NCLEX PN - Predictor Test with complete

NCLEX PN - Predictor Test with complete solution

The nurse on an inpatient mental health unit is caring with the paranoid delusions who is refusing to eat. The client states that all the food and drinks have been poisoned. Which intervention by the nurse is appropriate? - answerProvide the client food in unopened single serving packages After listening to the parents' report and seeing the ff pediatric clients, the nurse knows that which client demonstrates signs of abuse that may necessitate mandatory reporting? - answer5- year old whose x- ray reveals 1 new and 2 healed humerus fractures after falling from a tree.The nurse is discussing the care needs of a client in the last stage of Huntington disease with the family. When the nurse mentions arranging for delivery of a prescribed hospital bed, the client's spouse becomes visibly upset and says, "No hospital bed. I'm just not ready for it yet." What is the best response by the nurse? - answerWhat upsets you about having hospital bed?The nurse administers ondansetron to a hospitalized client. Which statement would indicate to the nurse that the ondansetron was effective? - answerThe nausea is a lot better The nurse has just received report on 4 clients. Which client should the nurse see first? - answerClient receiving IV normal saline at 250 mL/hr who is reporting puffy legs and a new cough An unaccompanied 16 year old girl comes to the emergency department with a severe abdominal pain and vomiting. The client has a temp of 102.2 F (39 C) and a pulse of 120/min and is lethargic.The client's parents are out of town, and no guardians can be reached. How should the client's care be handled? - answerAdminister care until the parents or guardians can be reached.The nurse reinforces teaching to the parents of a 12 month old who has begun weaning from breastfeeding. Which statement by the parents indicates that teaching has been effective? - answerI can start substituting breastfeeding sessions with whole cow's milk The child with congenital heart disease who weighs 88 lbs is prescribed furosemide 1 mg/kg by mouth every 8 hours. It is available as an oral solution of 10 mg/mL. How many milliliter (mL) of furosemide should the nurse administer to the client for each dose? - answerprescription x available data - mL/dose 4ml The nurse cares for a client with a terminal disease who has an advanced directive supporting a do not resuscitate (DNR) code status. The client stops breathing and loses a pulse. The client's adult client states, "I changed my mind. Do whatever you can to save him!" Which intervention is most appropriate at the time? - answerExplain the client's wishes to the client's child The nurse speaks with a client with schizophrenia who begins to look away toward the door and grimace. Which statement by the nurse is most therapeutic at this time? - answerWhat do you see at the door?

The nurse reinforces teaching to a 15 year primigravid client at 16 weeks gestation during an initial prenatal visit. Which information would be a priority for the nurse to include? - answerStress the importance of consistent prenatal care.A female client is visiting the clinic for an annual well-woman examination. The client reports having had sex with women. Which question will help the nurse determine the client's risk for sexually transmitted infections? - answerWhat barrier methods do you and your partner use?While the nurse is transporting a client to a new unit, the client's chest tube drainage system falls off the bed and the tube becomes dislodged from the chest wall. What is the nurse's priority action?

• answerFirmly cover the insertion site with the palm of a clean, gloved hand.

The nurse cares for a client with a burn on the arm and finds that the area is red, moist, and covered in shiny, fluid-filled vesicle. Which burn stage does the nurse document? - answersecond degree A nurse in the emergency department is caring for a client should the nurse see first? - answerClient with myasthenia gravis who has a fever and increasing difficulty swallowing.The nurse is caring for a client who has been treated for depression and suicidal ideation. Which client statement best Indicates that the client is not currently at risk for suicide? - answerI plan to attend my granddaughter's graduation next month The nurse removes personal protective equipment (PPE) after completing a wound dressing change for a client transmission-based precautions. Which PPE should the nurse remove first. - answerGloves The nurse is caring for client taking escitalopram who reports no improvement of depressive feelings since starting the medication 2 months ago. What is the best response by the nurse? - answerLet's talk more about how you have been taking this medication The client admitted to the psychiatric unit with severe anxiety is pacing rapidly in the room, crying, and hyperventilating. The client yells, "I can't believe you took my belonging! Where are you keeping them? This is so frustrating!" What is the appropriate response by the nurse? - answer"Your belongings are locked in a safe place to ensure that they are protected while you are here." The nurse is caring for a new mother whose infant has been diagnosed with Down syndrome. The client says to the nurse, "I'm so worried. My husband is so devastated that he won't even look at the baby." What is the best response by the nurse? - answerHow are you feeling about you baby?The new nurse reinforcing teaching to a client scheduled for electroconvulsive therapy (ECT). What information given by the new nurse would cause the charge nurse to intervene? - answerBe sure to take your vampiric acid prior to the procedure.The nurse is reinforcing self care and medication teaching for a client diagnosed with vaginal candidiasis who has been prescribed miconazole vaginal cream. Which statement by the client indicates that further teaching is needed? - answerI will refrain from having sex until my partner is also tested for the infection

