Decreased absent pedal pulse in the left leg - ANSWER NO.9 An 80-year-old
male client with a history of arteriosclerosis is experiencing severe pain in his left leg
that started approximately 20 minutes ago. When performing the admission
assessment, the nurse would expect to observe which of the following:
NCLEX PEDS EXAM ACTUAL EXAM | ALL Hematocrit 60% - ANSWER NO.10 A 16-month-old infant is being prepared for
QUESTIONS AND CORRECT AND CORRECT tetralogy of Fallot repair. In the nursing assessment, which lab value should elicit
further assessment and requires notification of physician? 7.39
ANSWERS WITH RATIONALES | GRADED A+ |
VERIFIED VERSION Walk him as he paces. - ANSWER NO.11 A male client is experiencing extreme
distress. He begins to pace up and down the corridor. What nursing intervention is
appropriate when communicating with the pacing client?
NO.1 A depressed client is seen at the mental health center for follow-up after an Walk with him as he paces. - ANSWER NO.11 A male client is experiencing
attempted suicide 1 week ago. She has taken phenelzine sulfate (Nardil), a extreme distress. He begins to pace up and down the corridor. What nursing
monoamine oxidase (MAO) inhibitor, for 7 straight days. She states that she is not intervention is appropriate when communicating with the pacing client?
feeling any better. The nurse explains that the drug must accumulate to an effective
level before symptoms are totally relieved. Symptom relief is expected to occur Locate the position of the placenta and fetus - ANSWER NO.12 Prior to an
within: - ANSWER 2-4 weeks months months B Explanation: amniocentesis, a fetal ultrasound is done in order to
NO.2 Cystic fibrosis is transmitted as an autosomal recessive trait. This means that - February 27 - ANSWER NO.13 A 25-year-old client believes she may be pregnant
ANSWER Both parents must be carriers for a child to have the disease with her first child. She schedules an obstetric examination with the nurse
practitioner to determine the status of her possible pregnancy. Her last menstrual
Delusion - ANSWER NO.3 A 24-year-old client presents to the emergency period began May 20, and her estimated date of confinement using Nagele's rule is:
department protesting "I am God. The nurse identifies this as a
Gestational diabetes mellitus - ANSWER NO.14 A client is now pregnant for the
Haloperidol (Haldol) - ANSWER acute episodes of mania, lithium is effective in 1-2 second time. Her first child weighed 4536 g at delivery. The client's glucose
weeks, but it may take up to 4 weeks, or even a few months treat symptoms fully. tolerance test shows elevated blood sugar levels. Because she only shows signs of
Sometimes an antipsychotic agent is prescribed the first few days or weeks of an diabetes when she is pregnant, she is classified as having:
acute episode to manage severe behavioral excitement and acute psychotic
symptoms. In addition to the lithium, which one of the following medications might Vitamin C - ANSWER NO.16 The nurse is assisting a 4th-day postoperative
the physician prescribe? cholecystectomy client in planning her meals for tomorrow's menu. Which vitamin is
the most essential in promoting tissue healing?
Release restraints every 2 hours for client to exercise. - ANSWER NO.5 A violent
client remains in restraints for several hours. Which of the following interventions is Allowing him to do as much for himself as he is able, including learning to do pin-site
most appropriate while he is in restraints? care under supervision - ANSWER NO.17 A 10-year-old client with a pin in the
right femur is immobilized in traction. He is exhibiting behavioral changes including
Observe for headaches, dizziness, and anorexia - ANSWER NO.6 The restlessness, difficulty with problem solving, inability to concentrate on activities, and
pediatrician has diagnosed tinea capitis in an 8-year-old girl and has placed her on monotony. Which of the following nursing implementations would be most effective in
oral griseofulvin. The nurse should emphasize which of these instructions to the helping him cope with immobility?
mother and/or child?
First trimester - ANSWER NO.18 In client teaching, the nurse should emphasize
Decrease ammonia formation - ANSWER n.7 A client with cirrhosis of the liver that fetal damage occurs more frequently with ingestion of drugs during:
becomes comatose and is started on neomycin 300 mg q6h nasogastric tube. The
rationale for this therapy is to: High Fowler - ANSWER NO.19 On admission, the client has signs and symptoms
of pulmonary edema. The nurse places the client in the most appropriate position for
Observe for evidence of bleeding. - ANSWER NO.8 A 5-year-old has just had a a client in pulmonary edema, which is:
tonsillectomy and adenoidectomy. Which of these nursing measures should be
included in the postoperative care?
