Nclex Exam

Front 1

After a tonsillectomy, a child is brought to the pediatric unit. The nurse places the child in which appropriate position?

Back 1

The child should be placed in a prone or side-lying position after tonsillectomy to facilitate drainage

Front 2

A nurse is collecting data from a client admitted to the hospital with a diagnosis of suspected gastric ulcer and is asking the client questions about pain. Which statement, if made by the client, would support the diagnosis of gastric ulcer?

Back 2

"My pain comes shortly after I eat, maybe a half hour or so later."

Hint 2

Gastric ulcer pain often occurs in the upper epigastrium, with localization to the left of the midline, and may be exacerbated by food. The pain occurs a half hour to an hour after a meal and rarely occurs at night.

Front 3

A nurse provides home care instructions to a client after cataract removal and placement of an intraocular implant in the right eye. Which statement by the client indicates a need for further instruction?

Back 3

"I need to remove the eye dressing as soon as I get home and place a warm pack on my eye."

Hint 3

Rationale:
After cataract surgery a dressing is applied to the eye. It usually is removed later on the day of surgery or the following day. The client should not place a warm pack on the eye unless this is specifically prescribed because of the risk of infection and increased edema in the surgical area. The client is instructed to wear a metal or plastic eye shield to protect the eye from accidental injury and is instructed not to rub the eye. Glasses may be worn during the day. The client is instructed not to sleep on the side of the body that was operated on to prevent pressure and edema in the affected eye. The use of stool softeners is recommended to prevent constipation and straining.

Front 4

A nurse provides home care instructions to a client undergoing hemodialysis with regard to care of an arteriovenous (AV) fistula. Which statement by the client indicates an understanding of the instructions?

Back 4

"I should check the fistula every day by feeling it for a vibration."

Front 5

A nurse instructs a client on pursed-lip breathing and asks the client to demonstrate the breathing technique. Which observation by the nurse indicates that the client is performing the technique correctly?

Back 5

the client breathes out slowly through the mouth.

Front 6

Insulin glargine (Lantus) is prescribed for a client with diabetes mellitus. The nurse tells the client that it is best to take the insulin:

Back 6

Once daily, at the same time each day

Hint 6

Rationale:
Insulin glargine is a long-acting recombinant DNA human insulin used to treat type 1 and type 2 diabetes mellitus. It has a 24-hour duration of action and is administered once a day, at the same time each day.

Front 7

A nurse in the health care provider's office is measuring vital signs on a postoperative client who underwent mastectomy of her right breast 2 weeks ago. The client tells the nurse that she is very concerned because she has numbness in the area of the surgery and along the inner side of the arm from the armpit to the elbow. The nurse should tell the client that:

Back 7

These sensations dissipate over several months and usually resolve after 1 year.

Hint 7

Numbness in the area of the surgery and along the inner side of the arm from the armpit to the elbow occurs in women after mastectomy. It is a result of injury to the nerves that provide sensation to the skin in those areas. These sensations may be described as heaviness, pain, tingling, burning, or "pins and needles." These sensations dissipate over several months and usually resolve 1 year after surgery.

Front 8

A client who has been receiving parenteral nutrition by way of a central venous access device complains of chest pain and dyspnea. The nurse quickly assesses the client's vital signs and notes that the pulse rate has increased and that the blood pressure has dropped. The nurse determines that the client is likely experiencing:

Back 8

Air embolism

Hint 8

Rationale:
The signs and symptoms of air embolism include chest pain, dyspnea, hypoxia, anxiety, tachycardia, and hypotension.

- The nurse also would hear a loud churning sound over the pericardium on auscultation of the chest.

Front 9

A client receiving intravenous (IV) fluid therapy complains of burning and a feeling of tightness at the IV insertion site. On assessment, the nurse detects coolness and swelling at the site and notes that the IV rate has slowed. The nurse determines that which of the following has occurred?

