NCLEX RN uworld #07
1 - Answer A licensed practical nurse is discussing some client findings with the
registered nurse (RN). Which client would be the PRIORITY for the RN to assess
#72116868 (33)
1. 72 year old client with pneumonia who is receiving intravenous fluids and has a new
S3 heart sound.
2. Client with metoprolol for hypertension with pulse of 54/min and blood pressure of
154/82 mm Hg
3. Client who is 8 hours postoperative hip arthroplasty with 205 mL drainage in the
suction drain.
4. Client with 345 ml gastric residual volume aspirated from a PEG tube before an
enteral feed.
1 - Answer The nurse is assessing for the presence of jugular venous distension (JVD)
on a newly admitted client with a history of heart failure. Which is the "BEST" position
for the nurse to place the client in when observing for JVD? #72116868 (34)
1. Head of the bed elevated to a 45 degree angle
2. Head of the bed elevated to a 60 degree angle
3. Head of the bed elevated to a 90 degree angle
4 Head of the bed flat
1,3,4 - Answer The nurse is providing postmortem care for a client who has died after a
long hospitalization. The client had a do-not-resuscitate order in place at the time of
death. Which of the following INTERVENTIONS should the nurse include during
postmortem care in preparation for transfer to the funeral home. "SELECT ALL THAT
APPLY" #72116868 (35)
1. Allow family member to assist with care
2. Call the medical examiner for an autopsy
3. Gently close the client's eyes
4. Place a pad under the perinium
5. Remove the client's dentures.
3 - Answer The nurse is performing well-child examinations in a pediatric clinic. Which
finding "REQUIRES FURTHER EVALUATION?" #72116868 (36)
1. Bilateral bowlegs (genu varum)in a 15 month old
2. Chest rounded with the anteriorposterior diameter equal to the lateral diameter in an
infant.
3. Lateral curvature to the spine noted on examination of a 10 year old girl
4. Presence of an S3 heart sound in a 2 year old.
4 - Answer The nurse is caring for an elderly client with hip replacement surgery. The
client is distressed because he has not had a bowel movement in 3 days. Which action
by the nurse would be "MOST APPROPRIATE.? #72116868 (37)
1. Administer the prescribed as-needed milk of magnesia.
2. Ask dietary services to add more fruits and vegetables to the client's tray
3. Notify the health care provider (HCP)
4. Perform a focused abdominal assessment.
, NCLEX RN uworld #07
1 - Answer An adolescent client with a sore throat is diagnosed with infectious
mononucleosis. Which comments by the caregiver would alert the nurse that
ADDITIONALINSTRUCTION IS NECESSARY?
#72116868 (38)
1. "I need to go to the pharmacy to pick up an antibiotic prescription."
2. "It is acceptable for my child to have ibuprofen for discomfort or fever."
3. "My child will be on bed rest with few activities for the next 2 weeks."
4. "Participation in soccer practice will not be allowed for the next month."
4 - Answer Which statement made by the nurse during a therapy session demonstrates
a need for "FURTHER INSTRUCTION" regarding effective therapeutic communication
techniques? #72116868 (39)
1. "I don't understand what you mean. Can you give me an example."
2. "It is doubtful the president is out to get you"
3. "Tell me more about the day your child died."
4. "Why did you get so angry when she ignored you ?"
1 - Answer A nurse working at the department of health tuberculosis clinic assesses a
client's tuberculin skin test (TST) response. Which response does the nurse identify as
a POSITIVE reaction?
#72116868 (40)
1. 5 millimeter raised, hard area in an HIV infected client.
2. 7 mm warm, red area in an organ transplant client.
3. 10 mm red wheal in an injection drug client
4. 12 mm raised, hard area in a healthy client with no risk factors.
900 mL - Answer A client postoperative from a transurethral prostatectomy has a triple-
lumen Foley catheter and is receiving continuous bladder irrigation of sterile normal
saline solution at 175 mL/hr. The nurse empties the urine drainage bag for a total of
2,300 ml at the end of the 8 hour shift. How many milliliters does the nurse document as
the total amount of urine output for the shift. RECORD YOUR ANSWER AS A WHOLE
NUMBER.
#72116868 (41)
Explanation: Calculate the total amount of irrigating solution infused into the bladder in
milliliters
175 mL x 8 hr = 1400 mL
Calculate the total amount of urine output in milliliters
Total amount of drainage in bag - total amount of irrigating solution infused.
2,300 mL -1,400 mL = 900 mL
1 - Answer A client in active pulmonary tuberculosis is prescribed 4 drug therapy with
ethambutol. The community health nurse instructs the client to notify the health care
provider IMMEDIATELY if which adverse effect associated with ethambutol occurs?
