NCLEX 7

1. The duodenum:

2. The flap of tissue that covers the trachea upon swallowing is called the:

3. Which of the following symptoms is a presumptive indication of pregnancy?

4. A client is being seen for confirmation of pregnancy. She states her last menstrual period was June 2nd. According to Naegele’s rule, what is this client’s estimated due date (EDD)?

5. A nurse attends the delivery of a full-term infant. After the infant is delivered, she carries him to the warmer and dries him off. His heart rate is 120 bpm, his body is flexed with good muscle tone, his hands and feet are blue while the rest of his body is pink, and he starts to cry when stimulated. Which of the following is the most appropriate Apgar score for this infant?

6. A nurse is caring for a woman who just had a baby 6 hours ago. The nurse is concerned because the mother seems more interested in letting her husband care for the baby. Which of Rubin’s puerperal phases is this mother exhibiting?

7. A nurse is performing a birth assessment on an infant who was born one hour ago. During her assessment, she strokes the sole of the infant’s foot from the heel up toward the toes and notices that the toes flare as a response. Which test is this nurse performing?

8. A sexually active client asks the nurse for information about contraception. The client is interested in an intrauterine device as a form of birth control. Which of the following is an advantage of an intrauterine device?

9. Which of the following best describes the cognitive development of an 18-month old child?

10. A nurse is assessing pain response in a 9-month old child. She uses the CRIES scale to determine if he is having pain. The “I” in the CRIES scale stands for:

11. All of the following are essential components of supervision EXCEPT:

12. Which of the following is an example of a breach to a client’s right to privacy?

13. Which of the following abides by the Americans with Disabilities Act of 1990?

14. A patient that is post-op day three from a total knee replacement informs the nurse that he lives alone and has two sets of stairs in his home. The following action taken by the nurse would be appropriate after gathering the above information:

15. Because of budget cuts in the hospital, the nursing manager informs the staff that they must either float to other units more often or take their turns staying home from work. Which principle is this nurse manager demonstrating?

16. A new nursing unit is opening in the hospital. In order to meet the staffing needs of the unit, nurses from other areas will be moved and required to work in the new area. When notifying the nurses chosen to staff this area, the nurse manager states “you will either move to work on this unit or you will no longer be employed at this hospital.” Which of the following strategies is this nurse manager using?

17. A group of nurses who work on the quality assurance council of a unit have gathered to discuss ideas about how to educate their coworkers about Joint Commission requirements. Each of the nurses gives ideas, which are listed together without initially criticizing any of the suggestions. Eventually, all ideas on the list will be discussed as to their validity. This activity is known as:

18. An assisted living facility is an example of which type of healthcare provider?

19. Which of the following statements is true regarding non-profit organizations?

20. Which of the following is a function of risk management?

21. Which of the following is an example of effective time management?

22. Which of these clients is the best candidate for using patient-controlled analgesia?

23. Which of the following clients is most likely to benefit from receiving a peripheral nerve block?

24. A nurse has been given an order for a 20 cc bolus to a client with a central line. The only syringes she has available are 5 or 10 cc in size. What is the most appropriate action of the nurse?

25. Mr. L is in the emergency room with a traumatic amputation. The physician determines that he needs a rapid infusion of packed red cells. Mr. L is unconscious and the nurse does not know his blood type. Which of the following blood types might be the safest to use in this situation?

26. Which of the following describes a benefit of using a Groshong® tunneled catheter?

27. Which of the following interventions should the nurse perform when changing a cap on a central line catheter?

28. A nurse is caring for a 5-year old child who just had an appendectomy. The physician wrote orders regarding pain control, diet, and fluid administration. The nurse reads the order that says “Maintain IV D5W at a rate of 500 cc/hr.” What is the most appropriate action of the nurse in this situation?

29. A nurse is teaching a client to care for a Broviac® catheter at home. Which statement from the client indicates understanding of the teaching?

30. Which of the following actions should the nurse consider when working with a multi-dose medication vial?

31. What common drug can be administered to treat wheezing in a patient with infectious pneumonitis?

32. A doctor writes out a prescription for medication to be taken as needed for pain. Which of the following abbreviations could the nurse expect to see on the prescription form?

33. Mrs. H has been diagnosed with multiple myeloma. Based on the risk factors associated with this condition, which of the following background information is most likely true for Mrs. H?

34. Based on Mrs. H’s diagnosis, which of the following complications is she most likely to develop?

35. An 80-year old patient is admitted with dyspnea, dependent edema, rales and distended neck veins. As the nurse monitors the patient, he becomes increasingly short of breath and begins to have cardiac dysrhythmias. The most critical intervention for this patient is to:

36. You are caring for a 20-year old patient with pericarditis. What is the likely cause of pericarditis in a young patient?

37. Your patient has been diagnosed with acute bronchitis. You should expect that all of the following will be ordered EXCEPT:

38. You are caring for an asthmatic patient with an early-phase reaction. Which of the following is indicative of an early phase reaction?

39. Clinical manifestations of asthma include:

40. What drives respiration in a patient with advanced chronic respiratory failure?

41. Which of the following is NOT a warning sign that compensatory mechanisms in a patient in shock are failing?

42. How does shock usually progress?

43. Patients who cannot move in their bed on their own should be turned at least ________________.

44. Cheryl M. has a serious swallowing disorder. She has asked you for a glass of water. The doctor has ordered honey thickness fluids for her. Water is not a honey thickness fluid. It is much thinner. What should you do?

