NCLEX RN uworld#31
4 - Answer A client is admitted to the emergency room with right lower quadrant pain
and suspected ACUTE APPENDICITIS. Which health care provider prescription should
the nurse implement FIRST?
#70890112 (59)
1. Administer 5-325 mg hydrocodone/
acetaminophen PO for pain.
2. Draw blood for complete blood count and electrolyte levels
3. Obtain urine specimen for urinalysis
4. Start intravenous (IV) line with normal saline 100 mL/hr.
3 - Answer A client returns to the unit after receiving hemodialysis for the first time. The
client vomits once, reports headache, and appears restless and disoriented. What is the
PRIORITY interven-tion ? #70890112 (60)
1. Administer antihypertensives that were held prior to dialysis.
2. Administer PRN ondansetron to relieve nausea
3. Contact the health care provider.
4. Place client in Trendelenburg position.
2,3,5 - Answer The nurse is assessing a group of clients in the community health clinic
for METABOLIC SYNDROME. Which clients exhibit features of the syndrome? SELECT
ALL THAT APPLY
#70890112 (61)
1. Female with a low-density lipoprotein (LDL) level of 96 mg/dL
2. Female with a waist circumference of 38 inches.
3. Female with blood pressure of 148/90 mm Hg
4. Male with a fasting blood glucose of 99 mg/dL
5. Male with a triglyceride level of 201 mg/dL
Metabolic syndrome - Answer Individual with
________________________________(insulin resistance syndrome) have an
increased risk of diabetes and coronary artery disease. The presence of abdominal
obesity causes increased insulin production (hyperinsulinemia), this excess insulin
leads to insulin resistance, the primary feature of #70890112 (61)
2 - Answer An emergency department nurse is assigned in triage. Which client should
the nurse assess FIRST? #70890112 (62)
1. Five year old with a superficial leg lacera-tion.
2. Lethargic 3 month old with diarrhea for the past 12 hours.
3. Seven year old with a elevated temperature of 101 F (38.3C) and hematuria
4. Seventeen year old with severe, acute abdominal pain.
2 - Answer The charge nurse evaluates the care provided by a new registered nurse
(RN) for a client re-ceiving mechanical ventilation (MV). Which action by the new RN
indicates the NEED FOR FURTHER EDUCATION? #70890112 (63)
1. Administers morphine to relieve anxiety and restlessness
2. Applies suction when inserting the catheter into the airway.
, NCLEX RN uworld#31
3. Increases the oxygen concentration on the MV before suctioning
4. Suctions when MV high-pressure alarm continues to sound and rhonchi are present.
2 - Answer The nurse is teaching a client, gravida 1 para 0, at 8 weeks gestation about
expected weight gain in pregnancy. The client's prepregnancy BMI is 21 kg/m2. Which
statement made by the client INDICATES an understanding about weight gain?
#70890112 (64)
1. "I should gain 10-15 lb during the first trimester"
2. "I should gain a total of about 30 lb during my pregnancy."
3. "I should gain no more than 0.5 lb per week during the third trimester."
4. "If I gain <20 lb during pregnancy, it will be easier to lose weight postpartum."
3 - Answer A 59 year old client comes to the clinic due to a blistering, linear rash on the
left chest. The client reports itching and pain around the rash.What is the PRIORITY
question for the nurse to ask the client? #70890112 (65)
1. "Did the rash start after taking a new medication?"
2. "Have you been keeping the rash covered."
3. "Have you ever had chickenpox?"
4. "What have you tried to help the pain?"
Herpes Zoster (Shingles) - Answer can occur in clients with a history of chickenpox
(varicella-zoster virus exposure). The vesicular rash has a characteristic, linear
dermatomal distribution and can present with severe pain.Vaccination prevents _____
#70890112 (65)
1,4,5 - Answer Which of these are correct nursing actions related to client positioning?
SELECT ALL THAT APPLY.
#70890112 (66)
1. Position client in high Fowler's for a paracen-tesis related to end-stage cirrhosis.
2. Position client on left side after liver biopsy.
3. Position client on side with head, back, and knees flexed after lumbar puncture.
4. Position client trendelenburg on left side if air embolism is suspected.
5. Position client with arm raised above head for chest tube placement.
Abdominal paracentesis - Answer is used to remove ascitic fluid from the peritoneal
cavity in end stage liver disease (cirrhosis). The client should be positioned in high
Fowler's or sat upright to facilitate the flow of fluid to the bottom of the peri-toneal cavity,
where the needle will be inserted. The client should void prior to the procedure to
decrease the risk of bladder puncture. #70890112 (66)
1 - Answer A client with advanced kidney disease has serum potassium of 7.1 mEq/L
and creatinine of 4.5 mg/dL. What is the PRIORITY prescribed interven-tion ?
