1. An elderly Cantonese-speaking client has been admitted to the emergency
department after suffering a fall and suspected hip fracture in her home. Emergency
medical services personnel have reported to the nurse that the client speaks no
English. Who is the best person to perform translation services?
- A hospital translator
2. A four-year-old child is diagnosed as having acute lymphocytic leukemia. The white
blood cell (WBC) count, especially the neutrophil count, is low. What is the most
important intervention the nurse should teach the parents?
The correct procedure for auscultating the client’s abdomen for bowel sounds is to:
-
3. . A client has chest pain rated at 8 on a 10-point visual analog scale. The 12-lead
electrocardiogram reveals ST elevation in the inferior leads and troponin levels are
elevated. What should the nurse do first?
4. A client is exhibiting pressured speech, a labile affect, euphoria, and hyperactivity.
The client states, "I am the savior of the city." The family states that the client has
hardly slept or eaten for days. Which client need is a priority in the nurse's plan of
care?
5. A client had an appendectomy 2 days ago and is now presenting with purulent
drainage, pain in the mid-incision, and a temperature of 101.3°F (38.5°C). What
would be the most appropriate action by the nurse?
6. A client with acquired immunodeficiency syndrome (AIDS) develops Pneumocystis
carinii pneumonia. Which nursing diagnosis has the highest priority?
7. Adolescents and adults who were sexually abused as children commonly mutilate
themselves. The nurse interprets this behavior as:
8. A client with diabetes mellitus asks the nurse to recommend something to remove
corns from his toes. The nurse should advise the client to
9. A nurse is developing a care plan for a client recovering from a serious thermal burn.
What does the nurse determine is the priority goal of therapy?
10. A distraught father is waiting for his son to come out of surgery. He accidentally
backed the car into his son, causing multiple fractures and a serious head injury.
Which statement by the father would most alert the nurse to the need for a
psychiatric consultation?
11. A nurse is completing discharge teaching for the client who has left-sided
hemiparesis following a stroke. When investigating the client's home environment,
the nurse should focus on which nursing diagnosis?
12. At which time should the nurse instruct the client to take ibuprofen, prescribed for left
hip pain secondary to osteoarthritis, to minimize gastric mucosal irritation?
13. Which nursing measure would be most effective in helping the client cough and deep
breathe after a cholecystectomy?
14. A child requires IV fluids to infuse at 27 ml/hr. The tubing delivers 60 gtts/ml. How
many gtts/min should the nurse count to ensure that the fluid is safely infusing?
- 27 gtt/min
15. Before administering the evening dose of an ordered medication, a nurse on the
evening shift finds an unlabeled, filled syringe in a client's medication drawer. What
should the nurse do?
16. A 13-year-old child has seen the school nurse several times with headache, vomiting,
and difficulty walking. When calling the adolescent's mother about these symptoms,
what should the nurse suggest the mother do first?
17. A newly-admitted client has told the nurse, "I always take a thyroid pill each morning
but I do not think I have been prescribed it here in the hospital." The nurse confirms
This study source was downloaded by 100000864888199 from CourseHero.com on 07-13-2023 07:12:37 GMT -05:00
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, that the client's medication orders do not include this. What is the nurse's best
action?
18. While assessing the incision of a client who had surgery 2 weeks ago, a nurse
observes that the suture line has a shiny, light pink appearance. Which step should
the nurse take next?
19. The health care provider (HCP) prescribes a serum lithium level tomorrow for a client
with bipolar disorder, manic phase, who has been receiving lithium 300 mg PO three
times daily for the past 5 days. At what time should the nurse plan to have the blood
specimen obtained?g times should the nurse plan to have the blood specimen
obtained?
20. While making a home visit to a multigravida 2 weeks after the birth of viable twins at
38 weeks’ gestation, the nurse observes that the client looks pale, has dark circles
around her eyes, and is breastfeeding one of the twins. The client’s apartment is
clean, and nothing appears out of place. The client tells the nurse that she completed
three loads of laundry this morning. A priority need for this client is:
21. A nurse is teaching a group of clients about birth control methods. When providing
instruction about subdermal contraceptive implants, the nurse should cite which
feature as the main advantage of this method?
