NCLEX 5

1. The heat-regulating center of the brain is the:

2. The anatomic structure located in the middle of the heart which separates the right and left ventricles is the:

3. Select the age group that is coupled with an infectious disease that is most common in this age group.

4. A nurse is providing information for a woman who is 36 weeks’ pregnant and who has hepatitis B. Which of the following statements from the client indicates understanding of this condition?

5. A nurse is caring for a 2-day old infant who has a bilirubin level of 19 mg/dl. The physician has ordered phototherapy. Which of the following actions indicates correct preparation of the infant for this procedure?

6. Mrs. D is a pregnant client who is 33 weeks’ gestation and is admitted for bright red vaginal bleeding. Her physician suspects placenta previa. All of the following nursing interventions are appropriate for this client except:

7. A nurse is caring for Mrs. L, a pregnant client who is 35 weeks’ gestation. The client complains of abdominal pain; her abdomen is rigid and she has little vaginal bleeding. The nurse notes few fetal accelerations on the fetal monitor. Which of the following conditions most likely describes these symptoms?

8. Mrs. L’s blood pressure has dropped to 86/58 and her heart rate is 112 bpm. Based on her assessment, what is the most appropriate action of the nurse?

9. A nurse is performing an education session to a group of middle-aged adults on prevention of osteoporosis. Which of the following statements made by the client indicates they need further teaching regarding prevention of osteoporosis?

10. A patient presents with vesicles covering the upper torso. Which of the following situations could cause this condition?

11. A client is being admitted to the stroke care unit of a rehabilitation center. Which of the following best describes the action of the nurse at admission?

12. A client is refusing to undergo any more treatments in the hospital and wants to leave against medical advice. When the nurse requests the client sign an AMA order, the client refuses and leaves. What is the next action of the nurse?

13. The case manager is determining the discharge needs of a patient on a medical-surgical floor in an acute care hospital. The patient is a 55 year old male that was admitted to the hospital following a fall at work in which he suffered a left femur fracture. His past medical history includes: CHF, COPD, DMII, and HTN. Which discipline’s assessment would be a priority in determining the level of care needs for this patient?

14. Which example best describes a nurse who exhibits moral courage?

15. Which method is most appropriate for managing moral distress in the workplace?

16. A nurse is required to float to another unit within the hospital where he is asked to care for a client on a ventilator. The nurse is uncomfortable with this assignment, as he has not had a ventilated client since nursing school. What is the nurse’s most appropriate response?

17. A nurse is asked to perform a task that she believes is outside her scope of practice. What is the appropriate response to this issue?

18. The staff on a post-partum unit has been complaining to the nurse manager about certain nurses not fulfilling the required weekend shifts. To address the problem, the nurse manager implements new staffing guidelines that would require each nurse to work four weekend shifts per month. The implementation of these guidelines is an example of the following leadership style:

19. A nursing unit is implementing a new electronic charting program for the nursing staff to use. Which of the following best describes a disadvantage of using electronic charting?

20. A client has volunteered to take part in a research study. After participating for two months, he decides that he can no longer tolerate the study and decides to leave. What are the client’s rights in this situation?

21. A client is seen in the emergency room as a victim of suspected domestic violence. The nurse’s aide brings the client to a center curtained area, gives her a gown to change into, and asks her to wait for the nurse. What is the most appropriate action of the nurse upon arrival?

22. Which of the following abbreviations is acceptable to use as part of medication documentation?

23. How many milliliters are equal to one quart of fluid?

24. A nurse receives an order for Iansoprazole (Prevacid) 15 mg daily. The medication is available in syrup form of 5 mg/ml. How many milliliters must this nurse give?

25. A nurse asks her coworker to administer Mr. J’s 12pm medication because she is running behind. Which of the following information must the nurse verify with Mr. J before giving him his medication?

