1. The nurse assesses a postoperative client whose skin is cool, pale, and moist. The client is
very restless and has scant urine output. Oxygen is being administered at 2 L/min, and a saline
lock is in place. Which intervention should the nurse implement first?
A. Measure the urine specific gravity.
B. Obtain IV fluids for infusion per protocol.
C. Prepare for insertion of a central venous catheter.
D. Auscultate the client's breath sounds.
2. During a health fair, a male client with emphysema tells the nurse that he fatigues easily.
Assessment reveals marked clubbing of the fingernails and an increased anteroposterior chest
diameter. Which instruction is best to provide the client?
A. "Pace your activities and schedule rest periods."
B. "Increase the amount of oxygen you use at night."
C. "Obtain medical evaluation for antibiotic therapy."
D. "Reduce your intake of fluids containing caffeine."
3. During the change of shift report, the charge nurse reviews the infusions being received by
clients on the oncology unit. The client receiving which infusion should be assessed first?
A. Continuous IV infusion of magnesium
B. One-time infusion of albumin
C. Continuous epidural infusion of morphine
D. Intermittent infusion of IV vancomycin
4. The nurse is planning care for a client with diabetes mellitus who has gangrene of the toes to
the midfoot. Which goal should be included in this client's plan of care?
A. Restore skin integrity.
B. Prevent infection.
C. Promote healing.
D. Improve nutrition.
This study source was downloaded by 100000830214522 from CourseHero.com on 07-07-2022 19:03:22 GMT -05:00
https://www.coursehero.com/file/105715164/Lab-NCLEX-assignment-7-28-21docx/
, 5. An 81-year-old male client has emphysema. He lives at home with his cat and manages self-
care with no difficulty. When making a home visit, the nurse notices that this client's tongue is
somewhat cracked and his eyeballs appear sunken into his head. Which nursing intervention is
indicated?
A. Help the client determine ways to increase his fluid intake.
B. Obtain an appointment for the client to have an eye examination.
C. Instruct the client to use oxygen at night and increase the humidification.
D. Schedule the client for tests to determine his sensitivity to cat hair.
6. The nurse is assessing a client who presents with jaundice. Which assessment finding is most
important for the nurse to follow up?
A. Urine specific gravity of 1.03
B. Frothy, tea-colored urine
C. Clay-colored stools
D. Elevated serum amylase and lipase levels
7. The nurse is interviewing a client who is taking interferon-alfa-2a (Roferon-A) and ribavirin
(Virazole) combination therapy for hepatitis C. The client reports experiencing overwhelming
feelings of depression. Which action should the nurse implement first?
A. Recommend mental health counseling.
B. Review the medication actions and interactions.
C. Assess for the client's daily activity level.
D. Provide information regarding a support group.
8. A client in the emergency department is bleeding profusely from a gunshot wound to the
abdomen. In what position should the nurse immediately place the client to promote
maintenance of the client's blood pressure above a systolic pressure of 90 mm Hg?
A. Place the client in a 45-degree Trendelenburg position to promote cerebral blood flow.
B. Turn the client prone to place pressure on the abdominal wound to help staunch the bleeding.
C. Maintain the client in a supine position to reduce diaphragmatic pressure and visualize the
wound.
This study source was downloaded by 100000830214522 from CourseHero.com on 07-07-2022 19:03:22 GMT -05:00
https://www.coursehero.com/file/105715164/Lab-NCLEX-assignment-7-28-21docx/
very restless and has scant urine output. Oxygen is being administered at 2 L/min, and a saline
lock is in place. Which intervention should the nurse implement first?
A. Measure the urine specific gravity.
B. Obtain IV fluids for infusion per protocol.
C. Prepare for insertion of a central venous catheter.
D. Auscultate the client's breath sounds.
2. During a health fair, a male client with emphysema tells the nurse that he fatigues easily.
Assessment reveals marked clubbing of the fingernails and an increased anteroposterior chest
diameter. Which instruction is best to provide the client?
A. "Pace your activities and schedule rest periods."
B. "Increase the amount of oxygen you use at night."
C. "Obtain medical evaluation for antibiotic therapy."
D. "Reduce your intake of fluids containing caffeine."
3. During the change of shift report, the charge nurse reviews the infusions being received by
clients on the oncology unit. The client receiving which infusion should be assessed first?
A. Continuous IV infusion of magnesium
B. One-time infusion of albumin
C. Continuous epidural infusion of morphine
D. Intermittent infusion of IV vancomycin
4. The nurse is planning care for a client with diabetes mellitus who has gangrene of the toes to
the midfoot. Which goal should be included in this client's plan of care?
A. Restore skin integrity.
B. Prevent infection.
C. Promote healing.
D. Improve nutrition.
This study source was downloaded by 100000830214522 from CourseHero.com on 07-07-2022 19:03:22 GMT -05:00
https://www.coursehero.com/file/105715164/Lab-NCLEX-assignment-7-28-21docx/
, 5. An 81-year-old male client has emphysema. He lives at home with his cat and manages self-
care with no difficulty. When making a home visit, the nurse notices that this client's tongue is
somewhat cracked and his eyeballs appear sunken into his head. Which nursing intervention is
indicated?
A. Help the client determine ways to increase his fluid intake.
B. Obtain an appointment for the client to have an eye examination.
C. Instruct the client to use oxygen at night and increase the humidification.
D. Schedule the client for tests to determine his sensitivity to cat hair.
6. The nurse is assessing a client who presents with jaundice. Which assessment finding is most
important for the nurse to follow up?
A. Urine specific gravity of 1.03
B. Frothy, tea-colored urine
C. Clay-colored stools
D. Elevated serum amylase and lipase levels
7. The nurse is interviewing a client who is taking interferon-alfa-2a (Roferon-A) and ribavirin
(Virazole) combination therapy for hepatitis C. The client reports experiencing overwhelming
feelings of depression. Which action should the nurse implement first?
A. Recommend mental health counseling.
B. Review the medication actions and interactions.
C. Assess for the client's daily activity level.
D. Provide information regarding a support group.
8. A client in the emergency department is bleeding profusely from a gunshot wound to the
abdomen. In what position should the nurse immediately place the client to promote
maintenance of the client's blood pressure above a systolic pressure of 90 mm Hg?
A. Place the client in a 45-degree Trendelenburg position to promote cerebral blood flow.
B. Turn the client prone to place pressure on the abdominal wound to help staunch the bleeding.
C. Maintain the client in a supine position to reduce diaphragmatic pressure and visualize the
wound.
This study source was downloaded by 100000830214522 from CourseHero.com on 07-07-2022 19:03:22 GMT -05:00
https://www.coursehero.com/file/105715164/Lab-NCLEX-assignment-7-28-21docx/
