Nclex Practice

Question 1

The nurse is reviewing the lab results of several clients. Which finding should the nurse report to the health care provider?

• client who has sodium levels of 140 mEq/L
• client who reports nausea with lithium level of 1.8 mEq/L
• client with heart rate of 62 bpm who has a digoxin level of 1.4 ng/mL
• A pregnant women whose fibrinogen level is 500mg/dL

Answer 1

Client who reports nausea with lithium level of 1.8.

• this patient has lithium toxicity. Lithium has a narrow therapeutic range of 0.6-1.2 mEq/L

Question 2

You walk into your clients room and they say, “ I haven’t gotten any sleep while being in this hospital.” Which response by the nurse illustrates a therapeutic communication with the client?

• “don’t worry, you will sleep well tonight”
• “you’re having trouble sleeping while being in the hospital?”
• “I’m sorry”
• “I would have a hard tie, sleeping here also”

Answer 2

“You’re having trouble sleeping while in the hospital “

• This is an open ended question and shows active listening skills, both of which display a therapeutic response

Question 3

You are a nurse working in a long term care facility. You are caring for a client with end stage Alzheimer’s disease. What communication techniques are appropriate to use when speaking with your client?

• ask open ended questions
• speak loudly so they can hear
• turn up the television so they can hear it better
• use simple statements and questions
• face the client while speaking

Pick all that apply

Answer 3

Use simple statements and questions

Face the client while speaking

Question 4

The nurse working in a OBGYN clinic is collecting data from a pregnant client who is 8 weeks pregnant. Which of the following statements by the client needs further intervention?

• client reports breast tenderness
• client reports feeling extreme fatigue
• client reports vaginal discharge that is white
• client is taking enalapril for hypertension

Answer 4

Client is taking Enalapril for hypertension

• ace inhibitors
  Remember: suffix ACE = “pril “
  Meaning these medications are teratogenic- causing harm to the developing fetus and shouldn’t be taken during pregnancy

Question 5

The nurse in the emergency department receives report on 4 clients. Which client should be seen first ?

• A 55 year old who is NPO asking for a snack
• A 60 year old who has a mean arterial pressure of 80mmhg
• A 20 year old who has a capillary refill of fewer than 3 seconds
• A 35 year old whose right hand is colder than his left

Answer 5

35 year old whose right hand is cooler than his left

• this patient needs immediate attention and should be assessed first due to the risk of losing his hand due to inadequate perfusion and blood supply. This finding could mean that a thrombus (clot) has formed, hemorrhage is occurring, infection, or circulatory impairment has occurred

Question 6

A client is scheduled for an elective laparoscopic cholecystectomy. The nurse should notify the health care provider (HCP) about what findings before the surgery?

• platelet count of 300,000/mm^3
• temperature of 100.4 f with mild cough
• wbc of 9,000/mm^3
• hemoglobin 15g/dL and hematocrit 48%

Answer 6

Temperature of 100.4 with mild cough

• this may indicate the patient has an infection.