Back 9

Infiltration

Front 10

One unit of packed red blood cells is infusing into a client over a 4-hour period. The unit of blood contains 250 mL. The drop factor is 15 drops (gtt) per 1 mL. The nurse determines that the flow rate should be set at how many drops per minute? Round answer to the nearest whole number.

Back 10

16 drops per minute

Front 11

A nurse is providing morning care to a client who has a closed chest tube drainage system to treat a pneumothorax. When the nurse turns the client to the side, the chest tube is accidentally dislodged from the chest. The nurse immediately applies sterile gauze over the chest tube insertion site and next:

Back 11

Notifies the registered nurse (RN)

Hint 11

If the chest drainage system is dislodged from the insertion site, the nurse immediately applies sterile gauze over the site and notifies the RN, who then calls the health care provider (HCP). The nurse would maintain the client in an upright position. A new chest tube system may be attached if the tube requires insertion, but this would not be the next action

Front 12

A nurse reviews the medication history of a client admitted to the hospital and notes that the client is taking leflunomide (Arava). During data collection, the nurse asks which question to determine medication effectiveness?

Back 12

"Do you have any joint pain?"

Hint 12

Leflunomide is an immunosuppressive agent and has an anti-inflammatory action. The medication provides symptomatic relief of rheumatoid arthritis. Diarrhea can occur as a side effect of the medication.

Front 13

A nulliparous woman asks the nurse when she will feel fetal movements. The nurse responds by telling the woman that the first recognition of fetal movement will occur at approximately:

Back 13

18 weeks of gestation

Hint 13

he first recognition of fetal movements, or "feeling life," by the multiparous woman may occur as early as the 14th to 16th week of gestation. The nulliparous woman may not notice these sensations until the 18th week of gestation or later. The first recognition of fetal movement is called "quickening."

Front 14

A nurse is performing a vaginal check of a pregnant client in labor. The nurse notes that the umbilical cord is protruding from the vagina. The nurse should immediately:

Back 14

Exert upward pressure against the presenting part with gloved fingers.

Hint 14

If the umbilical cord is protruding from the vagina, no attempt should be made to replace it because to do so could traumatize it and further reduce blood flow. The nurse would place a gloved hand into the vagina toward the cervix and exert upward pressure against the presenting part to relieve compression of the cord. The nurse also would wrap the cord loosely in a sterile towel saturated with warm, sterile normal saline solution. Oxygen, 8 to 10 L/min by face mask, is administered to the mother to increase fetal oxygenation, and the client is prepared for immediate delivery. However, the immediate action is to relieve pressure on the cord. The client should already have an external fetal monitor in place.

Front 15

A client in the third trimester of pregnancy visits the clinic for a scheduled prenatal appointment. The client tells the nurse that she frequently has leg cramps, primarily when she is reclining. On the basis of the client's complaint, the nurse should first:

Back 15

Check for signs of thrombophlebitis.

Hint 15

Leg cramps may be a result of compression of the nerves supplying the legs because of the enlarging uterus,

- a reduced level of diffusible serum calcium, an increase in serum phosphorus, or the presence of thrombophlebitis. In the pregnant client who complains of leg cramps, the nurse would first check for signs of thrombophlebitis and notify the registered nurse. If thrombophlebitis is not present, the nurse may be instructed to massage and place heat on the affected area, dorsiflex the foot until the spasm relaxes, or have the client stand on a cold surface. The health care provider may prescribe oral supplementation with calcium carbonate tablets or calcium hydroxide gel with each meal to increase the calcium level and lower the phosphorus level. Although the nurse may check for edema and assess the pedal pulses, these would not be the first actions.

Front 16

A postpartum client with mastitis in the right breast complains that the breast is too sore for her to breast-feed her infant. The nurse tells the client:

Back 16

To breast-feed from the left breast and gently pump the right breast

Hint 16

In most cases, the mother can continue to breast-feed with both breasts. If the affected breast is too sore, the mother can pump the breast gently. Regular emptying of the breast is important to prevent abscess formation. If an abscess forms and ruptures into the ducts of the breasts, breast-feeding should be discontinued and a pump used to empty the breast (but the milk should be discarded).

