NCLEX 3

1. A patient is asked to abduct her arms. Which of the following accurately describes her arm movement?

2. Which of the following sets of word parts means, “Pain”?

3. A public health nurse discovers that many of the children in the neighborhood where she works are developing lead toxicity. She implements a program to screen for lead exposures among clients in the community. This is an example of:

4. The community health nurse is educating a group of middle aged men about recommended health screenings. Which of the following statements indicates the client has understood the recommended health screenings for a 50 year old male?

5. Which situation might require an occupational health nurse consult?

6. Which of the following is the most appropriate example of anticipatory guidance for a 16-year old who has been hospitalized for an ankle fracture?

7. Becky is a 17-year-old type I diabetic who has been admitted for her third episode of diabetic ketoacidosis (DKA) since being diagnosed last year. She states that she hates feeling different than her friends and refuses to take her insulin as recommended. What would be the most helpful action for Becky?

8. Which of the following is a true statement about assessing blood pressure by palpation?

9. A student health nurse working at a college is discussing lifestyle choices with a female client who came to the office today. The female client is sexually active and informs the nurse “I use condoms every time, as far as I know”. The student reveals that she is not sexually active exclusively with one person. Which of the following topics should the nurse include in her teaching when educating the client?

10. A nurse is assisting a pregnant client who is having an amniocentesis. Which of the following statements by the nurse indicates the correct teaching for this procedure?

11. A nursing care plan states, “Assist the patient to the bedside commode prn”. When will this patient get this assistance to the commode?

12. You see a sign over Mary Jones’ bed when you arrive at 7 am to begin your day shift. The sign says, “NPO”. Ms. Jones is on a regular diet. The patient asks for milk and some crackers. You _____________.

13. A case manager is planning a discharge for a patient after being admitted to the hospital for an exacerbation of COPD. What information would be a priority in identifying the home care needs for the patient?

14. Match the abbreviation with the correct definition:

15. Which is NOT an acceptable abbreviation?

16. You are taking Mr. D’s blood pressure. The first sound that you hear is at 162 and the second sound that you hear is at 86. You should document and report that the blood pressure is _____________.

17. Your elderly patient has a temperature of 98.5 degrees. Is there anything else that a nurse should do, in addition to documenting this temperature?

18. The abbreviation ac is defined as _____________.

19. The abbreviation pc is defined as ________________.

20. At the beginning of the shift, a nurse receives report for her daily assignment. Which of the following situations should the nurse give first priority?

21. Mr. W has orders for a physical therapy consult. The nurse contacts the appropriate department but 12 hours later, no one has come to see the client. Which is the most appropriate action of the nurse?

22. A drug form in which medication particles are instilled into a liquid and combined through agitation of the solution is called:

23. Following a dose of medication, a client develops inflamed mucous membranes and nasal discharge. What type of minor reaction is this client experiencing?

24. Mr. Y is receiving medication through a catheter that has been placed into the subarachnoid space of his spinal column. What route of medication administration is this called?

25. A client is having difficulties swallowing a large tablet of medication. Which of the following interventions from the nurse may best assist this client?

26. A nurse is attempting to find the ventrogluteal muscle to administer an intramuscular medication. In which method does the nurse find this site?

27. A nurse is administering total parenteral nutrition for a client. The solution contains 12% dextrose and 5% amino acids. Which of the following sites is most appropriate to administer this solution?

28. Mr. S is complaining of pain following a surgical procedure. The nurse checks his orders and finds that he has an order for meperidine 25 mg prn q 4 hrs for shivering. What is the next action of the nurse?

29. Which of the following medications is an example of an adjuvant drug?

30. Which of the following is a potential complication of administering a dorsogluteal intramuscular injection?

31. A nurse is preparing to administer a rectal suppository to a client. After applying gloves, checking the client’s identification band, and closing the door, what is the next step of the nurse?

32. Mr. F has been prescribed isocarboxazid, a monoamine oxidase inhibitor, as part of treatment for depression. Which of the following foods should the nurse instruct the client to avoid while taking this drug?

33. Which of the following situations might warrant a laboratory magnesium level?

34. A client with asthma is being admitted for breathing difficulties. His arterial blood gas results are pH 7.26, PCO2 49, PaO2 90, and HCO3- 21. Which of the following best describes this condition?

35. Mrs. O is seen for follow-up after an episode of acute pancreatitis. Her physician orders a serum amylase level and the result is 200 U/L. Which of the following is a potential cause of this result?

36. Which of the following situations warrants a measurement for orthostatic hypotension?

37. A nurse is caring for a client who has a sodium level of 126 mEq/L. Which of the following symptoms should the nurse expect to see with this client?

38. A 58-year old client is being tested for rheumatoid arthritis. Her physician orders an erythrocyte sedimentation rate (ESR). Which of the following results is most likely to be associated with arthritis?

39. Which of the following statements best describes compartment syndrome?

40. Mrs. G is seen for follow-up after testing for chronically high blood glucose levels. Her physician diagnoses her with type 1 diabetes. Which of the following information is part of this client’s education about this condition?

41. Mrs. F has been diagnosed with hyperparathyroidism. Which of the following complications is Mrs. F at highest risk of developing?

