NCLEX-PN Assessment Questions

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NUR 20

10 terms Gab The nurse has provided discharge instructions to a client with an application of a halo device. The nurse determines that the client needs further teaching if which statement is made?

• "I will use a straw for drinking."
• "I will drive only during the daytime."
• "I will use caution because the device alters balance."
• "I will wash the skin daily under the lamb's-wool liner of the vest."

The nurse is caring for a client in preterm labor who is receiving terbutaline sulfate to stop uterine activity.During this medication therapy, the nurse implements nursing interventions to monitor which specific body organs that can be affected by this medication?

• Heart and lungs

2.Kidneys and lungs

• Heart and kidneys
• Lungs and gastrointestinal tract

The client with squamous cell carcinoma of the larynx is receiving bleomycin intravenously. The nurse caring for the client anticipates that which diagnostic study will be prescribed?

• Echocardiography
• Electrocardiography
• Cervical radiography
• Pulmonary function studies

The nurse caring for an infant with congenital heart disease is monitoring the infant closely for signs of heart failure (HF). The nurse should observe for which early sign of HF?

• Pallor
• Cough
• Tachycardia
• Slow and shallow breathing

The nurse is preparing to care for a dying client, and several family members are at the client's bedside. Which therapeutic techniques should the nurse use when communicating with the family? Select all that apply.

• Discourage reminiscing.
• Make the decisions for the family.
• Encourage expression of feelings, concerns, and fears.
• Explain everything that is happening to all family members.
• Touch and hold the client's or family member's hand if appropriate.
• Be honest and let the client and family know that they will not be abandoned by

the nurse.

The client arrives at the prenatal clinic for her first prenatal assessment. The client tells the nurse that the first day of her last menstrual period was October 20,

• Using Nägele's rule, the nurse determines the

estimated date of birth is which?

• July 12, 2017
• July 27, 2017*
• August 12, 2017
• August 27, 2017

Oxybutynin chloride (Ditropan XL) is prescribed for a client with neurogenic bladder. Which sign would indicate a possible toxic effect related to this medication?

• Pallor
• Drowsiness
• Bradycardia
• Restlessness

A client diagnosed with angina pectoris returns to the nursing unit after experiencing an angioplasty. The nurse reinforces instructions to the client regarding the procedure and home care measures. Which statement by the client indicates an understanding of the instructions?

• "I am considering cutting my workload."
• "I need to cut down on cigarette smoking."*
• "I am so relieved that my heart is repaired."

4."I need to adhere to my dietary restrictions." The nurse notes that the 4-hour postpartum client has cool, clammy skin and that she is restless and excessively thirsty. The nurse immediately notifies the registered nurse and then performs which action?

• Checks the vital signs

2.Begins fundal massage

• Encourages ambulation
• Encourages the client to drink fluids

The nurse is assigned to care for a client with a diagnosis of detached retina. Which finding would indicate that bleeding has occurred as a result of retinal detachment?

• Total loss of vision
• A reddened conjunctiva
• A sudden sharp pain in the eye
• Complaints of a burst of black spots or floaters

The nurse is caring for a child with a diagnosis of Kawasaki disease. The mother of the child asks the nurse about the disorder. Which statement most accurately describes Kawasaki disease?

• It is an acquired cell-mediated immunodeficiency disorder.
• It is a chronic multisystem autoimmune disease characterized by the

inflammation of connective tissue.

• It is also called mucocutaneous lymph node syndrome and is a febrile

generalized vasculitis of unknown cause.

• It is an inflammatory autoimmune disease that affects the connective tissue of

the heart, joints, and subcutaneous tissues.The nurse is assigned to care for a child with a spica cast.Which action should be avoided when caring for the child?

• Observing for nonverbal signs of pain
• Using pillows to elevate the head and shoulders
• Checking neurovascular status of the extremities
• Placing the child on a stretcher and bringing the child to the playroom

A child is brought to the emergency department, and a fracture of the left lower arm is suspected. The mother states that the child was rollerblading and attempted to break a fall with an outstretched arm. The child receives diagnostic x-rays, from which it has been determined that a fracture is present. A plaster of Paris cast is applied to the arm, and the nurse reinforces instructions to the mother regarding cast care at home. Which instructions should the nurse provide to the mother?

• "The cast should be dry in about 6 hours."
• "The cast is water resistant, so the child is able to take a bath or a shower."
• "The cast needs to be kept dry because, when wet, it will begin to disintegrate."

*

• "The cast will not mold to the body and should heal the fracture in no time at

all."

The nurse is caring for a client who is scheduled for electroconvulsive therapy (ECT). The nurse notes that an informed consent has not been obtained for the procedure. On review of the record, the nurse notes that the admission was an involuntary hospitalization. Based on this information, which determination does the nurse make regarding consent?