Front 17

A nurse reviews the arterial blood gas results of a client and notes that the results indicate a pH of 7.30, PCO2 of 52 mm Hg, and HCO of 22 mEq/L. The nurse interprets these results as indicating:

Back 17

Respiratory acidosis

Hint 17

Normal pH is 7.35 to 7.45. In a respiratory condition, an opposite effect will be seen between the pH and the PCO2. In this situation, the pH is low and the PCO2 is increased. In an acidotic condition, the pH is decreased. Therefore the values identified in the question indicate a respiratory acidosis.

Front 18

A nurse provides dietary instructions to a client at risk for hypokalemia about the foods high in potassium that should be included in the daily diet. The nurse tells the client that the fruit highest in potassium is:

Back 18

Kiwifruit

Hint 18

Foods that are high in potassium include bananas, cantaloupe, kiwifruit, and oranges. Fruits low in potassium include apples, cherries, grapefruit, peaches, pineapple, and cranberries.

Front 19

Which of the following cardiovascular manifestations would the nurse expect to note in a client with a diagnosis of hypocalcemia?

Back 19

Cardiovascular manifestations that occur with hypocalcemia include decreased heart rate, diminished peripheral pulses, and hypotension.

- On the ECG, the nurse would note a prolonged ST segment and a prolonged QT interval.

Front 20

A nurse is caring for a client who will be undergoing surgical treatment for Ménière's disease. The nurse plans care, understanding that surgical treatment for this disorder is performed to:

Back 20

Provide relief from accumulation of inner ear fluid in the endolymphatic sac

Front 21

A child seen in the clinic is found to have rubeola (measles), and the mother asks the nurse how to care for the child. The nurse tells the mother that she should

Back 21

Keep the child in a room with dim lights.

Hint 21

A nursing consideration in rubeola is eye care. The child usually has photophobia, so the nurse should suggest that the parent keep the child out of brightly lit areas.

Front 22

A nurse provides medication instructions to a client who had a kidney transplant about therapy with cyclosporine (Sandimmune). Which statement by the client indicates a need for further instruction?

Back 22

"I need to obtain a yearly influenza vaccine."

Hint 22

Cyclosporine is an immunosuppressant medication. Because of the medication's effects, the client should not receive any vaccinations without first consulting the HCP. The client should report decreased urine output or cloudy urine, which could indicate kidney rejection or infection, respectively. The client must be able to self-monitor blood pressure to check for the side effect of hypertension. The client needs meticulous oral care and dental cleaning every 3 months to help prevent gingival hyperplasia.

Front 23

When auscultating the abdomen, the nurse begins in the ?

Back 23

right lower quadrant (RLQ), in the ileocecal valve area, because bowel sounds are always present here normally.

Front 24

A client in the postpartum unit complains of sudden, sharp chest pain. The client is tachycardic and the respiratory rate is increased, and the health care provider diagnoses a pulmonary embolism.

Choose the interventions that apply in the care of this client.

Back 24

- Administer oxygen.

- Monitor the blood pressure.

- Prepare to administer morphine sulfate.

- Prepare to start an intravenous (IV) line

Hint 24

If pulmonary embolism is suspected, oxygen is administered to decrease hypoxia. The client also is kept on bedrest, with the head of the bed slightly elevated to reduce dyspnea. Morphine sulfate may be prescribed for the client to reduce pain and apprehension. An IV line also will be required, and vital signs must be monitored. Heparin therapy (not warfarin sodium) is administered.