26. Which of the following is more likely to occur with aging as a complication of medication administration?

27. Which of the following interventions should the nurse consider when giving an oral medication to a child?

28. Which of the following methods best describes administration of an intradermal injection?

29. Which of the following is a disadvantage of administering intravenous medications through the IV-push method?

30. A nurse is preparing to administer an ophthalmic medication to Mrs. W. Which of the following statements demonstrates that the nurse is performing this procedure correctly?

31. Which of the following effects does obesity have on drug distribution?

32. Which of the following is a potential side effect of ibuprofen?

33. An 85-year old client is diagnosed with hypernatremia due to lack of fluid intake and dehydration. The nurse knows that symptoms of hypernatremia include:

34. A client is brought into the emergency department after finishing a course of antibiotics for a urinary tract infection. The client is experiencing dyspnea, chest tightness and is agitated. Her blood pressure is 88/58, she has generalized hives over the course of her body and her lips and tongue are swollen. After the nurse calls for help, what is the next appropriate action?

35. A nurse is assessing a client who is post-op day #3 after an abdominal hernia repair. After a bout of harsh coughing, the client states, “it feels like something gave way.” The nurse assesses his abdomen and notes an evisceration from the surgical site. What is the next action of the nurse?

36. A nurse is performing CPR on a client when a co-worker brings an automated external defibrillator (AED). The nurse prepares to apply the patches to the client’s chest when she notes that he has a large amount of thick chest hair. What is the next action of the nurse?

37. A nurse is educating a client who was recently diagnosed with diverticulosis. What types of foods should the nurse recommend for this client?

38. A client is brought into the emergency room where the physician suspects that he has cardiac tamponade. Based on this diagnosis, the nurse would expect to see which of the following signs or symptoms in this client?

39. Which of the following descriptions best describes the function of the thyroid gland?

40. A client in the ICU has been intubated and placed on a ventilator. The physician orders synchronous intermittent mandatory ventilation (SIMV). Which statement best describes the work of this mode of ventilation?

41. A client is seen for testing to rule out Rocky Mountain Spotted Fever. Which of the following signs or symptoms is associated with this condition?

42. A nurse is caring for a newborn infant in the nursery who has developed vomiting, poor feeding, lethargy and respiratory distress. The physician has diagnosed this infant with necrotizing enterocolitis. Which of the following nursing interventions is most appropriate for this infant?

43. A nurse is coming onto her shift at 0700 and is assigned four patients on an orthopedic medical-surgical unit. The first patient is post-op day two from a left-knee replacement and has had uncontrolled pain through the night, rating the pain 9/10. The second patient is post-op day one and ordered an antibiotic IV at 0730. The third patient has physical therapy at 0800 and is requesting pain medication one hour before therapy. The fourth patient is complaining of SOB and hematemesis. Which patient would the nurse see first?

44. Which of the following signs or symptoms indicates a possible nutritional deficiency?

45. A nurse is preparing to insert a small-bore nasogastric feeding tube for a client’s enteral feedings. In which method does the nurse measure the correct length of the tube?

46. In which of the following ways can a nurse promote sleep for a client who is experiencing insomnia?

47. A nurse is preparing to irrigate a client’s colostomy. Which of the following situations is a contraindication for this type of irrigation?

48. Family members of a patient ask repeated questions about the monitors and various readings in the patient’s room. What is the most supportive response to their questions?

49. The mother of a 3-year-old pediatric patient would like to remain at the patient’s bedside throughout the night. The patient seems to be calmer when she is present. What is the most caring and appropriate response?

50. You are caring for a Hispanic patient who is scheduled for surgery in the morning. A member of the surgery staff is in a hurry when she visits the patient to obtain surgical consent. You know that the patient speaks limited English, and can see that he does not really understand what’s being said. What is the most appropriate next action?

51. Brandon is a 38-year-old with a history of cocaine addiction who has just been admitted for his second myocardial infarction that was due to cocaine use. What collaborative process should begin as soon as Brandon is stable enough to interact with additional resources?

