NCLEX 9

1. A nurse is asked to draw blood in the antecubital (AC) space. Which of the following veins are found in the AC?

2. The Sinoatrial Node (SA) is located within which of the following heart structures:

3. A nurse is experiencing difficulty managing her patient’s post-operative pain following a cholecystectomy. The current medications the patient is prescribed are ineffective, therefore the physician must be notified. The patient is stating “this is the worst pain I have ever felt in my life time”. The patient is exhibiting facial grimaces and moaning with repositioning. Which of the following statements should be included in the electronic medical record (EMAR) by the nurse?

4. A nurse is working with a client and her 9-month old son. The mother tells the nurse, “Sometimes, he is so naughty! I had to put him in time-out yesterday for throwing toys!” What is the most appropriate response of the nurse?

5. A nurse is preparing immunizations for a 5-year old child who is starting kindergarten. Which statement by the parent indicates understanding of this process?

6. A 72 year old patient was admitted to the hospital for a urinary tract infection (UTI). A nurse is discussing self-care strategies that the patient can perform at home in order to reduce the risk of a recurring UTI. Which of the following strategies would the nurse include in her teaching?

7. A client asks for assistance with correctly preparing bottles of formula for her baby. Which of the following statements should the nurse include as part of teaching?

8. A client who has entered the hospital for surgery tells the nurse that he wants to try and quit smoking. What is the most appropriate action of the nurse?

9. A nurse is providing care to a 7-year old child in the emergency room. Which of the following interventions may be most helpful in this situation?

10. Which of the following persons is at highest risk of developing type 2 diabetes?

11. The purpose of performing quality control is to:

12. Richard is a 72-year-old with stage 4 lung cancer who has been admitted to the hospital for pneumonia. He is alert and oriented, and states he would like to sign a do not resuscitate (DNR) order. His wife enters the room after he has signed it and is very upset that he has made this decision without discussing it with her. She wants to know what she can do to get the DNR reversed. What should your first response be?

13. You are on the unit and overhear another nurse talking on the phone to a patient’s friend who wants to see her patient who is comatose and on a ventilator. Since you cared for that patient yesterday, you know that the patient’s significant other, who is also the designated health care surrogate (HCS) and has power of attorney (POA), has expressly stated that he wants this person on the list for restricted visitors. The nurse whispers that she’ll call him to visit as soon as the significant other has gone home. What should your first response be?

14. Teresa is an 84-year-old with stage 4 ovarian cancer who has been admitted for a bowel obstruction. She recently stated that she has decided that she doesn’t want any further aggressive care and is requesting to be placed under hospice care. Her husband and daughter are supportive of her decision. She spoke with her oncologist about it, and he stated that he did not agree, and wrote orders on her chart for chemotherapy. What would be the best first response to this situation?

15. Upon entering an elderly patient’s room, you find a research assistant with a clipboard, obtaining consent to participate in a new study. After signing the form, the patient begins to ask questions about the study. The assistant smiles and says, “Don’t worry about all that, we’ll take good care of you. Now enjoy the chocolate I brought.” What should your first response be?

16. Monica is a 28-year-old nurse who had been admitted to the hospital after a near-drowning in which she suffered cardiac arrest and hypoxic encephalopathy. She has been stabilized and has a tracheostomy to room air. She has been on the general floor for several weeks, is in a persistent vegetative state, and has a very poor prognosis for any improvement in her neurological status. Monica had previously signed a living will, which indicated that she did not wish to receive enteral feedings to be kept alive if she had a terminal condition or was in a persistent vegetative state from other causes. Her parents have decided to move her to the hospice unit and have given permission for removal of her feeding tube. The patient care technician who has been caring for Monica is very distressed over this decision and feels that the parents are “killing” her. What would be an appropriate initial response?