#72116868 (42)
1. Blurred vision
1 - Answer A licensed practical nurse is discussing some client findings with the
registered nurse (RN). Which client would be the PRIORITY for the RN to assess
#72116868 (33)
1. 72 year old client with pneumonia who is receiving intravenous fluids and has a new
S3 heart sound.
2. Client with metoprolol for hypertension with pulse of 54/min and blood pressure of
154/82 mm Hg
3. Client who is 8 hours postoperative hip arthroplasty with 205 mL drainage in the
suction drain.
4. Client with 345 ml gastric residual volume aspirated from a PEG tube before an
enteral feed.
1 - Answer The nurse is assessing for the presence of jugular venous distension (JVD)
on a newly admitted client with a history of heart failure. Which is the "BEST" position
for the nurse to place the client in when observing for JVD? #72116868 (34)
1. Head of the bed elevated to a 45 degree angle
2. Head of the bed elevated to a 60 degree angle
3. Head of the bed elevated to a 90 degree angle
4 Head of the bed flat
1,3,4 - Answer The nurse is providing postmortem care for a client who has died after a
long hospitalization. The client had a do-not-resuscitate order in place at the time of
death. Which of the following INTERVENTIONS should the nurse include during
postmortem care in preparation for transfer to the funeral home. "SELECT ALL THAT
APPLY" #72116868 (35)
1. Allow family member to assist with care
2. Call the medical examiner for an autopsy
3. Gently close the client's eyes
4. Place a pad under the perinium
5. Remove the client's dentures.
3 - Answer The nurse is performing well-child examinations in a pediatric clinic. Which
finding "REQUIRES FURTHER EVALUATION?" #72116868 (36)
1. Bilateral bowlegs (genu varum)in a 15 month old
2. Chest rounded with the anteriorposterior diameter equal to the lateral diameter in an
infant.
3. Lateral curvature to the spine noted on examination of a 10 year old girl
4. Presence of an S3 heart sound in a 2 year old.
4 - Answer The nurse is caring for an elderly client with hip replacement surgery. The
client is distressed because he has not had a bowel movement in 3 days. Which action
by the nurse would be "MOST APPROPRIATE.? #72116868 (37)
1. Administer the prescribed as-needed milk of magnesia.
2. Ask dietary services to add more fruits and vegetables to the client's tray
3. Notify the health care provider (HCP)
4. Perform a focused abdominal assessment.
, NCLEX RN uworld #07
1 - Answer An adolescent client with a sore throat is diagnosed with infectious
mononucleosis. Which comments by the caregiver would alert the nurse that
ADDITIONALINSTRUCTION IS NECESSARY?
#72116868 (38)
1. "I need to go to the pharmacy to pick up an antibiotic prescription."
2. "It is acceptable for my child to have ibuprofen for discomfort or fever."
3. "My child will be on bed rest with few activities for the next 2 weeks."
4. "Participation in soccer practice will not be allowed for the next month."
4 - Answer Which statement made by the nurse during a therapy session demonstrates
a need for "FURTHER INSTRUCTION" regarding effective therapeutic communication
techniques? #72116868 (39)
1. "I don't understand what you mean. Can you give me an example."
2. "It is doubtful the president is out to get you"
3. "Tell me more about the day your child died."
4. "Why did you get so angry when she ignored you ?"
1 - Answer A nurse working at the department of health tuberculosis clinic assesses a
client's tuberculin skin test (TST) response. Which response does the nurse identify as
a POSITIVE reaction?
#72116868 (40)
1. 5 millimeter raised, hard area in an HIV infected client.
2. 7 mm warm, red area in an organ transplant client.
3. 10 mm red wheal in an injection drug client
4. 12 mm raised, hard area in a healthy client with no risk factors.
900 mL - Answer A client postoperative from a transurethral prostatectomy has a triple-
lumen Foley catheter and is receiving continuous bladder irrigation of sterile normal
saline solution at 175 mL/hr. The nurse empties the urine drainage bag for a total of
2,300 ml at the end of the 8 hour shift. How many milliliters does the nurse document as
the total amount of urine output for the shift. RECORD YOUR ANSWER AS A WHOLE
NUMBER.
#72116868 (41)
Explanation: Calculate the total amount of irrigating solution infused into the bladder in
milliliters
175 mL x 8 hr = 1400 mL
Calculate the total amount of urine output in milliliters
Total amount of drainage in bag - total amount of irrigating solution infused.
2,300 mL -1,400 mL = 900 mL
1 - Answer A client in active pulmonary tuberculosis is prescribed 4 drug therapy with
ethambutol. The community health nurse instructs the client to notify the health care
provider IMMEDIATELY if which adverse effect associated with ethambutol occurs?
#72116868 (42)
1. Blurred vision
