NCLEX 6

1. The Atlas and the Axis:

2. The body system that functions to maintain fluid balance, support immunity and contains the spleen is the:

3. Mr. and Mrs. K have just adopted a newborn infant and are preparing to take him home from the hospital for the first time. Which safety measure is most appropriate for the clients in this situation?

4. A nurse is caring for newborn infants in a nursery when a man enters the area to take his baby back to the room. The man does not have an identification bracelet and the nurse does not recognize him. What is the next action of the nurse?

5. A nurse is providing education to a group of 6th grade students on choosing well-balanced meals in the cafeteria. If she wants to use an example of a well-balanced meal, which of the following would be a good example? (assume no dietary restrictions apply)

6. Which of the following is an age-related developmental task for a 68-year old client?

7. Which of the following complications is associated with premature rupture of membranes in the pregnant client?

8. A nurse is educating a female client about progesterone. Which of the following information is appropriate to include in this teaching?

9. A nurse is assisting with counseling for a pregnant client who has had genetic testing performed for her unborn child. The geneticist tells this mother that her baby has an extra copy of the 21st chromosome in every cell. Based on this information, the nurse knows that the baby will most likely be born with which condition?

10. A pregnant client who is at 38 weeks’ gestation is seen for prenatal care at a community clinic. The nurse asks the client to lie down while waiting for the physician to arrive. After several minutes of lying on her back, the client becomes dizzy and lightheaded; she is agitated and states she feels she might faint. What is the next action of the nurse?

11. Which example best describes the concept of beneficence?

12. A nurse is at the beginning of her shift in a long-term care facility. Which of the following clients should she check on first?

13. The charge nurse is notified that the unit will be receiving an admission of a client from another bed in the hospital in order to make room for others being admitted through the emergency room. The unit is the Women’s Health Center of the hospital. Which of the following people would be most appropriate to be transferred to this unit?

14. A 22 year old patient has been declared to have experienced an irreversible cessation of brain activity following a motor vehicle accident. The nurse has the legal obligation to address organ donation with the family. The nurse’s priority action at this time would be to:

15. Examples of preservation of self-integrity include all of the following except:

16. Which of the following is an example of intragroup conflict?

17. What does an anti-kickback statute prevent?

18. The nurse working at an acute care hospital is transferring a patient to a skilled nursing facility. The patient’s vital signs documented at 1400 are: T-37.5 degrees Celcius, P- 88, RR-16, BP-135/70, Sp02 93% on RA. The following vital signs documented at 1800, just prior to discharge, are as follows: T-38.5 degrees Celcius, P-102, RR- 18, BP- 158/82, Sp02-91% on RA. What should be the nurse’s next course of action?

19. Which of the following is an example of intrapersonal conflict?

20. A nurse with five years of experience working in a hospital unit is promoted as a mentor and preceptor to a new nursing staff. This is an example of:

21. Which of the following is an example of libel?

22. Mr. R is being seen in his physician’s office for swollen and painful joints. The most obvious joint affected is his great toe, which has become large, red, and painful. Which of the following medications is most appropriate for this condition?

23. Which of the following interventions reduces the risk of infection when administering an intramuscular injection?

24. A nurse is attempting to start an IV in a client’s arm and is having difficulty with finding a vein to use. The client’s skin is cold. Which intervention of the nurse may improve this situation?

25. A client is being admitted on a routine basis for fluids to correct an electrolyte balance. Which of the following sites is most appropriate for starting an IV in this client?

26. Which of the following interventions best helps to facilitate insertion of an intravenous catheter?

27. A client with an IV is complaining of pain at the insertion site. There is a bruise at the site, the skin is tender, and the IV fluid will not flow. Which of the following conditions is the most likely cause of these symptoms?

28. Which of the following solutions is compatible with administration of packed red blood cells?

29. Which of the following is an example of a colloid solution?

30. A nurse is preparing to administer packed red cells for Mr. H when she realizes that he does not have an IV. What is the minimum size of catheter the nurse must use in this situation?

31. A nurse is caring for a client who has been ordered to receive a rapid infusion of packed cells to support his intravascular blood volume. She starts to administer the blood at a fast drip rate and realizes that the blood is not infusing. Which of the following actions may the nurse perform to correct this situation?

32. Which of the following actions is part of preparation of a medication from an ampule?

33. Mr. C is brought to the hospital with severe burns over 45% of his body. His heart rate is 124 bpm and thready, BP 84/46, respirations 24/minute and shallow. He is apprehensive and restless. Which of the following types of shock is Mr. C at highest risk for?

34. Based on Mr. C’s assessment, which of the following nursing interventions is most appropriate?

35. Mr. L was working in his garage at home and had an accident with a power saw. He is brought into the emergency department by a neighbor with a traumatic hand amputation. What is the first action of the nurse?

36. A client is admitted for a head injury. His body is lying in an abnormal position and the physician states he is exhibiting decorticate posturing. Based on this assessment, the nurse can expect to find the client with:

37. All of the following signs are indicative of increased intracranial pressure EXCEPT:

38. A client is diagnosed with Meniere’s disease after suffering from a viral infection. The nurse recognizes that this condition causes:

39. Mrs. P is being admitted for complications of coronary artery disease. The nurse places her on a cardiac monitor and notes that her heart rate is 210 bpm and occasionally irregular. She is unable to measure the P-R interval because the rate is too fast; the QRS complexes are wide. Which of the following conditions does this client most likely have?

40. A nurse is caring for Mr. W, who has been HIV-positive for seven years. Mr. W was recently diagnosed with mycobacterium avium complex (MAC). Based on this diagnosis, the nurse can expect which of the following symptoms from this client?