17. Jack is a 2-month-old with a diagnosis of spinal muscular atrophy (SMA) type I. He has been admitted to the hospital for progressive respiratory difficulty. His parents have been informed that if he is not placed on ventilatory support, he will continue to decompensate and die of respiratory failure. Jack’s physician discusses the poor prognosis of Jack’s condition, and tells the parents that he will not be able to be removed from ventilatory support once it is initiated, due to his progressive neurological disease. After much discussion, the parents have decided to decline ventilatory support, agree to a do not resuscitate (DNR) order, and request hospice care for Jack. Another parent heard them discussing Jack’s situation in the waiting room and says she could never do that to her baby. What is the most appropriate response to this parent?

18. Albert is a patient in the hospital who is scheduled for surgery the following morning. After the pre-operative visit from the anesthesia staff member who has obtained surgical consent, Albert asks for an explanation of what type of surgery he is going to have. He states that he’s not sure what he just signed. What is your best response?

19. If a nurse prevents intentional harm from occurring to a patient, which ethical principle is she supporting?

20. What ethical principle has led to the need for informed consent?

21. Victor is a 43-year-old patient who is HIV positive with a diagnosis of pneumocystis carinii pneumonia (PCP) who has been admitted to the hospital. His prognosis is very poor, and his partner, Roger, would like to have a ceremony performed in his room to honor their union in case something happens to Victor, who is in agreement. What is the most appropriate response to their request?

22. Hospitalized patients who are allowed to administer pain medications to themselves are connected to a PCA or ____________.

23. Which of the following would be an acceptable route for the delivery of parental nutrition for an NPO patient?

24. IV push and IV piggy back are different nicknames for the same method of administering medication.

25. After administering a drug, the time when the body first starts to respond to the medication is called:

26. The Controlled Substance Act categorizes substances into _______ groups based on varying qualifications such as currently accepted medical use and potential for abuse.

27. If a patient received a prescription for Ventolin HFA with the instructions 2 puffs TID, how many puffs per day is the patient instructed to take?

28. A PRN order is an order for a medication that is used on a(n) ________ basis in a hospital.

29. Systemic action pertains to action throughout the body and not at the ____ of administration.

30. The duration of a drug’s action is commonly referred to as its _______.

31. What do palliative drugs do?

32. A physician order for a 120 mg dose of Gentamycin 40mg/mL should be filled with ______ of Gentamycin.

33. Which fact about diabetes is true?

34. Diabetic patients are more prone to ____________ than other people without this chronic disorder.

35. A common childhood illness is caused by the Bordatella pertussis bacterium. Which of the following diseases is caused by this bacteria?

36. A patient that has been diagnosed with alopecia would be described as having:

37. A child is diagnosed with a Greenstick Fracture. Which of the following most accurately describes the broken bone?

38. A patient with Bell’s Palsy would have which of the following complaints?

39. A pathologic condition described as, “Increased intraocular pressure of the eye,” is:

40. A patient presents to the office with a pencil that has completely penetrated the palm of her hand. Which of the following treatments would be BEST in this situation?

41. Of the following, which best describes why subdural hemorrhages are more common in the elderly?

42. Renal failure is broadly divided into specific categories. Which type is the type II diabetic patient most likely to experience secondary to the diabetes?

43. Tommy R., your 68 year old patient, is at risk for falls. He has fallen 3 times in the last month. You should keep Tommy’s ______________ in order to prevent him from falling again.

44. A home care nurse is instructing a patient about routine ostomy care who was recently discharged from the hospital following a bowel resection. The following statement by the patient indicates that the patient understands the nurse’s instructions:

45. Albert B. is incontinent of urine. He also wears glasses and hearing aids. His ____________ lead(s) to his risk for falls.

46. Mr. Freeman has difficulty getting out of bed. The nurse should encourage Mr. Freeman to ______________.

47. A nurse has applied a cold pack to a client’s arm to help decrease swelling and inflammation after an injury. Which of the following signs indicates that the cold pack should be removed?

48. A client is undergoing treatment for alcoholism. Twelve hours after his last drink, he develops tremors, increased heart rate, hallucinations, and seizures. Which stage of withdrawal is this client experiencing?

49. Which of the following nursing interventions is essential when working with a client who has antisocial personality disorder?

50. Which is a true statement regarding stress related disorders?

51. Which of the following nursing outcomes is most appropriate during the crisis stage of caring for a victim of domestic violence?