, Respiratory obstruction - ANSWER NO.20 A client has returned to the unit from Move furniture out of the way and place a blanket under his head - ANSWER
the recovery room after having a thyroidectomy. The nurse knows that a major NO.32 The nurse enters the playroom and finds an 8-year-old child having a grand
complication after a thyroidectomy is: mal seizure. Which one of the following actions should the nurse take?
Mother calls infant by name. - ANSWER NO.2 The nurse should facilitate bonding Immerse both legs in cool water - ANSWER NO.33 An 11-year-old boy has
during the postpartum period. What should the nurse expect to observe in the taking- received a partial-thickness burn to both legs. He presents to the emergency room
hold phase? approximately 15 minutes after the accident in excruciating pain with charred
clothing to both legs. What is the first nursing action?
Respect the client's family's wishes. - ANSWER NO.22 A female client has just
died. Her family is requesting that all nursing staff leave the room. The family's Serum electrolytes - ANSWER NO.34 The nurse notes scattered crackles in both
religious leader has arrived and is ready to conduct a ceremony for the deceased in lungs and 1+ pitting edema when assessing a cardiac client. The physician is notified
the room, requesting that only family members be present. The nurse assigned to and orders furosemide (Lasix) 80 mg IV push stat. Which of the following diagnostic
the client should perform the appropriate nursing action, which might include: studies is monitored to assess for a major complication of this therapy?
Wear a patch over one eye - ANSWER NO.23 A woman diagnosed with multiple When I get home, I will need to take my medicines and call my therapist if I have any
sclerosis is disturbed with diplopia. The nurse will teach her to side effects or begin to hear voices. - ANSWER NO.35 A psychiatric client has
been stabilized and is to be discharged. The nurse will recognize client insight and
Level of consciousness - ANSWER NO.24 One of the most reliable assessment behavioral change by which of the following client statements? I
tools for adequacy of fluid resuscitation in burned children is:
Provide time for play and becoming acquainted. - ANSWER NO.36 A mother
Urine output - ANSWER NO.25 Which one of the following is considered a reliable brings a 6-month-old infant and a 4-year-old child to the nursing clinic for routine
indicator for assessing the adequacy of fluid resuscitation in a 3-year-old child who examination and screening. Which of these plans by the nurse would be most
suffered partial- and fullthickness burns to 25% of her body? successful?
Headache and facial flushing - ANSWER NO.26 A client with a diagnosis of C-4 Diminished or absent femoral pulses - ANSWER NO.37 Diagnostic assessment
injury has been stabilized and is ready for discharge. Because this client is at risk for findings for an infant with possible coarctation of the aorta would include:
autonomic dysreflexia, he and his family should be instructed to assess for and
report: Urine retention or a distended bladder - ANSWER NO.38 During a client's first
postpartum day, the nurse assessed that the fundus was located laterally to the
Phenytoin (Dilantin) - ANSWER NO.27 A client states to his nurse that I was told umbilicus.
by the doctor not to take one of my drugs because it seems to have caused
decreasing blood cells. Based on this information, which drug might the nurse expect A family member who is having marital problems and is regularly abusing alcohol -
to be discontinued? ANSWER NO.39 An 80-year-old widow is living with her son and daughter- in-law.
The home health nurse has been making weekly visits to draw blood for a
Administer the morning lithium dose as scheduled - ANSWER NO.28 A client has prothrombin time test. The client is taking 5 mg of coumadin per day. She appears
been taking lithium 300 mg po bid for the past two weeks. This morning her lithium more debilitated, and bruises are noted on her face. Elder abuse is suspected.
level was 1 mEq/L. The nurse should: Which of the following are signs of persons who are at risk for abusing an elderly
person?
Maintaining an adequate level of hydration - ANSWER NO.29 The primary focus
of nursing interventions for the child experiencing sickle cell crisis is aimed toward: Complaints of shortness of breath - ANSWER NO.40 A 32-year-old female client
is being treated for Guillain- Barre synd rome. She complains of gradually increasing
You've been feeling sad and alone for some time now? - ANSWER NO.30 Three muscle weakness over the past several days. She has noticed an increased difficulty
weeks following discharge, male client is readmitted to the psychiatric unit for in ambulating and fell yesterday. When conducting a nursing assessment, which
depression. His wife stated that he had threatened to kill himself with a handgun. As finding would indicate a need for immediate further evaluation?