• An informed consent does not need to be obtained.
• The health care provider will obtain the informed consent.
• An informed consent should be obtained from the family.
• An informed consent needs to be obtained from the client. *

The nurse is preparing a 2-year-old child with suspected nephrotic syndrome for a renal biopsy to confirm the diagnosis. The mother asks the nurse, "Will my child ever look thin again?" The nurse should respond by giving which statement?

• "Do you feel guilty about your child's weight gain?"
• "In most cases, medication and diet will control fluid retention." **
• "Wearing loose-fitting clothing should help conceal the extra weight."
• "When children are little, it's expected that they'll look a little chubby."

A client who has undergone cataract removal without an intraocular lens implant is visibly upset because his vision is still blurry. Which action should the nurse perform to provide realistic reassurance to this client?

• Explain that vision will improve with adjustment to aphakic lenses.
• Reassure the client that bright color contrasts in the environment will help.
• Tell the client that there are many resources available for those with impaired

vision.

4.Determine whether the client knows any other people who have experienced blindness.During a conversation with a depressed client on a psychiatric unit, the client says to the nurse, "My family would be better off without me." The nurse should make which therapeutic response to the client?

• "Have you talked to your family about this?"
• "Everyone feels this way when they are depressed."
• "You will feel better once your medication begins to work."
• "You sound very upset. Are you thinking of hurting yourself?"

The nurse is describing the process of fetal circulation to a client during a prenatal visit. The nurse should tell the client that fetal circulation consists of which?

• Two umbilical veins and one umbilical artery
• Two umbilical arteries and one umbilical vein
• Arteries that carry oxygenated blood to the fetus
• Veins that carry deoxygenated blood to the fetus

The nurse is employed at a drug abusers' residential treatment center. The nurse is preparing for the arrival of a new client and prepares to explain to the client that the emphasis of the center is on group and social interaction and that rules and expectations are mediated by peer pressure. The most likely focus of therapy of this residential center is which?

• Milieu therapy
• Aversion conditioning
• Systematic desensitization
• Cognitive behavioral therapy

The nursing student is asked to describe the correct steps for performing adult cardiopulmonary resuscitation (CPR). Arrange the steps of adult CPR in the order of priority. Drag and drop the options into the correct order.

• Determine unconsciousness by shaking the client and asking, "Are you OK?"
• Open the client's airway.
• Perform chest compressions.
• Initiate breathing.

A nursing instructor asks a nursing student to describe accountability. Which statement by the student indicates an inaccurate description of accountability?

• "Accountability can be delegated."
• "It carries legal implications for task performance."
• "One must answer for the care that one asks others to complete."
• "It refers to the process of answering or being responsible for what occurs."

The nurse is assigned to care for a client with a diagnosis of toxoplasmosis. The health care provider has prescribed sulfasalazine (Azulfidine). The nurse preparing to administer the medication understands that this medication is in which drug category?

• Antibiotic
• Sulfonamide
• Opioid analgesic
• Nonsteroidal anti-inflammatory

The nurse is assigned to care for a client following a cataract extraction. The nurse plans to place the client in which position?

• Prone
• Supine
• On the operative side
• On the nonoperative side

A client who is receiving antineoplastic medication by the intravenous (IV) route complains of pain at the insertion site of the IV. The nurse inspects the site and finds the area is swollen and reddened. The nurse further observes that the solution is no longer infusing. The nurse immediately takes which priority nursing action?When caring for a 3-year-old child, the nurse should provide which toy for the child?

• A puzzle
• A wagon
• A golf set
• A farm set

The nurse determines that a student in a basic cardiac life support (BCLS) course correctly performs cardiopulmonary resuscitation (CPR) on an infant when the nurse observes which rate of chest compressions delivered to the infant mannequin?

• 50 times per minute
• 80 times per minute
• 100 times per minute
• 160 times per minute

A client with end stage kidney disease (ESKD) undergoes a surgical procedure to create an arteriovenous fistula for hemodialysis in the upper extremity. The nurse should take which actions when the client returns from surgery?Select all that apply.

• Monitor pain and administer analgesics.
• Monitor bleeding and swelling at the site.
• Monitor for circulation above the fistula site.
• Measure the blood pressure in the arm every hour.
• Check for audible bruit and palpable thrill at the fistula site.

The nurse is instructing a client with diabetes mellitus about peritoneal dialysis. The nurse tells the client that it is important to maintain the dwell time for the dialysis at the prescribed time because of risk for which complication?

• Infection
• Fluid overload
• Hyperglycemia
• Disequilibrium syndrome

A client receiving an anxiolytic medication complains that he feels very "faint" when he tries to get out of bed in the morning. The nurse explains to the client that which is a side effect of this type of medication?

• Postural hypotension
• Cardiac dysrhythmias
• Psychosomatic symptoms
• Respiratory insufficiency