52. Which of the following is a symptom associated with sensory overload?

53. A nurse is providing care for a client who has just died. Her son states, “She was the most wonderful mother. There was no one who was a better mother than she was. She was perfect.” Which stage of grief is this son experiencing?

54. Which of the following is a true statement about palliative care?

55. According to the CDC, people in which of the following age groups are most likely to meet the criteria for major depression?

56. Your patient has been confused for years. Your patient can be best described as a patient with a chronic ___________ disorder.

57. A client is in need of hemodialysis for end-stage renal failure. The physician has inserted an AV fistula. Which of the following nursing interventions are appropriate when caring for this access site?

58. A nurse is instructing a client in the use of his incentive spirometer. Which of the following statements from the nurse indicates correct teaching about using this device?

59. Which of the following interventions should the nurse use when working with a Jackson-Pratt drain?

60. Which of the following techniques can help to prevent skin irritation or breakdown around a tracheostomy site?

61. A nurse is assisting with a physical exam for a client who presents with possible meningitis. The nurse bends the client’s leg at the hip to a 90-degree angle. When she extends the leg at the knee, the client experiences severe pain. Which type of test is this nurse performing?

62. Which of the following types of dressing changes works as a form of wound debridement?

63. A nurse is caring for a client who was recently diagnosed with breast cancer. The oncologist uses the TNM staging system to classify this case as T2, N2, M0. The nurse understands that TNM stands for:

64. Mr. V is receiving treatment for a spinal cord injury after falling off of his deck at home. He has undergone spinal surgery, and has been placed in a halo traction device. Which of the following nursing interventions are most appropriate for a client with a spinal cord injury?

65. Based on assessment and testing, the physician has diagnosed Mr. V with a cord transection at the level of C8 of the spine. Which of the following types of paralysis is Mr. V most likely to suffer?

66. Which of the following is the correct sequence for removing personal protective equipment?

67. A home health nurse is preparing to visit her next client, whom she has never visited before. Which of the following actions indicates the nurse is upholding safety precautions?

68. The primary purpose of emergency planning is to do which of the following?

69. You must wear gloves when you are _______________.

70. You are taking care of a patient who has active TB. The patient has been put on airborne precautions. The patient is in a special room. You must wear a HEPA mask when you enter the room. Now, the patient has to leave the room and go to the radiology department. How can you transport this patient to the radiology department without spreading the TB throughout the hospital?

71. A patient’s Foley catheter has been discontinued. You will dispose of this patient equipment by doing which of the following?

72. Your AIDS/HIV patient has just died. Should you still use standard precautions as you provide post mortem care?

73. The nurse assumes care of a 20-year-old client struck by a car with a deformity to the left ankle that EMS splinted temporarily utilizing cardboard. The nurse enters the client’s room for the initial client assessment. Which action should the nurse prioritize during the initial evaluation?

74. Exhibit 1: Physical Assessment 1345. Neurological: PERRLA, GCS 15, anxious, alert and oriented._x000D_
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Eyes, Ears, Nose, and Throat: No secretions noted, no scalp tenderness or swelling, no wounds observed, face is symmetrical._x000D_
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Respiratory: Clear lung sounds bilaterally, Equal rise and fall of the chest wall observed, non-labored respirations._x000D_
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Cardiovascular: Tachycardia, brisk capillary refill, +2 peripheral pulses, color appropriate for ethnicity._x000D_
_x000D_
Gastrointestinal: non-tender abdomen, soft, non-distended, bowel sounds active in all four quadrants._x000D_
_x000D_
Genitourinary: genitalia intact, client is continent._x000D_
_x000D_
Musculoskeletal: deformity, decreased movement, and swelling in the left ankle. Spontaneous movement to all other extremities._x000D_
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Integumentary: skin warm and dry, multiple abrasions on bilateral knees, over left scapula, puncture wound to the right knee with bleeding controlled._x000D_
_x000D_
Which of the following findings indicate that the client is receiving adequate circulation to the left foot below the fracture?_x000D_

75. After the nurse performs the initial assessment, which of the following interventions should the nurse anticipate for this client? Select all that apply.