the nurse admits him to the unit, he says, "I wish I were dead because I am
worthless to everyone; I guess I am just no good." Which response by the nurse is The disorder is a threat to his physical well-being - ANSWER NO.41 Plans for the
most appropriate at this time? care of a client with an ulcer caused by emotional problems need to take into
consideration that:
male client with a history of arteriosclerosis is experiencing severe pain in his left leg
that started approximately 20 minutes ago. When performing the admission
assessment, the nurse would expect to observe which of the following:
NCLEX PEDS EXAM ACTUAL EXAM | ALL Hematocrit 60% - ANSWER NO.10 A 16-month-old infant is being prepared for
QUESTIONS AND CORRECT AND CORRECT tetralogy of Fallot repair. In the nursing assessment, which lab value should elicit
further assessment and requires notification of physician? 7.39
ANSWERS WITH RATIONALES | GRADED A+ |
VERIFIED VERSION Walk him as he paces. - ANSWER NO.11 A male client is experiencing extreme
distress. He begins to pace up and down the corridor. What nursing intervention is
appropriate when communicating with the pacing client?
NO.1 A depressed client is seen at the mental health center for follow-up after an Walk with him as he paces. - ANSWER NO.11 A male client is experiencing
attempted suicide 1 week ago. She has taken phenelzine sulfate (Nardil), a extreme distress. He begins to pace up and down the corridor. What nursing
monoamine oxidase (MAO) inhibitor, for 7 straight days. She states that she is not intervention is appropriate when communicating with the pacing client?
feeling any better. The nurse explains that the drug must accumulate to an effective
level before symptoms are totally relieved. Symptom relief is expected to occur Locate the position of the placenta and fetus - ANSWER NO.12 Prior to an
within: - ANSWER 2-4 weeks months months B Explanation: amniocentesis, a fetal ultrasound is done in order to
NO.2 Cystic fibrosis is transmitted as an autosomal recessive trait. This means that - February 27 - ANSWER NO.13 A 25-year-old client believes she may be pregnant
ANSWER Both parents must be carriers for a child to have the disease with her first child. She schedules an obstetric examination with the nurse
practitioner to determine the status of her possible pregnancy. Her last menstrual
Delusion - ANSWER NO.3 A 24-year-old client presents to the emergency period began May 20, and her estimated date of confinement using Nagele's rule is:
department protesting "I am God. The nurse identifies this as a
Gestational diabetes mellitus - ANSWER NO.14 A client is now pregnant for the
Haloperidol (Haldol) - ANSWER acute episodes of mania, lithium is effective in 1-2 second time. Her first child weighed 4536 g at delivery. The client's glucose
weeks, but it may take up to 4 weeks, or even a few months treat symptoms fully. tolerance test shows elevated blood sugar levels. Because she only shows signs of
Sometimes an antipsychotic agent is prescribed the first few days or weeks of an diabetes when she is pregnant, she is classified as having:
acute episode to manage severe behavioral excitement and acute psychotic
symptoms. In addition to the lithium, which one of the following medications might Vitamin C - ANSWER NO.16 The nurse is assisting a 4th-day postoperative
the physician prescribe? cholecystectomy client in planning her meals for tomorrow's menu. Which vitamin is
the most essential in promoting tissue healing?
Release restraints every 2 hours for client to exercise. - ANSWER NO.5 A violent
client remains in restraints for several hours. Which of the following interventions is Allowing him to do as much for himself as he is able, including learning to do pin-site
most appropriate while he is in restraints? care under supervision - ANSWER NO.17 A 10-year-old client with a pin in the
right femur is immobilized in traction. He is exhibiting behavioral changes including
Observe for headaches, dizziness, and anorexia - ANSWER NO.6 The restlessness, difficulty with problem solving, inability to concentrate on activities, and
pediatrician has diagnosed tinea capitis in an 8-year-old girl and has placed her on monotony. Which of the following nursing implementations would be most effective in
oral griseofulvin. The nurse should emphasize which of these instructions to the helping him cope with immobility?
mother and/or child?
First trimester - ANSWER NO.18 In client teaching, the nurse should emphasize
Decrease ammonia formation - ANSWER n.7 A client with cirrhosis of the liver that fetal damage occurs more frequently with ingestion of drugs during:
becomes comatose and is started on neomycin 300 mg q6h nasogastric tube. The
rationale for this therapy is to: High Fowler - ANSWER NO.19 On admission, the client has signs and symptoms
of pulmonary edema. The nurse places the client in the most appropriate position for
Observe for evidence of bleeding. - ANSWER NO.8 A 5-year-old has just had a a client in pulmonary edema, which is:
tonsillectomy and adenoidectomy. Which of these nursing measures should be
included in the postoperative care?