52. A nurse is providing care for a patient on a medical-surgical unit who was admitted for nausea and abdominal pain. The patient states “these symptoms have been occurring on and off for months and nobody knows what is wrong with me”. The patient then becomes upset, begins crying, and breathing rapidly. The nurse recognizes that the patient is upset and is experiencing anxiety. What is the most appropriate nursing intervention?

53. What consideration is important when caring for a female Muslim patient?

54. Of the following, what is an important component of Vietnamese culture to consider when teaching the Vietnamese patient who has been treated for pneumonia, who needs to complete her antibiotic regimen at home?

55. If you are caring for a patient of the Hindu culture, what may you anticipate regarding visitors?

56. You are attempting to teach the wife of a Greek patient how to administer his gastrostomy tube feedings once he returns home. She smiles and nods through your explanations, but when you ask her for a return demonstration, she looks confused and shakes her head. Her daughter enters the room and states that she does not speak English. What would be most helpful in this situation?

57. A nurse is providing discharge instructions for a client who had back surgery. All of the following exhibit that the client is ready for discharge EXCEPT:

58. A patient is having a colposcopy procedure performed. How should the patient be instructed to prepare for the procedure?

59. Which of the following conditions may cause an increased respiratory rate?

60. A nurse is attempting to check a blood pressure on a client when she realizes that the cuff is too wide for the size of his arm. What type of reading might this blood pressure cuff produce?

61. A nurse is caring for a client who has just come from surgery and is in the recovery room. The client still has an endotracheal tube in place. The nurse deflates the cuff on the tube and pulls it out, at which time the client sits up in bed, grasps his throat, and begins to make wheezing sounds. Which of the following conditions is the most likely cause of this situation?

62. A client with adrenal insufficiency has a potassium level of 7.2 mEq/L. Which of the following signs or symptoms might the client exhibit with this result?

63. A nurse is assisting Mrs. K, a client who is undergoing a lumbar puncture. Which of the following elements should the nurse use to instruct Mrs. K about this procedure?

64. A nurse is caring for a client who has a right-sided chest tube. The chest tube shows 50 cc of serosanguinous fluid in the collection chamber and air bubbles are collecting in the water seal chamber. Which action is most appropriate for the nurse at this time?

65. A nurse is caring for a client with a broken femur who is in a traction splint in bed. All of the following interventions are part of care of this client EXCEPT:

66. You will be escorting a patient to the operating room on a stretcher. In order to prevent this patient from falling, you must do which of the following?

67. All hospitals and nursing homes are mandated to have the goal of a restraint free environment. The best way to achieve this goal is to________________.

68. Which of these devices is considered a protective device, rather than a restraint?

69. Restraints are sometimes used for what patient conditions or situations?

70. The chain of infection includes the ________________.

71. Asepsis is defined as ________________.

72. Mary T. was admitted to a nursing home on May 1st. On July 4th, she was diagnosed with a skin infection. This infection is considered a ________________ infection.

73. The nurse assumes care of a 76-year-old client post-operatively following a partial small bowel resection on post-op day one._x000D_
_x000D_
Exhibit 1 Vital Signs at 1622:_x000D_
_x000D_
Vital Signs: T 99.0°F (37.2℃); BP 158/90 mm Hg; HR 102 bpm; RR 22 breaths/minute; Pulse oximetry 96%; Pain 8/10._x000D_
During the nursing rounds, the nurse reviews the client’s vital signs. Which prescription does the nurse follow after reviewing the client’s vital signs?

74. The nurse administers the client’s analgesia and returns shortly afterward to reevaluate the pain. The nurse notices the client’s eyes are closed, and when the nurse calls for the client, they do not respond. Which is the best response by the nurse?

75. Exhibit 2 Verbal Prescription from the surgeon: “Administer 0.4mg Naloxone IV now and q 2-3 minutes prn for a total of 3 doses”._x000D_
_x000D_
The nurse determines the client’s respiratory rate is 10 breaths/minute, applies oxygen, and immediately contacts the surgeon. Which of the following actions does the nurse prioritize next after receiving the prescription?_x000D_