NCSBN NCLEX QUESTIONS

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NCSBN NCLEX QUESTIONS

408 terms ANNEMARIEBISHOP Preview Med Su 44 terms ble When communicating with a client who speaks a different language, which best practice should the nurse implement?Arrange for an interpreter to translate.The nurse hears a patient calling out for help, hurries down the hallway to the patients room, & finds the patient lying on the floor.The nurse performs an assessment, assists the client back to bed, notifies the doctor of the incident, & completes an incident report.Which statement should the nurse document on the incident report?The patient was found lying on the floor.The nurse has made an error in a narrative documentation of an assessment finding on a patient & obtains the patients record to correct the error. The nurse should take which actions to correct the error?Draw 1 line through the error, initialing, & dating it., Document the correct information & end with the nurses signature & title.Which identifies accurate nursing documentation? The client slept through the night., Abdominal wound dressing is dry & intact without drainage., & The patients left lower medial leg wound is 3 cm in length without redness, drainage, or edema.The nurse calls the doctor regarding a new medication prescription because the dosage prescribed is higher than the recommended dosage.The nurse is unable to locate the doctor, & the medication is due to be administered. Which action should the nurse take?Contact the nursing supervisor..The nurse is assigned to care for 4 patients. In planning patient rounds, which patient should the nurse assess first?A patient with asthma who requested a breathing treatment during the previous shift.

A nurse in the E.R. is assigned to triage patients coming to the E.R. for treatment on the evening shift. The nurse should assign priority to which patient?A patient with chest pain who states that he just ate pizza that was made with a very spicy sauce.The nurse has received the assignment for the day shift.After making initial rounds & checking all of the assigned patients, which patient should the nurse plan to care for first?A patient with a white blood cell count of 14,000 & a temperature of 101.1 The nurse is giving a bed bath to an assigned patient when a P.C.T. enters the room & tells the nurse that another patient is in pain & needs pain medication. Which is the most appropriate nursing action?Cover the patient, raise the side rails, tell the patient that you will return shortly, & administer the pain medication to the other client.The nurse is planning the patient assignments for the day.Which is the most appropriate assignment for the P.C.T.?A patient who requires urine specimen collection.The nurse is caring for a patient with heart failure. On assessment, the nurse notes that the patient is dyspneic, & crackles are audible on auscultation.What additional manifestations would the nurse expect to note in this patient if excess fluid volume is present?an increase in blood pressure & increased respiration. .The nurse provides instructions to a patient with a low potassium level about the foods that are high in potassium & tells the patient to consume which foods?Raisins, potatoes, cantaloupe, & strawberries The nurse is reviewing lab results & notes that patients serum sodium level is 150. The nurse reports the serum sodium level to the doctor & they prescribe dietary instructions based on the sodium level.which acceptable food items does the nurse instruct the patient to consume?Peas, nuts, & cauliflower..Which patient is at risk for the development of a sodium level at 130?The client who is taking diuretics.The nurse is caring for a patient with heart failure who is receiving high doses of diuretic.On assessment, the nurse notes that the patient has flat neck veins, generalized muscle weakness, & diminished deep tendon reflexes.The nurse suspects hyponatremia. What additional signs would the nurse expect to note in a client with hyponatremia?Hyperactive bowel sounds.The nurse is assigned to care for a group of patients. On review of the patients medical records, the nurse determines that which patient is most likely at risk for a fluid volume deficit?A patient with an ileostomy.

The nurse caring for a patient who has been receiving I.V.diuretics suspects that the patient is experiencing a fluid volume deficit. Which assessment finding would the nurse note in a patient with this condition?Weight loss & poor skin turgor.On review of the patients medical records, the nurse determines that which patient is at risk for fluid volume excess?The patient with kidney disease & a 12 year history of diabetes mellitus.The nurse is caring for a patient with a nasogastric tube that is attached to low suction. The nurse monitors the patient for manifestations of which disorder that they are at risk for?metabolic alkalosis.The nurse is caring for a patient with several broken ribs.The patient is most likely to experience what type of acid base imbalance?respiratory acidosis from inadequate ventilation A nurse is precasting a new graduate nurse & the new graduate is assigned to care for a patient with chronic pain. which statement indicates the need for further teaching regarding pain management?I will be sure to cue in to any indications that the patient may be exaggerating their pain.The nurse is explaining the appropriate methods for measuring an accurate temperature to a P.C.T. Which method indicates the need for further teaching?Taking an oral temperature for a patient with a cough & nasal congestion.The nurse is caring for a post-op patient who is receiving hydromorphone. The nurse enters the patients room & finds the patient drowsy & records the following vital

signs:

97.2 oral temp, pulse 52, 101 over 58 blood pressure, respiratory 11, & 93% oxygen on 3 liters of oxygen via nasal cannula.Which action should the nurse take next?attempt to arouse the patient.A nurse is teaching a patient who has iron deficiency anemia about foods she should include in the diet. The nurse determines that the patient understand the dietary modifications if which items are selected from the menu?oranges & dark green leafy vegetables.the nurse is planning to teach a patient with malabsorption syndrome about the necessity of following a low-fat diet. the nurse develops a list of high fat foods to avoid & should include which food items on the list?margarine, cream cheese, & lunch meats.the nurse instructs a patient with chronic kidney disease who is receiving hemodialysis about dietary modifications.the nurse determines that the patient understands these dietary modifications if the patient selects which items from the dietary menu?cream of wheat, blueberries, coffee.

The nurse is conducting a dietary assessment on a patient who is on a vegan diet. The nurse provides dietary teaching & should focus on foods high in which vitamin that may be lacking in a vegan diet?Vitamine B. 12 A patient with hypertension has been told to maintain a diet low in sodium. The nurse who is teaching this patient about foods that are allowed, should include which food item in a list provided to the patient?summer squash a post-op patient has been placed on a clear liquid diet.the nurse should provide the patient with which items that are allowed to be consumed on this diet?broth, coffee, & gelatin The nurse is instructing a patient with hypertension on the importance of choosing food low in sodium. The nurse should teach the patient to limit intake of which food?smoked sausage A patient who is recovering from surgery has been advanced from a clear liquid diet to a full liquid diet.the patient is looking forward to the diet change because he has been bored with the clear liquid diet.the nurse should offer which full liquid item to the patient?custard a patient is recovering from abdominal surgery & has a large abdominal wound. the nurse should encourage the patient to eat which food item that is naturally high in vitamin C. to promote wound healing?oranges The nurse is caring for a patient with cirrhosis of the liver.To minimize the effects of the disorder, the nurse teaches the patient about foods that are high in thiamine The nurse determines that the patient has the best understanding of the dietary measures to follow if the patient states an intention to increase the intake of which food?legumes..The nurse is preparing to change the parenteral nutrition solution bag & tubing. The patient's central venous line is located in the right subclavian vein.the nurse ask the patient to take which essential action during the tubing change?take a deep breath, hold it, & bear down..a patient with parenteral nutrition infusing has disconnected the tubing from the central line catheter.The nurse assess the patient & suspects an air embolism.The nurse should immediately place the patient in which position?on the left side, with the head lower than the feet. .the nurse monitors the patient receiving parenteral nutrition for complications of the therapy & should assess the patient for which manifestations of hyperglycemia?weakness, thirst, & increased urine output