A client telephones the emergency room stating that she thinks that she is in labor. The nurse should tell the client that labor has probably begun when:

    1. Her contractions are 2 minutes apart.

    2. She has back pain and a bloody discharge.

    3. She experiences abdominal pain and frequent urination.

    4. Her contractions are 5 minutes apart.

  124. The nurse is teaching a group of prenatal clients about the effects of cigarette smoke on fetal development. Which characteristic is associated with babies born to mothers who smoked during pregnancy?

    1. Low birth weight

    2. Large for gestational age

    3. Preterm birth, but appropriate size for gestation

    4. Growth retardation in weight and length

  125. The physician has ordered an injection of RhoGam for the postpartum client whose blood type is A negative but whose baby is O positive. To provide postpartum prophylaxis, RhoGam should be administered:

    1. Within 72 hours of delivery

    2. Within 1 week of delivery

    3. Within 2 weeks of delivery

    4. Within 1 month of delivery

+ نوشته شده در  پنجشنبه بیست و پنجم تیر 1388ساعت 14:11  توسط علی خواجوی  | 
صفحه نخست
پست الکترونیک
آرشیو وبلاگ
عناوین مطالب وبلاگ

نوشته های پیشین

مرداد 1388
تیر 1388

آرشیو موضوعی

سوالات و نکات خلاصه امتحانات پرستاری
Nursing News & Articles

پیوندها

جامعه پرستاران ایران
 RSS 

POWERED BY
BLOGFA.COM