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
A 27-year-old healthy primigravida is brought to the labor and birthing room by her husband
at 32 weeks’ gestation. She experienced a sudden onset of painless vaginal bleeding. Following an
ultrasound examination, the diagnosis of bleeding secondary to complete placenta previa is made.
Expected assessment findings concerning the abdomen would include:
A soft relaxed abdomen
The nurse assesses a client on the second postpartum day and finds a dark red discharge on
the peripad. The stain appears to be about 5 inches long. Which of the following correctly describes
the character and amount of lochia?
Lochia rubra, moderate
Which of the following blood values would require further nursing action in a newborn who
is 4 hours old?
Serum glucose 30 mg/dL
A client was not using his seat belt when involved in a car accident. He fractured ribs 5, 6, and
7 on the left and developed a left pneumothorax. Assessment findings include:
Decreased breath sounds on the left and chest pain with movement
MgSO4 is ordered IV following the established protocol for a client with severe PIH. The
anticipated effects of this therapy are anticonvulsant and:
Vasodilative
The nurse is caring for a 6-week-old girl with meningitis. To help her develop a sense of trust,
the nurse should:
Pick her up when she cries
The nurse working in a prenatal clinic needs to be alert to the cardinal signs and symptoms of
PIH because:
The client may not recognize the early symptoms of PIH
A client at 9 weeks’ gestation comes for an initial prenatal visit. On assessment, the nurse
discovers this is her second pregnancy. Her first pregnancy resulted in a spontaneous abortion. She is
28 years old, in good health, and works full-time as an elementary school teacher. This information
alerts the nurse to which of the following:
The need for anticipatory guidance regarding the pregnancy
A mother is unsure about the type of toys for her 17-month-old child. Based on knowledge of
growth and development, what toy would the nurse suggest?
A pull toy to encourage locomotion
During an examination, the nurse notes that an infant has diaper rash on the convex surfaces
of his buttocks, inner thighs, and scrotum. Which of the following nursing interventions will be most
effective in resolving the condition?
Removing the diaper entirely for extended periods of time
The nurse is admitting a client with folic acid deficiency anemia. Which of the following
questions is most important for the nurse to ask the client?
“Do you drink alcohol on a regular basis?”
A client is receiving IV morphine 2 days after colorectal surgery. Which of the following
observations indicate that he may be becoming drug dependent?
He is euphoric for about an hour after each injection.
When preparing insulin for IV administration, the nurse identifies which kind of insulin to
use?
Regular
A 74-year-old female client is 3 days postoperative. She has an indwelling catheter and has
been progressing well. While the nurse is in the room, the client states, “Oh dear, I feel like I have to
urinate again!” Which of the following is the most appropriate initial nursing response?
Check the collection bag and tubing to verify that the catheter is draining properly.
Following TURP, which of the following instructions would be appropriate to prevent or
alleviate anxiety concerning the client’s sexual functioning?
“A transurethral resection does not usually cause impotence.”
The most frequent cause of early postpartum hemorrhage is:
Uterine atony
A husband asks if he can visit with his wife on her ECT treatment days and what to expect
after the initial treatment. The nurse’s best response is:
“Yes, you may visit. She may experience temporary drowsiness, confusion, or memory loss after
each treatment.”
A client at 6 months’ gestation complains of tiredness and dizziness. Her hemoglobin level is
10 g/dL, and her hematocrit value is 32%. Her nutritional intake is assessed as sufficient. The most
likely diagnosis is:
Iron-deficiency anemia
At 32 weeks’ gestation, a client is scheduled for a fetal activity test (nonstress test). She calls
the clinic and asks the RN, “How do I prepare for the test I am scheduled for?” The RN will most likely
inform her of the following instructions to help prepare her for the test:
You will have to remain as still as you possibly can.”
An infant with a congenital heart defect is being discharged with an order for the
administration of digoxin elixir every 12 hours. The parents need to be taught when administering
digoxin to the infant that:
If the infant vomits two or more consecutive doses or becomes listless or anorexic, notify the
physician
A 26-year-old client has no children. She has had an abdominal hysterectomy. In the first 24
hours postoperatively, the nurse would be concerned if the client:
Develops a temperature of 102_F
A 9-year-old child was in the garage with his father, who was repairing a lawnmower. Some
gasoline ignited and caused an explosion. His father was killed, and the child has split-thickness and
full-thickness burns over 40% of his upper body, face, neck, and arms. All of the following nursing
diagnoses are included on his care plan. Which of these nursing diagnoses should have top priority
during the first 24-48 hours postburn?
Potential for impaired gas exchange related to edema of respiratory tract
A 35-year-old client is admitted to the hospital with diabetic ketoacidosis. Results of arterial
blood gases are pH 7.2, PaO2 90, PaCO2 45, and HCO3 16. The nursing assessment of arterial blood
gases indicate the presence of:
Metabolic acidosis
A client is dilated 8 cm and entering the transition phase of labor. Common behaviors of the
laboring woman during transition are:
Frustration, vague in communication
A 30-year-old client has a history of several recent traumatic experiences. She presents at the
physician’s office with a complaint of blindness. Physical exam and diagnostic testing reveal no
organic cause. The nurse recognizes this as:
Conversion
One afternoon 3 weeks into his alcohol treatment program, a client says to the nurse, “It’s
really not all my fault that I have a drinking problem. Alcoholism runs in my family. Both my
grandfather and father were heavy drinkers.” The nurse’s best response would be:
“Risk factors can often be controlled by self-responsibility.”
A female client at 36 weeks’ gestation has been treated successfully for premature labor for 4
weeks. She has begun having uterine contractions today and has been admitted to the labor and
delivery suite. Her amniocentesis results reveal a lecithin/sphingomyelin (L/S) ratio of 2 and positive
phosphatidylglycerol (PG). These lab values indicate:
Fetal lung maturity
Due to his prolonged history of alcohol abuse, an alcoholic client will most likely have
deficiencies of which of the following nutrients?
Thiamine and pyroxidine
A complication for which the nurse should be alert following a liver biopsy is:
Shock
Proper positioning for the child who is in Bryant’s traction is:
Both hips flexed at a 90-degree angle with the knees extended and the buttocks elevated off the
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