NCLEX 4

1. One of the three smallest bones in the body is the:

2. Which of the following organs would be described as being located retroperitoneally?

3. A nurse is caring for a client in who is in labor. The nurse has attached an electronic fetal monitor to the client’s abdomen and is assessing the baby’s heart rate. She notes that the baby’s heart rate seems to slow down during each contraction. The heart rate does not return to normal limits until after the contraction is complete. Which type of fetal heart rate change does this pattern describe?

4. Which of the following reasons indicates a need for a non-stress test in a pregnant client?

5. The key to the prevention of a pandemic influenza is:

6. Which risk factor places patients and residents at the greatest risk for falls?

7. A nurse is working at the community clinic and is completing a risk behavior assessment on a 16 year old sexually active female who is coming to the clinic for birth control. The nurse should recommend the client undergoes which of the following:

8. You are taking care of Mary Eden. She is an elderly and frail 91 year old resident. She gets confused during evening hours and at times she thinks that she hears her daughter calling her from the other side of the nursing home. Which physical problem places Mary Eden at risk for falls?

9. What kind of preventive measures is MOST likely to be used to prevent Mary Eden from falling because of her muscular frailness?

10. Elderly patients are more prone to dehydration than younger people because the elderly ___________.

11. The “B” in the SBAR acronym stands for:

12. A case manager is planning a discharge for a patient who will be placed on long-term antibiotics secondary to a left hip replacement that has become septic. To facilitate a safe discharge, prioritize the following four “at risk” problems for the discharge plan:

13. Decide which of the following tasks may be delegated to unlicensed assistive personnel.

14. According to HIPAA, which of the following is considered an individual right for privacy of a client’s protected health information?

15. Which of the following clients is most likely ready to be dismissed from an inpatient care setting to home?

16. The nurse is performing discharge teaching for Mrs. S after cardiac angioplasty. Her husband is present for the teaching. While explaining the prescription for antiplatelet medication to use at home, Mrs. S’s husband states, “I don’t think I can afford to refill that medication.” What is the most appropriate response of the nurse?

17. The discharge planning team is discussing plans for the dismissal of a 16-year old admitted for complications associated with asthma. The client’s mother has not participated in any of the discharge planning process, but has stated that she wants to be involved. Which of the following reasons might prohibit this mother from participating in discharge planning?

18. Which of the following is an example of the intervention phase of the individualized nursing care plan for a client who receives a colostomy after a bowel resection?

19. Which of the following is an example of a living will?

20. What is involved with obtaining informed consent?

21. Which of the following questions must the nurse ask when formulating a nursing diagnosis?

22. Which of the following is a disadvantage of taking medication through an oral route?

23. One tablespoon of medication is equal to how many milliliters of fluid?

24. Which of the following must the nurse consider before administering medications through a nasogastric tube?

25. What gauge of needle is most appropriate when giving an adult a subcutaneous injection?

26. Which is the most appropriate muscle site for an intramuscular injection for a 9-month old child?

27. A nurse is caring for a client who is breastfeeding her baby. Which of the following medications can the nurse administer to this client?

28. A nurse is administering a blood transfusion when the client begins to complain of a headache and difficulty breathing. His blood pressure is 170/110 mmHg. What is the next action of the nurse?

29. A nurse is caring for a client who has a triple-lumen, peripherally inserted central catheter (PICC) in the right arm. Which of the following is a consideration when working with this type of central line?

30. A nurse is caring for a client who has low blood pressure. The physician has ordered dopamine 2 mcg/kg/min on a continuous infusion. The nurse notes that the client weights 186 pounds. What is the appropriate rate for this infusion?

31. A nurse needs to administer 15 units of regular insulin and 20 units of NPH subcutaneously to a client with diabetes. In what order does the nurse draw these medications?

32. When preparing to give a client a narcotic analgesic, which of the following information should the nurse provide as part of education?

33. A client is admitted to a nursing unit with a remittent fever. Which statement best describes this pattern of fever?

34. Which of the following components is associated with hypertonic dehydration?

35. Your patient has been diagnosed with herpes simplex virus 2. Which of the following would NOT be included in your teaching of this patient?

36. Sinusitis is caused by a:

37. A local sign of infection is which of the following?

38. A systemic sign of infection is ______________.

39. A complication of osteoporosis is _______________.

40. A nurse finds one of her clients unresponsive in his room. He is not breathing and does not have a pulse. After calling for help, what is the next action of the nurse?

41. A nurse is caring for a client with severe mitral regurgitation and decreased cardiac output. The nurse assesses the client for mental status changes. What is the rationale for this intervention?.

42. Which of the following interventions must the nurse implement while a client is having a grand mal seizure?

43. Which of the following reasons is the most likely cause of constipation in a client?

44. A nurse is assisting a client with range of motion exercises. She moves his leg in a pattern of circumduction. Which movement is this nurse performing?

45. A nurse is assisting a client to lie in the Sims’ position. In what position does the nurse arrange the client?

46. A nurse is instructing a client about how to use his crutches. Which of the following information should the nurse include in her teaching?

