NCLEX PN EXAM LATEST GUIDE RATED A.

NCLEX PN EXAM LATEST GUIDE RATED A.

The nurse is assisting with the admission of a client who is scheduled for a colon resection. Which of the following statements made by the client would be most important for the nurse to clarify?

• "I have urinary incontinence when I sneeze."
• "I had successful cataract surgery 2 years ago."
• "I take acetaminophen for occasional headaches."
• "I usually have a few glasses of wine in the evening."

The nurse is caring for a client who is scheduled to have an arterial blood gas (ABG) sample obtained. Which of the following tests should the nurse anticipate will be performed prior to the procedure?

• Coombs' test
• Schilling test
• Ham test
• Allen test

The nurse is contributing to a staff education program about client confidentiality. Which of the following information should the nurse suggest including? Select all that apply.

• "The client is the sole owner of the client's medical record."
• "Unneeded computer-generated worksheets must be shredded at the end of

the shift to ensure client confidentiality."

• "Personal computer passwords may not be shared with anyone, including

other members of the client's health care team."

• "Keep your voice low when speaking with the client because direct

interactions with clients must be kept as private as possible."

• "Medical information about the client may be shared with a police officer

who brought the client into the emergency department (ED)."

The charge nurse in a long-term care facility has been advised that the following assigned clients will be admitted during the shift. The charge nurse should assign the only available private room to the client with

• hepatitis C (HCV)
• a positive varicella-zoster titer
• Pneumocystis pneumonia (PCP)
• a positive cytomegalovirus (CMV) titer

The nurse is contributing to the plan of care for a client with chronic obstructive pulmonary disease (COPD). Which of the following interventions should the nurse suggest including in the client's plan of care?

• Restrict the client's fluid intake to 500 mL daily.
• Place the client in low-Fowler's position for meals.
• Provide the client with a high-carbohydrate diet and high-carbohydrate

snacks.

• Provide the client with small, frequent meals, and schedule a rest period

before and after meals

The nurse is reinforcing teaching with the parents of a child who is scheduled for surgical repair of hypospadias in 3 hours. The nurse should reinforce that intended outcomes of the procedure include

• relief from pain
• relief from bladder obstruction
• the ability to void while standing
• the ability to achieve an erection

The nurse is caring for a client who has an order for a sputum specimen for culture and sensitivity (C & S). Which of the following actions should the nurse take?

• Request a prescription for a bronchodilator to be administered before the

specimen is obtained.

• Place the specimen in the refrigerator until it can be transported to the

laboratory.

• Tell the client to rinse the mouth with water before the specimen is

obtained.

• Obtain the sputum specimen before the client goes to bed at night.

The nurse in a pediatric outpatient care facility has received telephone messages from parents of clients who were previously seen at the facility. The nurse should first telephone the parent of a client who has

• acute otitis media and reports insomnia after taking amoxicillin 6 hours ago
• a fracture of the left tibia and has placed a crayon in the cast
• a colostomy and reports skin irritation around the stoma
• pneumonia and has pink, frothy sputum

The nurse is caring for a 6-year-old client who is receiving skeletal traction.Which of the following would be a priority for the nurse to monitor?

• the distance between the client's knees

• the pull of the traction on the client's pins
• the degree of flexion of the client's ankles
• the position of the client's cervical spine on the bed

The nurse is collecting data from a client with an acute myocardial infarction (MI). Which of the following findings would be consistent with an acute MI?Select all that apply.

• nailbed splinter hemorrhages
• nausea and vomiting
• diaphoresis
• dyspnea
• Petechiae

The nurse is caring for a client who sustained a closed head injury. Which of the following findings would require immediate intervention?

• blood pressure of 136/76 mm Hg
• ecchymotic area over the left temple
• headache that worsens with coughing
• Glasgow Coma Scale (GCS) score of 13

The nurse has attended a staff education program about elder abuse. Which of the following statements by the nurse would indicate a correct understanding of the teaching?

• "A health care worker or family member who threatens to withhold food,

water, or medical care is committing a form of abuse."

• "The nurse should explain to the victim of elder abuse that data collected

about the abuse will be kept confidential."

• "Clients who are physically disabled and living in a long-term care facility

are the typical victims of elder abuse."

• "Older adults who are abused will readily explain their situation to a health

care provider if asked directly" The nurse is caring for a client born 6 hours ago and observes the finding depicted below.

• Notify the primary health care provider of the finding.
• Administer oxygen therapy prescribed p.r.n.
• Continue to perform routine newborn care.
• Prepare the client for phototherapy. Which of the following actions should

the nurse take?The nurse is contributing to a staff education program about confidentiality.Which of the following information should the nurse suggest including?

• "Clients must wait until after discharge to view their medical records."

• "Clients must disclose all personal information in order to receive care."
• "Nurses in a hospital unit may review the medical records for all clients in

that unit."

• "Certain information in the client's medical record may not be considered

confidential." The nurse and unlicensed assistive personnel (UAP) are caring for assigned clients. Which of the following activities would be appropriate for the nurse to assign to UAP?

• applying a condom catheter to the male client with a hip fracture who is

incontinent

• applying a pressure dressing to the right hand of the client who has a stab

wound

• obtaining vital signs from the client who is experiencing delirium tremens

(DTs)

• inserting a nasogastric (NG) tube for the client with anorexia nervosa (AN)

The nurse is reinforcing teaching with the parents of a 9-year-old child who is receiving methylphenidate. Which of the following information should the nurse reinforce?

• "Check your child's pulse daily before administering methylphenidate."
• "Give your child methylphenidate no more than 3 hours before bedtime."
• "Your child will need to visit the primary health care provider

periodically."

• "Increase your child's intake of foods that are high in iron and potassium."

The nurse is reinforcing teaching with the parents of a 10-year-old client with a seizure disorder about ketogenic diet therapy. The nurse should reinforce that a ketogenic diet includes foods that are

• high in fat, contain adequate protein, and are low in carbohydrates
• high in fat, low in protein, and contain caffeine
• low in fat, low in sodium, and are lactose-free
• low in fat, high in sodium, and high in protein

The nurse has reinforced dietary teaching with a client who has esophageal varices. Which of the following food choices by the client would indicate a correct understanding of the teaching?

• 1 fresh apple
• 1 bag of baby carrots
• 4 oz (113.2 g) of pretzels
• 8 oz (226.4 g) of vanilla yogurt

The nurse is observing a newly hired nurse administer a client's transdermal patch. The nurse should intervene if the newly hired nurse is observed

• instructing the client to avoid massaging the patch