22. A client diagnosed with antisocial personality disorder asks the nurse if he can have
an additional smoke break because he's anxious. Which response by the nurse is
best?
23. Which statement indicates that a client with esophageal reflux disorder understands
the dietary teaching?
24. A client comes to the emergency department reporting pain in the right leg. When
obtaining the history, the nurse learns that the client has a history of obesity and
hypertension. Based on this information the nurse anticipates the client having which
musculoskeletal disorder?
25. The nurse is caring for a client being discharged following kidney transplantation. The
client is ordered mofetil to prevent organ rejection. Which nursing instruction is
essential regarding medication use?
26. The nurse is planning care for an infant with bronchiolitis. What is the nurse’s
priority intervention for this child?
27. Which of the following behaviors would indicate to the nurse that follow-up is needed
for a client having difficulty attaching to her newborn?
28. A 20-year-old female client says, “I feel that my vaginal opening constricts whenever
I am about to have intercourse. I seem to have no control over it.” Which of the
following terms should the nurse use to document the client’s condition?
29. After lobectomy for lung cancer, a client receives a chest tube connected to a
disposable chest drainage system. The nurse observes that the drainage system is
functioning correctly when she notes tidal movements or fluctuations in which
compartment of the system as the client breathes?
30. The client has sore nares while a nasogastric (NG) tube is in place. Which nursing
measure would be most appropriate to help alleviate the client's discomfort?
31. A charge nurse is developing the client care assignments for the shift. Which client is
most appropriately assigned to a licensed practical nurse (LPN)?
32. A client with a longstanding diagnosis of generalized anxiety disorder presents to the
emergency room. The triage nurse notes upon assessment that the patient is
hyperventilating. The triage nurse is aware that hyperventilation is the most common
cause of:
This study source was downloaded by 100000864888199 from CourseHero.com on 07-13-2023 07:12:37 GMT -05:00
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department after suffering a fall and suspected hip fracture in her home. Emergency
medical services personnel have reported to the nurse that the client speaks no
English. Who is the best person to perform translation services?
- A hospital translator
2. A four-year-old child is diagnosed as having acute lymphocytic leukemia. The white
blood cell (WBC) count, especially the neutrophil count, is low. What is the most
important intervention the nurse should teach the parents?
The correct procedure for auscultating the client’s abdomen for bowel sounds is to:
-
3. . A client has chest pain rated at 8 on a 10-point visual analog scale. The 12-lead
electrocardiogram reveals ST elevation in the inferior leads and troponin levels are
elevated. What should the nurse do first?
4. A client is exhibiting pressured speech, a labile affect, euphoria, and hyperactivity.
The client states, "I am the savior of the city." The family states that the client has
hardly slept or eaten for days. Which client need is a priority in the nurse's plan of
care?
5. A client had an appendectomy 2 days ago and is now presenting with purulent
drainage, pain in the mid-incision, and a temperature of 101.3°F (38.5°C). What
would be the most appropriate action by the nurse?
6. A client with acquired immunodeficiency syndrome (AIDS) develops Pneumocystis
carinii pneumonia. Which nursing diagnosis has the highest priority?
7. Adolescents and adults who were sexually abused as children commonly mutilate
themselves. The nurse interprets this behavior as:
8. A client with diabetes mellitus asks the nurse to recommend something to remove
corns from his toes. The nurse should advise the client to
9. A nurse is developing a care plan for a client recovering from a serious thermal burn.
What does the nurse determine is the priority goal of therapy?
10. A distraught father is waiting for his son to come out of surgery. He accidentally
backed the car into his son, causing multiple fractures and a serious head injury.
Which statement by the father would most alert the nurse to the need for a
psychiatric consultation?
11. A nurse is completing discharge teaching for the client who has left-sided
hemiparesis following a stroke. When investigating the client's home environment,
the nurse should focus on which nursing diagnosis?
12. At which time should the nurse instruct the client to take ibuprofen, prescribed for left
hip pain secondary to osteoarthritis, to minimize gastric mucosal irritation?