47. Which of the following is a disadvantage of using a dry heat application?

48. A nurse is assigned to care for a deaf client. During her lunch hour, she visits the hospital library and reads more about deaf culture in order to better provide appropriate care for her client. This action is an example of:

49. Which of the following clients have a barrier to accessing healthcare?

50. A client in a long-term care facility tells the nurse “my daughter never visits me.” The nurse responds by telling the client that when her own mother was in a long-term care facility, she found it difficult to visit. This is an example of which communication technique?

51. A nurse caring for a pediatric client shows little concern when the parents attempt to speak with her about their daughter’s illness. When approached by the nurse manager about her behavior, the nurse responds by saying “I don’t want to get involved. It doesn’t matter what I do anyway; my work does not make much of a difference.” This nurse is exhibiting which of the following characteristics?

52. A nurse is asked by a physician to speak to a colleague about her unprofessional behavior in front of a client. The nurse does not want to create conflict with her colleague, so she does not confront her and stays away from the physician when he comes in to work the next day. Which type of conflict resolution is this nurse exhibiting?

53. You have accompanied the physician into the family waiting room to tell a young husband that his wife has not survived the car accident she was in. The husband is crying and distraught. What is the most appropriate approach to supporting this family member?

54. Rachel is a 48-year-old mother of three who has been admitted after a drug overdose in a failed suicide attempt. When she regains consciousness, she states that she is ashamed and embarrassed that she tried to take her own life. What is the most therapeutic response to Rachel’s statement?

55. A male nurse that is working on a labor and delivery unit has been pulled from providing care for a patient who is of the Islamic faith . The patient asks the charge nurse to remove her from the nurse’s assignment. The charge nurse understands, fulfills her request, and notifies the nurse. Which explanation by the charge nurse is correct?

56. A 42 year old female was admitted to the ICU following complications after a motor vehicle accident. The patient suffered a Traumatic Brain Injury (TBI) and is now intubated and non-responsive. The patient’s daughter is 17 years old and is at the bedside alone. She is sobbing, saying “she is all I have, if she dies I want to die too”. What question by the nurse elicits the most information in evaluating the daughter’s support system?

57. Manual hematocrits are done:

58. A patient has come to the office for a blood draw. The patient starts to sweat and is very anxious. Which of the following would be the BEST way to proceed?

59. Which of the following tests would MOST LIKELY be performed on a patient that is being monitored for coagulation therapy?

60. Which of the following is MOST TRUE about the ESR test?

61. Which of the following is considered an abnormal lab result?

62. The mordant in the Gram Stain procedure is:

63. A urine pregnancy test:

64. Mr. K is admitted to the orthopedic unit one morning in preparation for a total knee replacement to start in two hours. Which of the following is a priority topic to instruct this client on admission?

65. A nurse in the emergency room enters a client’s care area to start an IV. She finds a man sitting on the table, hunched over, and attempting to take deep breaths. He states, “my chest hurts so much!” His wife is sitting on a chair in the corner, crying. Which of the following is the first action of the nurse?

66. Which of the following screening tools have been found to have a high diagnostic accuracy for screening for intimate partner violence?

67. A family member is complaining that the lights are too dim in the middle of the night when she comes in to visit her husband. What is the most objective response?

68. What is a key principle of patient teaching that must take place to ensure patient safety?

69. A nurse is assessing a client’s pulse oximetry on the surgical unit. As part of routine interventions, the nurse turns off the exam light over the client’s bed. Which of the following best describes the rationale for this intervention?

70. Which of the following conditions increases a client’s risk of aspiration of stomach contents?

71. Hepatitis C virus (HCV) can be spread through hugging, sneezing, coughing, sharing eating utensils and other forms of casual contact.

72. The primary route of transmission of MRSA is via:

73. Exhibit 3: Hourly glucose (2200). 2014: 524 mg/dL; 2100: 468 mg/dL; 2200: 396 mg/dL._x000D_
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At 2032, the nurse begins administering a prescribed continuous IV insulin infusion at 0.1 unit/kg/hr and checks the client’s glucose hourly. Which is the appropriate action by the nurse after reviewing the client’s trending glucose during the infusion?_x000D_

74. During the nurse’s rounding to check the glucose at 2300, the client reports, “my head really hurts.” Which is the most appropriate response by the nurse?

75. Exhibit 4 Nursing Note (2350): The client had reported a headache, and the healthcare provider was immediately notified. The client remained alert and oriented and is acting appropriately for the client’s age. Acetaminophen was administered for the client’s headache, and the client is reporting relief from symptoms. The client is currently resting comfortably, and vital signs are stable. The client is maintained on continuous cardiac monitoring and maintained on insulin infusion per the healthcare provider’s orders. This RN will continue to monitor the client’s neurological status closely._x000D_
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The client’s DKA has resolved after IV insulin and fluid replacement. The nurse educates the client and family regarding type 1 diabetes. Which of the following statements does the nurse include in the education?_x000D_