NCLEX Flashcards
The FHR pattern in a laboring client begins to show early decelerations. The nurse would best
respond by:
Continuing to monitor the FHR closely
A female client decides on hemodialysis. She has an internal vascular access device placed. To
ensure patency of the device, the nurse must:
Auscultate the site for a bruit
A client has a chest tube placed in his left pleural space to re-expand his collapsed lung. In a
closed-chest drainage system, the purpose of the water seal is to:
Prevent air from entering the pleural space
A 42-year-old male client has been treated at an alcoholic rehabilitation center for
physiological alcohol dependence. The nurse will be able to determine that he is preparing for
discharge and is effectively coping with his problem when he shares with her the following
information:
“I know that I will not ever be able to socially drink alcohol again and will need the support of the
AA group.”
Which of the following should be included in discharge teaching for a client with hepatitis C?
He should avoid alcoholic beverages during his recovery period.
A physician’s order reads: 0.25 normal saline at 50 mL/hr until discontinued. The nurse is using
a microdrip tubing set. How many drops per minute should the nurse administer?
50 gtt/min
A 48-year-old male client is hospitalized with mild ascites, bruising, and jaundice. He has a 20-
year history of alcohol abuse. The client is diagnosed with cirrhosis. His serum ammonia level is high,
indicating hepatic encephalopathy. He has esophageal varices. Which of the following may cause the
varices to rupture?
Lifting heavy objects
The nurse is admitting an infant with bacterial meningitis and is prepared to manage the
following possible effects of meningitis:
Seizure
A male client received a heart-lung transplant 1 month ago at a local transplant center. While
visiting the nursing center to have his blood pressure taken, he complains of recent weakness and
fatigue. He also tells the nurse that he is considering stopping his cyclosporine because it is expensive
and is causing his face to become round. He fears he will catch viruses and be more susceptible to
infections. The nurse responds to this last statement by explaining that cyclosporine:
Is given to prevent rejection and makes him less susceptible to infection than other oral
corticosteroids
After the RN is finished the initial assessment of a newborn baby and after the initial bonding
between the newborn and the mother has taken place in the delivery room, the RN will bring the
newborn to the well-baby nursery. Before the newborn is taken from the delivery room and brought
to the well-baby nursery, the RN makes sure that which of the following interventions was
completed?
The nurse makes sure the mother and her newborn have been tagged with identical bands.
A client has been in labor 10 hours and is becoming very tired. She has dilated to 7 cm and is
at 0 station with the fetus in a right occipitoposterior position. She is complaining of severe backache
with each contraction. One comfort measure the nurse can employ is to:
Apply strong sacral pressure during the contraction
A client returned to the unit following a pneumonectomy. As the nurse is assessing her
incision, she notices fresh blood on the dressing. The nurse should first:
Notify the physician.
A 48-year-old female client is going to have a cholecystectomy in the morning. In planning for her postoperative care, the nurse is aware that a priority nursing diagnosis for her will be high risk
for:
Ineffective breathing pattern
To appropriately monitor therapy and client progress, the nurse should be aware that
increased myocardial work and O2 demand will occur with which of the following?
Positive inotropic therapy
A gravida 2 para 1 client is hospitalized with severe preeclampsia. While she receives
magnesium sulfate
(MgSO4) therapy, the nurse knows it is safe to repeat the dosage if:
Respirations are>16 breaths/min
The physician orders haloperidol 5 mg IM stat for a client and tells the nurse that the dose can
be repeated in 1-2 hours if needed. The most likely rationale for this order is:
Rapid neuroleptization is the most effective approach to care for the violent or potentially violent
client
A 27-year-old primigravida stated that she got up from the chair to fix dinner and bright red
blood was running down her legs. She denies any pain previously or currently. The client is very
concerned about whether her baby will be all right. Her vital signs include P 120 bpm, respirations 26
breaths/min, BP 104/58 mm Hg, temperature 98.2_F, and fetal heart rate 146 bpm. Laboratory
findings revealed hemoglobin 9.0 g/dL, hematocrit 26%, and coagulation studies within normal range.
On admission, the peripad she wore was noted to be half saturated with bright red blood. A medical
diagnosis of placenta previa is made. The priority nursing diagnosis for this client would be:
Decreased cardiac output related to excessive bleeding
A client has chronic obstructive pulmonary disease. She is slowly losing weight, and her
daughter is very concerned about increasing her nutrition. The nurse helps the daughter devise a
plan of care for her mother. The plan of care should include which of the following interventions to
promote nutrition?
Offer her oral hygiene before and after meals.
In admitting a client to the psychiatric unit, the nurse must explain the rules and regulations of
the unit. A client with antisocial personality disorder makes the following remark, “Forget all those
rules. I always get along well with the nurses.” Which nursing response to him would be most
effective?
“I’m pleased that you get along so well with the staff. You must still know and abide by the rules.”
A 14-year-old teenager is demonstrating behavior indicative of an obsessive-compulsive
disorder. She is obsessed with her appearance. She will not leave her room until her hair, clothes, and
makeup are perfect. She always dresses immaculately. Recently, she expressed disgust over her
appearance after she gained 5 lb. After observing a marked weight loss over a 2-week period, her
mother suspects that she is experiencing bulimia. She eats everything on her plate, then runs to the
bathroom. In interviewing the teenager, she discusses in great detail all of the events leading to her
bulimia, but not her feelings. What defense mechanism is she using?
Intellectualization