A 4-year old is diagnosed with Duchenne muscular dystrophy. Which nursing teaching is most appropriate to reinforce for this child's parents? - answerRemove throw rugs from the home The nurse checks a client's blood pressure using an automatic, noninvasive machine. The nurse notes that the machine inflates for an unusually long amount of time, and the client reports intense pain in the arm with the cuff. The device suddenly stops inflation and displays an error message. Which action by the nurse is appropriate? - answerSend the machine for maintenance and repeat the measurement manually The nurse is reinforcing teaching to the caregiver of a client with a new prescription for risperidone. Which statement indicates that the caregiver needs further instruction? - answerIt is normal for a client to become shaky and restless when agitated The nurse is reviewing a client's preoperative questionnaire, which indicates a religious preference with spiritual needs concerning surgery scheduled later today. Which action is most appropriate at this time? - answerFollow up with the client regarding the nature of the spiritual needs or religious practices.The new nurse, caring for a 3-month-old client who is sedated in the intensive care unit ff surgery, needs to prevent skin breakdown. Which action performed by the new nurse would cause the charge nurse to intervene? - answerPlacing a donut pillow under the head An elderly client with diabetes comes to the clinic in winter reporting numbness of the feet. After removing the client's shoes and socks, the nurse notes that the feet are ice cold to the touch and appear waxy and pale. What is the appropriate nursing action? - answerSoak the client's lower legs in a warm water bath The home health nurse visits a client with inflammatory bowel disease who recently underwent a total colectomy with ileostomy creation. Which statement by the client indicates that the client understands ileostomy care? - answerI cut the appliance opening slightly larger than my stoma.The staff nurse is preparing a presentation about strategies to reduce horizontal violence. The nurse educator is reviewing the presentation beforehand. Which recommendation included in the presentation indicates a need for further teacher? - answerWorking toward diversification of staff age and gender For which client is it most important for the nurse to reinforce teaching regarding ways to prevent the spread of the condition? - answerThe client with tinea corporis The nurse assists with medication reconciliation for a client. visiting the clinic for a follow-up appointment. Which medication reported by the client requires further investigation? - answer200mg of celecoxib PO once daily A client is in cardiac arrest. and resuscitation efforts are in progress when the client's spouse arrives. The client's spouse insists on coming into the room. How should the nurse respond? - answerAllow the spouse into the room and provide a chair The nurse in a psychiatric unit is approached by a aggressive client who grabs the nurse's stethoscope and attempts to strangle the nurse with it. The nurse is able to escape the client's grasp unharmed. Which action should the nurse take first? - answerBegin escorting other clients out of

the room A client comes to the emergency department after being bitten by a bat. The nurse observes 2 small, nondraining puncture wounds resembling pinpricks on the fingertip. Which action should the nurse implement first? - answerScrub the wound with povidone-iodine solution or soap and water The nurse on a medical-surgical unit prepares scheduled daily medications for a client and places them in a pill cup. After receiving the pill cup. the client state, "I take a whole tablet of metoprolol at home. Why did you cut this one in half?" What is the best response by the nurse? - answerShow me which pill you're talking about so I can verify your prescriptions again A 10 year old client with autism spectrum disorder is hospitalized for a diagnostic workup. Which is the most appropriate nursing action? - answerGiving the client a schedule of daily activities The charge nurse is educating a new nurse on IM injection technique for a 6 year old with autism spectrum disorder. Which statement by the new nurse indicates that further teaching is required? - answerI will hold the child's hand as a soothing measure The nurse is reinforcing client teaching about newly prescribed cyclosporine. Which client statement indicates a need for further teaching? - answerI am going to a concert with my friends this weekend The nurse is caring for a client who reports abdominal pain and vaginal spotting. The client had a positive urine pregnancy test at home, and her lat menstrual period was 8 weeks ago. Which client report to the nurse is most concerning? - answerRight shoulder pain in dizziness The nurse is reinforcing teaching to a client newly prescribed verapamil for chronic migraine headaches. Which statement by the client indicates the need for further teaching? - answerI will take this medication at first sign of migraine The nurse is reviewing the medical hx for a client who has sustained a right tibia/fibula fracture from a fall. The nurse identifies which finding is most likely to hinder healing? - answerPeripheral arterial disease The student nurse assists in caring for a client who is scheduled for electroconvulsive therapy for the treatment of depression. Which statement by the student indicates a need for further teaching?

• answerBecause this client has a mental illness, the agent with medical power of attorney should

sign the informed consent document.A student nurse is accompanying the charge nurse when conducting daily rounds. Which personal protective measure by the charge nurse does the student nurse question? - answerWears 2 pairs of gloves when emptying the urinary catheter collection bag of a client with HIV.The nurse helps a client with the end-stage renal disease and a serum potassium level of 5.2 mEq/L to plan menu choices. Which items would be best to include in the meal plan? - answerGrilled chicken sandwich on white bread, applesauce.The nurse receives handoff of care report on four clients. Which client should see first? - answerClient who has a urinary tract infection, temperature of 102 F and respiratory rate of 25/min