NCLEX Practice Questions- Kaplan Live Review

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133 terms Family_firstPreview NCLEX 26 terms plo A client receives IV 0.9% NS at a rate of 125 mL/hr. Two hours later, the nurse notes the client has crackles in both lungs that do not clear with coughing. The client reports shortness of breath. It is important for the nurse to take which action immediately?

• Decrease 0.9% sodium chloride infusion flow rate to

keep vein-open (KVO) rate.

• Remain with the client.
• Place the client in high-Fowler position.
• Auscultate breath sounds.
• Place the client in high-Fowler position.

A laparotomy is scheduled for a client who is admitted to the hospital for a ruptured ectopic pregnancy.Preoperatively, which goal is most important for the nurse to include in the plar of care?

• Fluid replacement.
• Pain relief.
• Emotional support.
• Respiratory therapy.
• Fluid replacement.

The nurse comes upon a multicar accident. Which client should the nurse care for first?

• A middle-aged client reporting chest pain.
• An adult client with a compound fracture of the tibia.
• An adolescent client with a broken jaw.
• A toddler client with a bruise on the forehead.
• An adolescent client with a broken jaw.

The nurse provides care for a newborn who is three hours of age in the nursery. Which findings cause the nurse to reevaluate the newborn in 15 minutes? (Select all that apply.)

• Heart rate of 140 beats per minute.
• Absent breath sounds in lower lobes bilaterally.
• Negative Babinski reflex.
• Positive stepping reflex.
• Acrocyanosis.
• Respiratory rate of 80 breaths per minute.
• Absent breath sounds in lower lobes bilaterally.
• Negative Babinski reflex.
• Respiratory rate of 80 breaths per minute.

The nurse performs nutritional counseling for a client on a lacto-vegetarian diet. The nurse determines that teaching is successful if the client makes which menu selection? (Select all that apply.)

• Oatmeal, banana, toast, and milk.
• Cheeseburger, french fries, fruit salad, and tea.
• Stir-fried tofu with vegetables, cottage cheese, and

apple juice.

• Scrambled eggs, strawberries, and yogurt.
• Peanut butter on whole-wheat toast, carrot and celery

sticks, and lemonade.

• Lentil chili, tossed salad with vinegar and oil dressing,

and fruit ice.

• Oatmeal, banana, toast, and milk.
• Stir-fried tofu with vegetables, cottage cheese, and apple juice.
• Peanut butter on whole-wheat toast, carrot and celery sticks, and lemonade.
• Lentil chili, tossed salad with vinegar and oil dressing, and fruit ice.

A client undergoes treatment for a fracture of the right femur by using skeletal traction with balanced suspension through the use of a Thomas splint and a Pearson attachment. Which observation causes the nurse to intervene?

• The client grasps the overhead trapeze with the right

arm to lift the body.

• The client turns to the right side to answer the

telephone.

• The client contracts and relaxes the right quadriceps

and gluteal muscles for 5 minutes 4 times a day.

• The client flexes the left leg and pushes up in bed.
• The client turns to the right side to answer the telephone.

The nurse assesses a client receiving parenteral nutrition (PN). Which assessment most concerns the nurse?

• The client's urinary output is 150 mL per hour.
• The client's oral temperature is 100.2°F (37.9°C).
• The client's serum albumin is 3.8 g/dL (38 g/L).
• Crackles that clear with coughing are heard during

auscultation in both lungs.

• The client's urinary output is 150 mL per hour.

The nurse performs an assessment on a client admitted to the hospital with terminal cancer. The client reports to the nurse that, "I am short of breath, have no appetite, and hurt everywhere." Which statement by the nurse is best?

• "Have you used a client-controlled analgesia machine

for pain control before?"

• "What have you found to be effective for pain control

in the past?"

• "I will get you a stronger pain medication that will help

relieve your pain."

• "Let me turn on the television for you. That should help

the pain."

• "What have you found to be effective for pain control in the past?"

An older adult client reports difficulty sleeping. Which response by the nurse is best?

• "How many times do you awaken during the night?"
• "Does leg jerking ever wake you up at night?"
• "Watching television or reading before bedtime will

help you fall asleep.

• "When you were working, how many hours of sleep did

you average?"

• "How many times do you awaken during the night?"

The nurse provides discharge teaching for a client after a right posterior total hip replacement. Which statement by the client indicates that teaching is successful? (Select all that apply.)

• "My knees should be higher than my hips when I am

sitting."

• "I should ask my spouse to put on my socks and shoes."
• "I should clean the incision with a mixture of hydrogen

peroxide and water before applying a sterile dressing."

• "I don't need to continue the leg exercises learned in

the hospital."

• "It's okay to sit for long periods of time."
• "It is important that I use my walker when ambulating."
• "I should ask my spouse to put on my socks and shoes."
• "It is important that I use my walker when ambulating."

The nurse provides care for an older adult client diagnosed with a fractured right femur. Which observation most concerns the nurse?

• The right foot's large toe remains pale for 3 seconds

after pressure is applied to the nail bed.

• The client is incontinent of urine and stool.
• The client reports "slight shortness of breath" while

moving in bed.

• The client plucks at the bed covers and is confused

about the current date and location.

• The client plucks at the bed covers and is confused about the current date and

location.

The nurse provides care for a client during an autologous blood transfusion. The client reports chills thirty minutes after the transfusion began. The client's blood pressure has decreased from 122/84 mmHg to 108/62 mmHg.Which action will the nurse take first?

• Administer IV imipenem eilastatin sodium 500 mg.
• Administer 0.9% sodium chloride 100 mL/hour IV.
• Stop the transfusion and remove the blood infusion

tubing immediately.

• Check the client's oral temperature and oxygen

saturation A level.

• Stop the transfusion and remove the blood infusion tubing immediately.

The nurse prepares to administer packed red blood cells to a client. In which order does the nurse perform the actions? Rank in order from first activity to last activity.Use all answer choices.

• The nurse starts an IV with an

18-gauge needle.

• The nurse begins the transfusion at a slow rate.
• The nurse obtains a history of transfusion reactions.
• The nurse obtains the blood product from the blood

bank.

• The nurse obtains a history of transfusion reactions.
• The nurse starts an IV with an

18-gauge needle.

• The nurse obtains the blood product from the blood bank.
• The nurse begins the transfusion at a slow rate.

The nurse provides care for a client several hours after insertion of a central venous access device in the subclavian vein. 0.9% sodium chloride IV solution is infusing through the line at 75 mL/hr. The client becomes restless and reports shortness of breath. Which action does the nurse take first?

• Elevate the head of the bed to 90°
• Check the IV flow rate and insertion site.
• Obtain equipment for insertion of a chest tube.
• Reassure the client that symptoms will improve.
• Elevate the head of the bed to 90°

The nurse provides care for a client receiving hydroxyethyl starch intravenously. Which is the priority action for the nurse to take?

• Assess for bilateral pretibial edema.
• Measure the hourly urine output.
• Obtain daily weights.
• Auscultate lung sounds.
• Auscultate lung sounds.