Front 25

A nurse receives a telephone call from the admissions office and is told that a child with acute bacterial meningitis will be admitted to the pediatric unit. The nurse prepares for the child's arrival and plans to implement:

Back 25

Droplet precautions

Hint 25

A major priority in nursing care for a child suspected of having meningitis is to administer the prescribed antibiotic as soon as it is prescribed. The child also is placed in a private room, with droplet precautions, for at least 24 hours after antibiotics are given

Front 26

A clinic nurse reads the results of a Mantoux test performed on a 5-year-old child. The results indicate an area of induration measuring 8 mm. The nurse should interpret these results as:

Back 26

Negative

Hint 26

Induration measuring 15 mm or greater is considered a positive result in a child 4 years or older who has no associated risk factors. Since this child's results show an area of induration measuring 8 mm, the finding is negative.

Front 27

RBC lab value

Back 27

female: 4.2-5.4 million/ul

(height)

male: 4.7 - 6.1 million/ul

(lucky 7)

Hint 27

- increased = chronic hypoxia or polycythemia

- decreased = anemia or hemorrhage

Front 28

Platelets

Back 28

150,000 - 400,000 mm3

when decreased = with autoimmune disease , bone marrow suppression, or enlarged spleen

when increased = evidence of malignancy or polycythemia vera

Front 29

HCT (Hematocrit)

Back 29

female: 37-47 %

male: 42-52 %

Front 30

PT

seconds?

%?

Purpose?

Back 30

11- 12.5 sec

85-100 %

* monitors Coumadin (Warfarin)

Hint 30

- increased time: can be evidence of clotting factor deficiency or excessive warfarin

- decreased time: vitamin K excess

Front 31

INR

therapeutic range?

normal range?

Purpose?

Back 31

therapeutic range (on Warfarin therapy) : 2-3

normal: 0.7 to 1.8

* measures mean of PT

* used to monitor Warfarin

* increased time = excessive warfarin

Front 32

Sodium (NA+)

Back 32

136 - 145 MEQ/L

Front 33

chloride

Back 33

98-106 meq/L

Front 34

calcium

Back 34

9 - 10.5 mg/dl

Front 35

Magnesium

Back 35

1.3 to 2.1 mEQ/L

Front 36

Phosphrous

Back 36

3.5 -4.5 mg/dL

Front 37

HCO3 (bicarb)

Back 37

22-26 mEq/L

Front 38

PaCo2

Back 38

35-45

Front 39

AST (aspartate aminotransferase)

Back 39

5 - 40 units/L

* increased indicates hepatitis and cirrhosis

Front 40

ALT (alanine aminotransferase)

Back 40

* 8-20 units/L

3-35 Iu/L

- most definitive for assessment of liver tissue damage

- increased hepatitis and cirrhosis

Front 41

ALP (alkaline phosphatase)

Back 41

* 42 - 128 u/L

30 - 85 iu/L

- increased means liver damage and biliary obstruction

Front 42

GTT (liver enzyme)

Back 42

female: 0-45 u/L

male: 0-65 u/L

* increased alcohol intake

Front 43

Amylase

Back 43

56- 90 iu/L

increased = pancreatitis

Front 44

Lipase

Back 44

0 - 110 units/L

* increased = pancreatitis

Front 45

Total Bilirubin

Back 45

0.3 - 1.0 mg/dL

- increased altered liver function

- bile duct obstruction

- other hepatobiliary disorders

Front 46

Direct (conjugated) bilirubin

Back 46

0.1 - 0.4 mg/dL

Hint 46

- increased means altered liver function

- bile duct obstruction

or other hepatobiliary disorders

Front 47

Albumin

Back 47

3.5 - 5.0 g/dL

* decreased may indicate hepatic disease

Front 48

Ammonia

Back 48

15 -110 mg/dL

* increased in liver disease

Front 49

BUN

Back 49

10-20 mg/dL

increased = liver and kidney disease

Front 50

creatinine

female?

male?