42. A client has entered disseminated intravascular coagulation (DIC) after becoming extremely ill after surgery. Which of the following laboratory findings would the nurse expect to see with this client?

43. A school nurse is providing care for a student who had injured his left ankle on the playground. The student is rating pain a 6/10. The nurse advises the student not to bear weight on his left ankle until he is assessed by a primary care provider. While the student waits for his mother to arrive, the school nurse applies ice to the ankle. This is a correct action by the nurse because cold:

44. A nurse is caring for a client with ariboflavinosis. Which of the following foods should the nurse serve this client?

45. A client is taking a walk down the hallway when she suddenly realizes that she needs to use the restroom. Although she tries to make it to the bathroom on time, she is incontinent of urine before reaching the toilet. What type of incontinence does this situation represent?

46. Which of the following is part of client teaching regarding anti-embolism stockings?

47. A nurse is providing discharge instructions to a 15 year old female following a left fibula fracture. The physician has written the discharge instructions as ‘partial-weight bearing for 2 weeks and must use crutches for all transferring for one week until walker is fit by physical therapy.’ The patient indicates she has understood the instructions when she states the following:

48. Which of the following may be a cultural barrier that impacts a nurse’s ability to provide care or education to the client?

49. Which of the following is an example of low health literacy skills?

50. A nurse is caring for an in-patient client in the hospital who is from another country and who fasts for temporary periods in order to promote his own spiritual growth. The nurse responds by saying, “You need to eat something while you are here. Food and proper nutrition is extremely important for your health.” What social philosophy is the nurse demonstrating?

51. A nurse is using active listening as a form of therapeutic communication when:

52. A client asks a nurse, “Do you think I should move back home after this procedure?” and the nurse responds by saying, “do you think you should move back home?” What type of therapeutic communication is the nurse representing?

53. A nurse walks into a client’s room to find the nursing assistant yelling “sit back down or I won’t help you eat and then you will starve!” This type of behavior is known as:

54. A nurse is talking to the daughter of a patient who just passed away following complications of a motor vehicle accident. The toxicology results reveal the patient’s blood alcohol content was 2.0. The daughter states “My dad has missed every softball game of my daughters this year and now he is gone. I cannot believe he would be so stupid as to drink and drive.” Which of the following statements by the nurse would facilitate mourning?

55. A nurse is examining a woman who has bruises on her face and back in various stages of healing. The client states “sometimes he just gets so angry.” Which of the following statements is most appropriate as a response from the nurse?

56. A nurse is caring for a dying client whose family wants to be with him in the operating suite. The surgeon, however, does not allow families to be present during surgery. The nurse recognizes this as an ethical dilemma. What is the initial step of the nurse when managing this situation?

57. A physician may assess turgor when:

58. When performing an EKG, the patient starts to laugh out of feelings of anxiety. What would you expect the EKG to show? (Choose the BEST answer.)

59. When printing out an EKG, a nurse notices that the QRS complexes are extremely small. What should be the next step?

60. Each small square on the EKG paper is:

61. A patient’s urine specimen tested positive for bilirubin. Which of the following is most true?

62. Which vacutainer tubes should be used when a requisition calls for blood to be drawn for an H&H and glucose test?

63. Specific gravity in urinalysis:

64. When placing a patient in the AP position for an X-ray, what position would the patient be in?

65. A patient’s urine tests positive for glucose. The doctor asks you to confirm this finding. Which of the following would BEST confirm this finding?

66. When teaching a patient to use the three point gait technique of crutch use:

67. A nurse enters a client’s room and finds her lying on the floor near the bathroom door. As the nurse provides assistance, the client states, “I thought I could get up on my own.” What information must the nurse document in this situation?

68. A nurse is performing an end-of-shift count of narcotics kept in the locked cabinet. The narcotic log states there should be 26 oxycodone pills left, but there are only 24 in the drawer. What is the first action of the nurse?

69. Which of the following is an example of whistle blowing?

70. A teacher brings a 5-year old child to the school nurse because of a bruise under her eye. When asked about the bruise, the child responds, “my daddy did it.” What is the nurse’s initial action in this situation?

71. Which of the following accurately reflects the order of discharge/relocation under the criteria for discharge/relocation of patients?

72. OSHA has very strict standards for hospital employees who may encounter hazardous materials or patients who have been exposed to them. These regulations include all of the following EXCEPT:

73. Which of the following conditions should the nurse be concerned about after assessing the client?

74. Which of the following actions should the nurse anticipate to take? Select all that apply.

75. Exhibit 2: Laboratory values (2014): Client’s laboratory values: Serum glucose 524 mg/dL; Serum pH 7.23; Sodium 131 mEq/L; HCO-3 9 mEq/L; BUN 36 mg/dL; Creatinine 1.9 mg/dL; Urine ketones positive._x000D_
_x000D_
Expected range: Serum glucose non-fasted 70-200 mg/dL; Serum pH 7.35- 7.45; Sodium 135-145 mEq/L; HCO-3 22-29 mEq/L; BUN 6-24 mg/dL; Creatinine for women: 0.59 to 1.04 mg/dL; Urine ketones negative._x000D_
_x000D_
The nurse reviews the client’s laboratory values. The nurse should anticipate the healthcare provider to order which of the following for this client?_x000D_