13. Which nursing measure would be most effective in helping the client cough and deep
breathe after a cholecystectomy?
14. A child requires IV fluids to infuse at 27 ml/hr. The tubing delivers 60 gtts/ml. How
many gtts/min should the nurse count to ensure that the fluid is safely infusing?
- 27 gtt/min
15. Before administering the evening dose of an ordered medication, a nurse on the
evening shift finds an unlabeled, filled syringe in a client's medication drawer. What
should the nurse do?
16. A 13-year-old child has seen the school nurse several times with headache, vomiting,
and difficulty walking. When calling the adolescent's mother about these symptoms,
what should the nurse suggest the mother do first?
17. A newly-admitted client has told the nurse, "I always take a thyroid pill each morning
but I do not think I have been prescribed it here in the hospital." The nurse confirms
This study source was downloaded by 100000864888199 from CourseHero.com on 07-13-2023 07:12:37 GMT -05:00
https://www.coursehero.com/file/15850255/PrepU-Nclex-questions-L4MS/
, that the client's medication orders do not include this. What is the nurse's best
action?
18. While assessing the incision of a client who had surgery 2 weeks ago, a nurse
observes that the suture line has a shiny, light pink appearance. Which step should
the nurse take next?
19. The health care provider (HCP) prescribes a serum lithium level tomorrow for a client
with bipolar disorder, manic phase, who has been receiving lithium 300 mg PO three
times daily for the past 5 days. At what time should the nurse plan to have the blood
specimen obtained?g times should the nurse plan to have the blood specimen
obtained?
20. While making a home visit to a multigravida 2 weeks after the birth of viable twins at
38 weeks’ gestation, the nurse observes that the client looks pale, has dark circles
around her eyes, and is breastfeeding one of the twins. The client’s apartment is
clean, and nothing appears out of place. The client tells the nurse that she completed
three loads of laundry this morning. A priority need for this client is:
21. A nurse is teaching a group of clients about birth control methods. When providing
instruction about subdermal contraceptive implants, the nurse should cite which
feature as the main advantage of this method?
22. A client diagnosed with antisocial personality disorder asks the nurse if he can have
an additional smoke break because he's anxious. Which response by the nurse is
best?
23. Which statement indicates that a client with esophageal reflux disorder understands
the dietary teaching?
24. A client comes to the emergency department reporting pain in the right leg. When
obtaining the history, the nurse learns that the client has a history of obesity and
hypertension. Based on this information the nurse anticipates the client having which
musculoskeletal disorder?
25. The nurse is caring for a client being discharged following kidney transplantation. The
client is ordered mofetil to prevent organ rejection. Which nursing instruction is
essential regarding medication use?
26. The nurse is planning care for an infant with bronchiolitis. What is the nurse’s
priority intervention for this child?
27. Which of the following behaviors would indicate to the nurse that follow-up is needed
for a client having difficulty attaching to her newborn?
28. A 20-year-old female client says, “I feel that my vaginal opening constricts whenever
I am about to have intercourse. I seem to have no control over it.” Which of the
following terms should the nurse use to document the client’s condition?
29. After lobectomy for lung cancer, a client receives a chest tube connected to a
disposable chest drainage system. The nurse observes that the drainage system is
functioning correctly when she notes tidal movements or fluctuations in which
compartment of the system as the client breathes?
30. The client has sore nares while a nasogastric (NG) tube is in place. Which nursing
measure would be most appropriate to help alleviate the client's discomfort?
31. A charge nurse is developing the client care assignments for the shift. Which client is
most appropriately assigned to a licensed practical nurse (LPN)?
32. A client with a longstanding diagnosis of generalized anxiety disorder presents to the
emergency room. The triage nurse notes upon assessment that the patient is
hyperventilating. The triage nurse is aware that hyperventilation is the most common
cause of:
This study source was downloaded by 100000864888199 from CourseHero.com on 07-13-2023 07:12:37 GMT -05:00
https://www.coursehero.com/file/15850255/PrepU-Nclex-questions-L4MS/