45. You have been asked to record the amount of food that the person has eaten during each meal. What kinds of words or numbers would you use to record this food intake?

46. Mr. Thomas is a well groomed 68 year old male patient. He had prostate surgery two days ago. He has an indwelling catheter and a urinary drainage bag. You have weighed him at 9 am each morning for 3 mornings in a row. Today, on the 4th day, his morning weight is 3 pounds more than it was the day before. Why could he have gained these 3 pounds in one day, on a 1000 calorie diet?

47. The nurse is providing teaching instructions to a group of clients who will have planned orthopedic surgeries next week. She is reviewing methods to reduce the compression of leg veins post-operatively when a client voices concerns of blood clots. Which of the following statements by the client would indicate the need for further teaching?

48. A nurse is assessing a client diagnosed with a substance use disorder in preparation to be discharged from a rehabilitation facility. Which of the following would be the most effective support system in preventing relapse?

49. Which of the following is an example of an opioid?

50. A client comes into the emergency room and asks to see a doctor. He is anxious, visibly upset, and keeps looking behind him to the waiting room. When the nurse asks his chief complaint, he says, “My roommate is trying to kill me.” Which of the following is the most appropriate initial response of the nurse?

51. A 17-year old Asian client is being seen for lower abdominal pain in the right quadrant. The client is accompanied by his parents. The nurse notes that the client’s father does not make eye contact and shows little response when told that the client will need surgery. Which of the following is the most appropriate action of the nurse?

52. Which of the following best describes Eye Movement Desensitization and Reprocessing (EMDR)?

53. Which of the following is an example of neurofeedback used with a child diagnosed with reactive attachment disorder (RAD)?

54. A nurse is using therapeutic techniques to help a client who is having difficulty applying for a job because of panic and anxiety. The nurse pretends to be the job supervisor while the client practices answering questions during an imaginary interview. This technique is an example of:

55. Which of the following actions of the nurse is most appropriate when working with a client who is extremely angry?

56. Which of the following is an advantage of working with psychiatric clients in a group setting?

57. A nurse is caring for a client who is having blood tests and who has an elevated lymphocyte level. Based on knowledge of cellular components, the nurse knows that these cells:

58. Mr. Y had surgery two days ago and is recovering on the surgical unit of the hospital. Just before lunch, he develops chest pain and difficulties with breathing. His respiratory rate is 32/minute, his temperature is 100.8, and he has rales on auscultation. Which of the following nursing interventions is most appropriate in this situation?

59. A client returns from surgery after having a colon resection. The nurse is performing his assessment and notes the wound edges have separated. This condition is called:

60. Mobility is an important human function. The hazards of immobility lead to many physical problems and emotional problems. Immobility can lead to detrimental cardiac, muscular, respiratory, skeletal, urinary, gastrointestinal, skin and emotional changes. Which of the following is an example of a skeletal hazard of immobility?

61. Which is a physical, integumentary risk among the elderly population?

62. You are turning your patient in bed and you see that this confused and lethargic patient had loose car keys and lipstick in the bed and had been lying on them. What is this person at risk for because of all three of these factors: the confusion, lethargy and items in the bed?

63. One of the complications of complete bed rest and immobility is which of the following?

64. Plantar flexion can be prevented with ________________.

65. The smallest of the white blood cells which also can be involved in humoral immunity is the:

66. A nurse is treating a client with suspected carbon monoxide poisoning. Which of the following symptoms are associated with this condition?

67. A nurse attempts to plug in a sequential compression device when she notices a tingling sensation in her hands while touching the cord. What is the next action of the nurse?

68. A client has become combative and is attempting to pull out his IV and take off his surgical dressings. The nurse receives an order to apply wrist restraints. Which action of the nurse signifies that restraints are being used safely?

69. An attack using microorganisms such as bacteria or viral agents with intent to harm others is called:

70. All of the following factors may contribute to client falls EXCEPT:

71. A small fire has erupted in a wastebasket in the client waiting room. Which of the following is the first action of the nurse?

72. A nurse is assisting a client with ambulation in the hallway. The nurse is using a gait belt for further assistance. The client becomes dizzy and starts to faint while walking. What is the first action of the nurse?

73. Which of the following actions should the nurse anticipate upon the client’s arrival? Select all that apply.

74. Exhibit 2 Primary Assessment (Pre and Post Intubation): Prior to intubation (2024): Neurological: GCS 14, anxious, PERRLA; Respiratory: clear breath sounds bilaterally, tachypnea, labored respirations with accessory muscle use; Cardiovascular: sinus tachycardia regular rhythm, S1S2, skin warm and dry._x000D_
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Post intubation (2032): Neurological GCS 3; Respiratory: Decreased left-sided breath sounds and clear right-sided breath sounds, assisted respirations via bag valve mask ventilation; Cardiovascular: sinus tachycardia regular rhythm, S1S2, skin warm and dry._x000D_
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The healthcare provider arrives at the client’s bedside and intubates the client after a sedative and paralytic are administered. Which of the following findings in the client’ s reassessment should most concern the nurse?_x000D_

75. Which of the following information regarding the client’s history obtained from the wife is most significant regarding the client’s current condition?