Back 50

female: 0.5 - 1.1 mg/dL

male: 0.6 -1.2 mg /dL

Front 51

ESR

Back 51

female: 1-13 mm/hg

male: 1- 20 mm/hg

> 20 mmHg / mild inflammation

Front 52

specific gravity (urine)

Back 52

1.005 - 1.030

Front 53

PH urine

Back 53

4.6 - 8

Front 54

Bacteria (urine)

Back 54

< than 1,000 colonies

Front 55

serum osmolarity

Back 55

270 - 300 mosm/L

Front 56

PSA

Back 56

0-4

Front 57

cholesterol

Back 57

< 200 mg/dL

* screen test for heart disease

Front 58

HDL

Back 58

> 40 mg/dL

* good cholesterol produced by liver

Front 59

LDL

Back 59

< 130 mg/dL

* bad cholesterol can be up to 70 %

Front 60

Triglycerides

Back 60

< 150 mg/dL

* evaluating tests for atherosclerosis

Front 61

Fasting Blood glucose

Back 61

< 110 mg/dL

Front 62

oral glucose tolerance

Back 62

< 140 mg/dL

Front 63

HbA1c

Back 63

4- 6 %

> 8 % = poor control of diabetes

- HbA1c is the best indicator of an average blood glucose level for the past 120 days

Front 64

TSH

Back 64

0.4 - 6.15 microunits/ mL

- increased indicates primary hypothyroidism

Front 65

T3

Back 65

70-205 ng/dL

- high level of T3 is more diagnostic of hyperthyroidism than T4

Front 66

T4

Back 66

40- 12.0 mcg/dL

Front 67

Alpha-fetoprotein

Back 67

< 40 mcg/ dL

* increased liver cancer

Front 68

A health care provider prescribes "eye patching" for a child with strabismus of the right eye. The nurse instructs the mother regarding this procedure and tells the mother to:

Back 68

Place the patch on the left eye.

Hint 68

Eye patching may be used in the treatment of strabismus to strengthen the weak eye. In this treatment, the "good" eye is patched. This encourages the child to use the weaker eye. It is most successful when done during the preschool years. The schedule for patching is individualized and is prescribed by the ophthalmologist.

Front 69

A nurse in a newborn nursery is told that a newborn with spina bifida (myelomeningocele type) will be transported from the delivery room. The nurse is asked to prepare for the arrival of the newborn. The nurse places which of the following priority items at the newborn's bedside?

Back 69

A bottle of sterile normal saline

- The newborn with spina bifida is at risk for infection before the closure of the gibbus. A sterile normal-saline dressing is placed over the gibbus to maintain moisture of the gibbus and its contents. This prevents tearing or breakdown of the skin integrity at the site

Front 70

A nurse is assisting in caring for a client with an endotracheal tube attached to a ventilator when the high-pressure alarm sounds. The nurse checks the client and system for which most likely cause

Back 70

Accumulation of secretions in the client's lungs

Hint 70

When the high-pressure alarm sounds on a ventilator, it is most likely due to an obstruction. The obstruction can be caused by the client biting on the tube, kinking of the tubing, or mucus in the lungs that requires suctioning. It is also important to assess the tubing for the presence of any water and determine if the client is out of rhythm with breathing with the ventilator.

Front 71

A client receiving parenteral nutrition through a central intravenous line is exhibiting signs and symptoms of an air embolism. The nurse immediately places the client in which position?

Back 71

Left side in Trendelenburg's

Front 72

This morning a client sustained a right proximal fibula and tibia fracture that was casted in a long leg plaster cast. During evening rounds, the nurse notes that the right lower extremity capillary refill is greater than 3 seconds and the toes are edematous and dusky. The client states that the pain medication is not working anymore and that the right foot feels like it is asleep. The nurse analyzes the data and determines that the client's symptoms are indicative of:

Back 72

Compartment syndrome

Hint 72

In this situation, the edema and the cast are compressing the structures within the leg. As pressure within the fascia compartment increases, nerves and blood vessels are occluded, resulting in ischemia and unrelieved pain, known as compartment syndrome. The health care provider needs to be notified as soon as possible.