41. Based on Mr. W’s diagnosis of MAC, which of the following information should be provided to this client?

42. A client begins to choke on food while eating in her room and a nurse is attempting to perform the Heimlich maneuver. After several seconds, the client becomes unconscious. What is the next action of the nurse?

43. A nurse is providing discharge instructions to a patient who will be discharged to a transitional care unit following a right-sided CVA. The patient is ordered a standard walker for ambulation. Which statement by the nurse is the correct discharge instructions for the patient?

44. The nurse is assessing a patient at 1900 who has underwent a total knee replacement. The patient was ordered antiembolic stockings by his physician to prevent thrombus formation. The stockings were applied at 1100 and have not yet been removed. The following action taken by the nurse is a priority:

45. A nurse is preparing to attach a TENS unit to a client who is experiencing pain. Which of the following actions is most appropriate in this situation?

46. When cleansing the genital area during perineal care, the nurse should _______________.

47. You are ready to wash your patient’s face. You would start by washing what area of the face?

48. A nurse is attempting to assess a client’s pulse in his foot. She palpates the pulse on the anterior aspect of his ankle, below the lower end of the medial malleolus. Which type of pulse is this nurse taking?

49. A client has been diagnosed with a form of terminal cancer and has started receiving hospice care. The nurse notes that both the client and his family avoid talking about the diagnosis. All attempts at discussion result in changing the subject. The nurse recognizes that this family is exhibiting:

50. A nurse is preparing to talk about body changes with a client who just had a bilateral mastectomy. Which of the following actions of the nurse is most appropriate during this discussion?

51. A nurse is attempting to speak with a client about his personal feelings of self-esteem and self-concept. Which of the following questions is most appropriate for assessing a client’s personal identity?

52. A term that refers to a comprehensive set of thoughts or images of oneself is called:

53. A nurse is experiencing stress on a busy medical-surgical unit. Each staff nurse has five patients and one of the two nursing assistants (NA) called off this morning. The nurse has one patient requesting pain medication every two hours, one asking for a bed bath, and another patient who is hemodynamically unstable. The nurse begins to cry in the hall stating “I can’t do this” to another nurse. The nurse is advised to prioritize the patient needs and delegate what she can to another nurse, a charge nurse or the NA. The advice given to the nurse is an example of which of the following behavioral techniques:

54. Which of the following interventions is most appropriate when supporting the psychosocial needs of a client who is experiencing negative side effects associated with chemotherapy?

55. Which of the following clients is at the highest risk of becoming a victim of intimate partner violence?

56. A nurse is assessing a client who is being seen for increased anxiety, restlessness, and insomnia. Which of the following interventions is the first priority of the nurse?

57. A nurse is educating a client who is preparing to give a stool sample for occult blood. All of the following information is part of teaching for this client EXCEPT:

58. Which of the following interventions is necessary before insertion of an arterial line into the radial artery?

59. Mrs. M has had diabetes for seven years. She has worked hard to control her blood glucose levels and watch her dietary intake. Her physician orders a hemoglobin A1C test. Which of the following best describes the action of this test?

60. A nurse is monitoring a client for decreased tissue perfusion and increased risk of skin breakdown. Which measure best improves tissue perfusion in this client?

61. A nurse is caring for an 83-year old man who has had swallowing difficulties. All of the following interventions are appropriate for this client EXCEPT:

62. A nurse is preparing to insert an indwelling catheter in a female client. Which of the following positions of the client is most appropriate for this procedure?

63. A client is preparing to undergo a cystoscopy for stones. Which of the following statements indicates that the client understands the procedure?

64. Which of the following conditions may warrant a serum creatinine level?

65. Which nursing intervention is most appropriate to maintain the patency of a client’s nasogastric tube?

66. Alzheimer’s disease patients wander. The dangers associated with this wandering can be prevented with which of the following?

67. Mr. S has just been diagnosed with active tuberculosis. Which of the following nursing interventions should the nurse perform to prevent transmission to others?

68. Which of the following is an example of client handling equipment?

69. Which practice will help to reduce the risk of a needlestick injury?

70. Which of the following actions can a nurse do to prevent a fire from occurring in the area where he works?

71. Which principle of body mechanics may help to reduce the risk of a back injury incurred by the nurse?

72. A nurse caring for a client diagnosed with pertussis is ordered to maintain droplet precautions. Which of the following actions of the nurse upholds droplet precautions?

73. Exhibit 3: Flow sheet of vital signs: 1622:
GCS 15.
T 99.0°F (37.2); BP 110/72 mm Hg; HR 92 bpm; Pulse oximetry 96%; RR 22 breaths/minute;
Pain 8/10.

1626:
GCS 9.
T 98.7°F (37.0); BP 100/66 mm Hg; HR 78 bpm; Pulse oximetry 89%; RR 10 breaths/minute;. Pain unable to rate due to drowsiness.

1632:
GCS 10.
T 98.7°F (37.0); BP 124/76 mm Hg; HR 86 bpm; Pulse oximetry 95% 2 L nasal cannula; RR 12 breaths/minute; Pain unable to rate due to drowsiness.

1637.
GCS 9.
T 98.6°F (37.0); BP 112/72 mm Hg; HR 88 bpm; Pulse oximetry 95% 2 L nasal cannula; RR 10 breaths/minute; Pain unable to rate due to drowsiness.

The nurse administers naloxone at 1627. After reviewing the client’s vital signs and GCS, which action does the nurse take next?

74. The subsequent naloxone administration achieves the desired effect. The client’s pain returns and the nurse observes mild sanguineous drainage and slight swelling under the sutures after assessing the surgical site. Which response by the nurse is correct when the client asks, “How does it look?”

75. In addition to analgesics, which interventions does the nurse include in the client’s plan of care for pain management? Select all that apply.