#70890112 (67)
1. Administer IV 50% dextrose and regular insulin
2. Administer IV furosemide
3. Administer oral sodium polystyrene sulfonate.
4 - Answer A client is admitted to the emergency room with right lower quadrant pain
and suspected ACUTE APPENDICITIS. Which health care provider prescription should
the nurse implement FIRST?
#70890112 (59)
1. Administer 5-325 mg hydrocodone/
acetaminophen PO for pain.
2. Draw blood for complete blood count and electrolyte levels
3. Obtain urine specimen for urinalysis
4. Start intravenous (IV) line with normal saline 100 mL/hr.
3 - Answer A client returns to the unit after receiving hemodialysis for the first time. The
client vomits once, reports headache, and appears restless and disoriented. What is the
PRIORITY interven-tion ? #70890112 (60)
1. Administer antihypertensives that were held prior to dialysis.
2. Administer PRN ondansetron to relieve nausea
3. Contact the health care provider.
4. Place client in Trendelenburg position.
2,3,5 - Answer The nurse is assessing a group of clients in the community health clinic
for METABOLIC SYNDROME. Which clients exhibit features of the syndrome? SELECT
ALL THAT APPLY
#70890112 (61)
1. Female with a low-density lipoprotein (LDL) level of 96 mg/dL
2. Female with a waist circumference of 38 inches.
3. Female with blood pressure of 148/90 mm Hg
4. Male with a fasting blood glucose of 99 mg/dL
5. Male with a triglyceride level of 201 mg/dL
Metabolic syndrome - Answer Individual with
________________________________(insulin resistance syndrome) have an
increased risk of diabetes and coronary artery disease. The presence of abdominal
obesity causes increased insulin production (hyperinsulinemia), this excess insulin
leads to insulin resistance, the primary feature of #70890112 (61)
2 - Answer An emergency department nurse is assigned in triage. Which client should
the nurse assess FIRST? #70890112 (62)
1. Five year old with a superficial leg lacera-tion.
2. Lethargic 3 month old with diarrhea for the past 12 hours.
3. Seven year old with a elevated temperature of 101 F (38.3C) and hematuria
4. Seventeen year old with severe, acute abdominal pain.
2 - Answer The charge nurse evaluates the care provided by a new registered nurse
(RN) for a client re-ceiving mechanical ventilation (MV). Which action by the new RN
indicates the NEED FOR FURTHER EDUCATION? #70890112 (63)
1. Administers morphine to relieve anxiety and restlessness
2. Applies suction when inserting the catheter into the airway.
, NCLEX RN uworld#31
3. Increases the oxygen concentration on the MV before suctioning
4. Suctions when MV high-pressure alarm continues to sound and rhonchi are present.
2 - Answer The nurse is teaching a client, gravida 1 para 0, at 8 weeks gestation about
expected weight gain in pregnancy. The client's prepregnancy BMI is 21 kg/m2. Which
statement made by the client INDICATES an understanding about weight gain?
#70890112 (64)
1. "I should gain 10-15 lb during the first trimester"
2. "I should gain a total of about 30 lb during my pregnancy."
3. "I should gain no more than 0.5 lb per week during the third trimester."
4. "If I gain <20 lb during pregnancy, it will be easier to lose weight postpartum."
3 - Answer A 59 year old client comes to the clinic due to a blistering, linear rash on the
left chest. The client reports itching and pain around the rash.What is the PRIORITY
question for the nurse to ask the client? #70890112 (65)
1. "Did the rash start after taking a new medication?"
2. "Have you been keeping the rash covered."
3. "Have you ever had chickenpox?"
4. "What have you tried to help the pain?"
Herpes Zoster (Shingles) - Answer can occur in clients with a history of chickenpox
(varicella-zoster virus exposure). The vesicular rash has a characteristic, linear
dermatomal distribution and can present with severe pain.Vaccination prevents _____
#70890112 (65)
1,4,5 - Answer Which of these are correct nursing actions related to client positioning?
SELECT ALL THAT APPLY.
#70890112 (66)
1. Position client in high Fowler's for a paracen-tesis related to end-stage cirrhosis.
2. Position client on left side after liver biopsy.
3. Position client on side with head, back, and knees flexed after lumbar puncture.
4. Position client trendelenburg on left side if air embolism is suspected.
5. Position client with arm raised above head for chest tube placement.
Abdominal paracentesis - Answer is used to remove ascitic fluid from the peritoneal
cavity in end stage liver disease (cirrhosis). The client should be positioned in high
Fowler's or sat upright to facilitate the flow of fluid to the bottom of the peri-toneal cavity,
where the needle will be inserted. The client should void prior to the procedure to
decrease the risk of bladder puncture. #70890112 (66)
1 - Answer A client with advanced kidney disease has serum potassium of 7.1 mEq/L
and creatinine of 4.5 mg/dL. What is the PRIORITY prescribed interven-tion ?
#70890112 (67)
1. Administer IV 50% dextrose and regular insulin
2. Administer IV furosemide
3. Administer oral sodium polystyrene sulfonate.