Front 73

Oral iron is prescribed for a child with an iron deficiency anemia, and the nurse provides instructions to the mother regarding the administration of the iron. The nurse instructs the mother to administer the iron

Back 73

Between meals

Hint 73

The mother should be instructed to administer oral iron supplements between meals. The iron should be given with a citrus fruit or juice high in vitamin C because vitamin C increases the absorption of iron by the body

Front 74

A nurse is assisting in providing a class to new mothers on newborn care. In teaching cord care, the nurse makes which suggestion to the new mothers?

Back 74

apply alcohol to the cord, ensuring that all areas around the cord are cleaned two or three times a day.

Hint 74

The cord and base should be cleaned with alcohol two or three times a day. The steps are to lift the cord, wipe around the cord starting at the top, clean the base of the cord, and fold the diaper below the umbilical cord to allow the cord to air dry. Continuation of cord care is necessary until the cord falls off in 7 to 14 days. The baby does not feel pain in this area. Water and soap are not necessary; in fact, the cord should be kept from getting wet.

Front 75

A 6-month-old infant receives a diphtheria, tetanus, and acellular pertussis (DTaP) immunization at the well-baby clinic. The mother returns home and calls the clinic to report that the infant has developed swelling and redness at the site of injection. Which instruction by the nurse is appropriate?

Back 75

apply an ice pack to the injection site.

Front 76

A nurse assists with admitting a child with a diagnosis of acute-stage Kawasaki disease. When obtaining the child's medical history, which clinical manifestation is likely to be reported?

Back 76

Conjunctival hyperemia

Hint 76

-During the acute stage of Kawasaki disease, the child presents with fever, conjunctival hyperemia, a red throat, swollen hands, a rash, and enlargement of the cervical lymph nodes.

- During the subacute stage, cracking lips and fissures, desquamation of the skin on the tips of the fingers and toes, joint pain, cardiac manifestations, and thrombocytosis occur. During the convalescent stage, the child appears normal, but signs of inflammation may be present.

Front 77

A nurse is caring for a client who has had spinal fusion with insertion of hardware. The nurse should be especially concerned with which of the following findings?

Back 77

an oral temperature of 101° F orally

Hint 77

For this specific type of surgery, the nurse monitors the neurovascular status of the lower extremities, watches for signs and symptoms of infection, and inspects the surgical site for evidence of cerebrospinal fluid leakage (drainage is clear, tests positive for glucose). A mild temperature is expected after insertion of hardware, but a temperature of 101° F or higher should be reported, because it might indicate infection or require that the hardware be removed.

Front 78

A 9-year-old child is diagnosed with chlamydial conjunctivitis. The nurse consults with the primary health care provider regarding necessary follow-up because this infection can be associated with:

Back 78

Possible sexual abuse

Hint 78

A diagnosis of chlamydial conjunctivitis in a child who is not sexually active should signal the health care provider to assess the child for possible sexual abuse

Front 79

A client is brought to the emergency department immediately following a smoke inhalation injury. The initial nursing action is to prepare the client to receive:

Back 79

100% humidified oxygen by face mask

Hint 79

If the client sustains a smoke inhalation injury, the client is treated immediately with 100% humidified oxygen delivered by face mask. Oxygen via nasal cannula will not provide adequate oxygenation

Front 80

A postpartum client has lost 700 mL of blood. The vital signs indicate hypovolemia and the uterus remains atonic in spite of treatment. The nurse assisting in caring for the client understands the treatment that is necessary in this situation and prepares the client for:

Back 80

Emergency surgery

When uterine atony cannot be reversed, surgery is required.

Front 81

A client who is experiencing severe respiratory acidosis has a potassium level of 6.2 mEq/L. The nurse interprets that this result is:

Back 81

Expected and indicates that acidosis has driven hydrogen ions into the cell, forcing potassium out