, Respiratory obstruction - ANSWER NO.20 A client has returned to the unit from Move furniture out of the way and place a blanket under his head - ANSWER
the recovery room after having a thyroidectomy. The nurse knows that a major NO.32 The nurse enters the playroom and finds an 8-year-old child having a grand
complication after a thyroidectomy is: mal seizure. Which one of the following actions should the nurse take?
Mother calls infant by name. - ANSWER NO.2 The nurse should facilitate bonding Immerse both legs in cool water - ANSWER NO.33 An 11-year-old boy has
during the postpartum period. What should the nurse expect to observe in the taking- received a partial-thickness burn to both legs. He presents to the emergency room
hold phase? approximately 15 minutes after the accident in excruciating pain with charred
clothing to both legs. What is the first nursing action?
Respect the client's family's wishes. - ANSWER NO.22 A female client has just
died. Her family is requesting that all nursing staff leave the room. The family's Serum electrolytes - ANSWER NO.34 The nurse notes scattered crackles in both
religious leader has arrived and is ready to conduct a ceremony for the deceased in lungs and 1+ pitting edema when assessing a cardiac client. The physician is notified
the room, requesting that only family members be present. The nurse assigned to and orders furosemide (Lasix) 80 mg IV push stat. Which of the following diagnostic
the client should perform the appropriate nursing action, which might include: studies is monitored to assess for a major complication of this therapy?
Wear a patch over one eye - ANSWER NO.23 A woman diagnosed with multiple When I get home, I will need to take my medicines and call my therapist if I have any
sclerosis is disturbed with diplopia. The nurse will teach her to side effects or begin to hear voices. - ANSWER NO.35 A psychiatric client has
been stabilized and is to be discharged. The nurse will recognize client insight and
Level of consciousness - ANSWER NO.24 One of the most reliable assessment behavioral change by which of the following client statements? I
tools for adequacy of fluid resuscitation in burned children is:
Provide time for play and becoming acquainted. - ANSWER NO.36 A mother
Urine output - ANSWER NO.25 Which one of the following is considered a reliable brings a 6-month-old infant and a 4-year-old child to the nursing clinic for routine
indicator for assessing the adequacy of fluid resuscitation in a 3-year-old child who examination and screening. Which of these plans by the nurse would be most
suffered partial- and fullthickness burns to 25% of her body? successful?
Headache and facial flushing - ANSWER NO.26 A client with a diagnosis of C-4 Diminished or absent femoral pulses - ANSWER NO.37 Diagnostic assessment
injury has been stabilized and is ready for discharge. Because this client is at risk for findings for an infant with possible coarctation of the aorta would include:
autonomic dysreflexia, he and his family should be instructed to assess for and
report: Urine retention or a distended bladder - ANSWER NO.38 During a client's first
postpartum day, the nurse assessed that the fundus was located laterally to the
Phenytoin (Dilantin) - ANSWER NO.27 A client states to his nurse that I was told umbilicus.
by the doctor not to take one of my drugs because it seems to have caused
decreasing blood cells. Based on this information, which drug might the nurse expect A family member who is having marital problems and is regularly abusing alcohol -
to be discontinued? ANSWER NO.39 An 80-year-old widow is living with her son and daughter- in-law.
The home health nurse has been making weekly visits to draw blood for a
Administer the morning lithium dose as scheduled - ANSWER NO.28 A client has prothrombin time test. The client is taking 5 mg of coumadin per day. She appears
been taking lithium 300 mg po bid for the past two weeks. This morning her lithium more debilitated, and bruises are noted on her face. Elder abuse is suspected.
level was 1 mEq/L. The nurse should: Which of the following are signs of persons who are at risk for abusing an elderly
person?
Maintaining an adequate level of hydration - ANSWER NO.29 The primary focus
of nursing interventions for the child experiencing sickle cell crisis is aimed toward: Complaints of shortness of breath - ANSWER NO.40 A 32-year-old female client
is being treated for Guillain- Barre synd rome. She complains of gradually increasing
You've been feeling sad and alone for some time now? - ANSWER NO.30 Three muscle weakness over the past several days. She has noticed an increased difficulty
weeks following discharge, male client is readmitted to the psychiatric unit for in ambulating and fell yesterday. When conducting a nursing assessment, which
depression. His wife stated that he had threatened to kill himself with a handgun. As finding would indicate a need for immediate further evaluation?
the nurse admits him to the unit, he says, "I wish I were dead because I am
worthless to everyone; I guess I am just no good." Which response by the nurse is The disorder is a threat to his physical well-being - ANSWER NO.41 Plans for the
most appropriate at this time? care of a client with an ulcer caused by emotional problems need to take into
consideration that:
