NCLEX PN Exam Preview

EXAM NEWEST 2024 ACTUAL

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The nurse is assisting with the admission of a client who is
scheduled for a colon resection. Which of the following
statements made by the client would be most important for
the nurse to clarify?
1. "I have urinary incontinence when I sneeze."
2. "I had successful cataract surgery 2 years ago."
3. "I take acetaminophen for occasional headaches."
4. "I usually have a few glasses of wine in the evening."

The nurse is caring for a client who is scheduled to have an

arterial blood gas (ABG) sample obtained. Which of the
following tests should the nurse anticipate will be performed
prior to the procedure?
1. Coombs' test
2. Schilling test
3. Ham test
4. Allen test

The nurse is contributing to a staff education program about

client confidentiality. Which of the following information
should the nurse suggest including? Select all that apply.
1. "The client is the sole owner of the client's medical
record."
2. "Unneeded computer-generated worksheets must be
shredded at the end of the shift to ensure client
confidentiality."
3. "Personal computer passwords may not be shared with
anyone, including other members of the client's health care
team."
4. "Keep your voice low when speaking with the client
because direct interactions with clients must be kept as
private as possible."
5. "Medical information about the client may be shared with
a police officer who brought the client into the emergency
department (ED)."
The charge nurse in a long-term care facility has been
advised that the following assigned clients will be admitted
during the shift. The charge nurse should assign the only
available private room to the client with
1. hepatitis C (HCV)
2. a positive varicella-zoster titer
3. Pneumocystis pneumonia (PCP)
4. a positive cytomegalovirus (CMV) titer

The nurse is contributing to the plan of care for a client with

chronic obstructive pulmonary disease (COPD). Which of
the following interventions should the nurse suggest
including in the client's plan of care?
1. Restrict the client's fluid intake to 500 mL daily.
2. Place the client in low-Fowler's position for meals.
3. Provide the client with a high-carbohydrate diet and high-
carbohydrate snacks.
4. Provide the client with small, frequent meals, and
schedule a rest period before and after meals

The nurse is reinforcing teaching with the parents of a child

who is scheduled for surgical repair of hypospadias in 3
hours. The nurse should reinforce that intended outcomes of
the procedure include
1. relief from pain
2. relief from bladder obstruction
3. the ability to void while standing
4. the ability to achieve an erection

The nurse is caring for a client who has an order for a sputum
specimen for culture and sensitivity (C & S). Which of the
following actions should the nurse take?
1. Request a prescription for a bronchodilator to be
administered before the specimen is obtained.
2. Place the specimen in the refrigerator until it can be
transported to the laboratory.
3. Tell the client to rinse the mouth with water before the
specimen is obtained.
4. Obtain the sputum specimen before the client goes to bed
at night.

The nurse in a pediatric outpatient care facility has received

telephone messages from parents of clients who were
previously seen at the facility. The nurse should first
telephone the parent of a client who has
1. acute otitis media and reports insomnia after taking
amoxicillin 6 hours ago
2. a fracture of the left tibia and has placed a crayon in the
cast
3. a colostomy and reports skin irritation around the stoma
4. pneumonia and has pink, frothy sputum

The nurse is caring for a 6-year-old client who is receiving

skeletal traction. Which of the following would be a priority
for the nurse to monitor?
1. the distance between the client's knees
2. the pull of the traction on the client's pins
3. the degree of flexion of the client's ankles
4. the position of the client's cervical spine on the bed

The nurse is collecting data from a client with an acute

myocardial infarction (MI). Which of the following findings
would be consistent with an acute MI? Select all that apply.
1. nailbed splinter hemorrhages
2. nausea and vomiting
3. diaphoresis
4. dyspnea
5. petechiae

The nurse is caring for a client who sustained a closed head

injury. Which of the following findings would require
immediate intervention?
1. blood pressure of 136/76 mm Hg
2. ecchymotic area over the left temple
3. headache that worsens with coughing
4. Glasgow Coma Scale (GCS) score of 13

The nurse has attended a staff education program about

elder abuse. Which of the following statements by the nurse
would indicate a correct understanding of the teaching?
1. "A health care worker or family member who threatens to
withhold food, water, or medical care is committing a form
of abuse."
2. "The nurse should explain to the victim of elder abuse that
data collected about the abuse will be kept confidential."
3. "Clients who are physically disabled and living in a long-
term care facility are the typical victims of elder abuse."
4. "Older adults who are abused will readily explain their
situation to a health care provider if asked directly"
The nurse is caring for a client born 6 hours ago and
observes the finding depicted below.
1. Notify the primary health care provider of the finding.
2. Administer oxygen therapy prescribed p.r.n.
3. Continue to perform routine newborn care.
4. Prepare the client for phototherapy
. Which of the following actions should the nurse take?
The nurse is contributing to a staff education program about
confidentiality. Which of the following information should
the nurse suggest including?
1. "Clients must wait until after discharge to view their
medical records."
2. "Clients must disclose all personal information in order to
receive care."
3. "Nurses in a hospital unit may review the medical records
for all clients in that unit."
4. "Certain information in the client's medical record may
not be considered confidential."

The nurse and unlicensed assistive personnel (UAP) are

caring for assigned clients. Which of the following activities
would be appropriate for the nurse to assign to UAP?
1. applying a condom catheter to the male client with a hip
fracture who is incontinent
2. applying a pressure dressing to the right hand of the client
who has a stab wound
3. obtaining vital signs from the client who is experiencing
delirium tremens (DTs)
4. inserting a nasogastric (NG) tube for the client with
anorexia nervosa (AN)

The nurse is reinforcing teaching with the parents of a 9-

year-old child who is receiving methylphenidate. Which of
the following information should the nurse reinforce?
1. "Check your child's pulse daily before administering
methylphenidate."
2. "Give your child methylphenidate no more than 3 hours
before bedtime."
3. "Your child will need to visit the primary health care
provider periodically."
4. "Increase your child's intake of foods that are high in iron
and potassium."

The nurse is reinforcing teaching with the parents of a 10-

year-old client with a seizure disorder about ketogenic diet
therapy. The nurse should reinforce that a ketogenic diet
includes foods that are
1. high in fat, contain adequate protein, and are low in
carbohydrates
2. high in fat, low in protein, and contain caffeine
3. low in fat, low in sodium, and are lactose-free
4. low in fat, high in sodium, and high in protein

The nurse has reinforced dietary teaching with a client who

has esophageal varices. Which of the following food choices
by the client would indicate a correct understanding of the
teaching?
1. 1 fresh apple
2. 1 bag of baby carrots
3. 4 oz (113.2 g) of pretzels
4. 8 oz (226.4 g) of vanilla yogurt

The nurse is observing a newly hired nurse administer a

client's transdermal patch. The nurse should intervene if the
newly hired nurse is observed
1. instructing the client to avoid massaging the patch
2. cleansing the client's skin with soap and water after
removing the old patch
3. initialing the patch and writing the date and time the patch
was applied on the patch
4. omitting documentation about the location on the client's
body where the patch was applied

The nurse is caring for a client who has an order to remove a

nasogastric (NG) tube. Which of the following actions should
the nurse take?
1. Have the client hyperextend the neck before withdrawing
the tube.
2. Withdraw the tube steadily while the client takes shallow
breaths.
3. Withdraw the tube quickly while the client holds a deep
breath.
4. Have the client flex the neck before withdrawing the tube.

The nurse is contributing to the plan of care for a client with

multiple sclerosis (MS). Which of the following should the
nurse recommend be included?
1. limiting the amount of time that the client spends in a hot
environment
2. encouraging the client to perform aerobic exercise several
times daily
3. offering the client between-meal snacks that are high in
vitamin C
4. keeping the client's legs elevated when sitting upright in a
chair

The charge nurse in a long-term care facility is making client

care assignments for unlicensed assistive personnel (UAP).
Which of the following statements by the charge nurse
would provide UAP with the best directions about an
assignment?
1. "The client is weak on the right side, so please assist the
client with dressing and bathing."
2. "Please check the client's capillary blood glucose level
and tell me the results by 0700."
3. "We need to document vital signs for the client every 4
hours today."
4. "Please encourage the client to change positions
frequently."

The nurse is preparing to administer regular insulin to a

client. Which of the following routes should the nurse
understand can be used to administer regular insulin?
Select all that apply.
1. oral
2. intradermal
3. intravenous
4. subcutaneous
5. intramuscular

The nurse is reinforcing teaching about sleep and rest at

home for a client who had a vaginal delivery 24 hours ago.
Which of the following information should the nurse
reinforce?
1. "Take a nap when your baby is sleeping."
2. "Wake up and go to sleep at the same time every day."
3. "On the weekend, plan and prepare all meals for the week
to prevent fatigue."
4. "Perform all of your household chores in the morning,
when you have more energy."

A nurse who is pregnant is assigned to care for a 3-month-

old client with respiratory syncytial virus (RSV) pneumonia.
The client is receiving ribavirin therapy. Which of the
following actions would be most appropriate for the nurse to
take?
1. Maintain transmission-based precautions while caring for
the client.
2. Request a change of assignment from the charge nurse.
3. Discuss the assignment with the client's physician.
4. Switch the client assignment with a coworker.
INFO:
Intermittent urethral catheterization was performed, and
400 mL of clear yellow urine was obtained. Client has facial
flushing and foul-smelling liquid stool leaking from the anus.
Semi-firm mass is still present in the LLQ of the abdomen.

The nurse should recognize that the client is potentially

experiencing ____________________ and
____________________

Word Choices:
an infection
urinary retention
a fecal impaction
autonomic dysreflexia
1100: Client has piloerection on the arms and legs and
diaphoresis on the forehead. During abdominal palpation, a
semi-firm mass is noted in the left lower quadrant (LLQ).
Bladder is nonpalpable.
1115: Intermittent urethral catheterization was performed,
and 400 mL of clear yellow urine obtained. Client has facial
flushing and foul-smelling liquid stool leaking from the anus.
Semi-firm mass is still present in the LLQ of the abdomen.
1130:Client reports a headache rated 10/10 on the
Numerical Rating Scale and blurred vision.
The nurse has reviewed the Nurses' Notes from 1130 and
has collaborated with the registered nurse. Complete the
following sentence by choosing from the list of options. The
nurse should recognize that the client is most likely
experiencing___________________________
an infection
autonomic dysreflexia
an abdominal aneurysm
1100: Client has piloerection on the arms and legs and
diaphoresis on the forehead. During abdominal palpation, a
semi-firm mass is noted in the left lower quadrant (LLQ).
Bladder is nonpalpable.
1115: Intermittent urethral catheterization was performed,
and 400 mL of clear yellow urine obtained. Client has facial
flushing and foul-smelling liquid stool leaking from the anus.
Semi-firm mass is still present in the LLQ of the abdomen.

1130:Client reports a headache rated 10/10 on the

Numerical Rating Scale and blurred vision.

For each potential nursing intervention, click to specify

whether the intervention is indicated or not indicated for the
client.

Place the client in the left lateral position.

Remove the client’s low-top athletic shoes.

Inform the client that the Credé method will be performed.

Request a prescription for an overthe-counter (OTC) laxative.

Place the client in the left lateral position.

Remove the client's low-top athletic shoes.
Inform the client that the Credé method will be performed.
Request a prescription for an overthe-counter (OTC) laxative.
1100: Client has piloerection on the arms and legs and
diaphoresis on the forehead. During abdominal palpation, a
semi-firm mass is noted in the left lower quadrant (LLQ).
Bladder is nonpalpable.
1115: Intermittent urethral catheterization was performed,
and 400 mL of clear yellow urine obtained. Client has facial
flushing and foul-smelling liquid stool leaking from the anus.
Semi-firm mass is still present in the LLQ of the abdomen.
1130:Client reports a headache rated 10/10 on the
Numerical Rating Scale and blurred vision.
Select 2 actions the nurse should take.
1. Request a prescription for hydralazine.
2. Place the client in Trendelenburg's position.
3. Check the client's blood pressure every 30 minutes.
4. Apply lubricant to gloved fingers to remove fecal
impaction.
5. Inform the client that a magnetic resonance imaging (MRI)
scan will be performed.
1100: Client has piloerection on the arms and legs and
diaphoresis on the forehead. During abdominal palpation, a
semi-firm mass is noted in the left lower quadrant (LLQ).
Bladder is nonpalpable.
1115: Intermittent urethral catheterization was performed,
and 400 mL of clear yellow urine obtained. Client has facial
flushing and foul-smelling liquid stool leaking from the anus.
Semi-firm mass is still present in the LLQ
1130:Client reports a headache rated 10/10 on the
Numerical Rating Scale and blurred vision.1145: Elevated
the head of the client's bed and removed the client's lowtop
athletic shoes. Requested a prescription for digital fecal
impaction removal and lidocaine lubricant.
1200: Client is having tonic-clonic seizures, so the client in
side-lying position.
Specify whether the finding indicates that the client's status
has worsened or is unchanged
pulse
respirations
blood pressure
tonic-clonic se
pulse
respirations
blood pressure
tonic-clonic seizures
The nurse is assisting to admit a client who has
streptococcal pharyngitis. Which of the following actions
should the nurse take?
1. Wear a surgical mask when checking the client's vital
signs.
2. Ensure the assigned room has monitored negative air
pressure.
3. Request the dietary department provide disposable
dishes and utensils for the client's meals.
4. Obtain particulate respirator masks (N95s) for staff
members to use when providing client care.
The nurse has reinforced teaching with a client who is
receiving alendronate. Which of the following statements by
the client would indicate a correct understanding of the
teaching?
1. "I can take the medication at any time of day."
2. "I should take the medication with orange juice."
3. "I must sit upright for 30 minutes after taking the
medication."
4. "I will avoid taking over-the-counter (OTC) vitamin D
supplements."
The nurse is talking with a client who has borderline
personality disorder. Which of the following statements
would the nurse expect the client to make?
1. "I often feel bored and empty."
2. "I hear voices others are unable to hear."
3. "I need to go to my room to wash my hands again."
4. "I am worried the food on this meal tray has been
poisoned."
The nurse is caring for a client with moderate Alzheimer's
disease (AD). The nurse should immediately intervene if a
staff member is observed
1. providing the client with a sandwich to eat while the client
is wandering in the hallway
2. securing the client to a shower chair before the shower
begins
3. offering the client several ounces of fluid at regular
intervals
4. letting the client choose what sweater to wear
The nurse is caring for a client who had a thoracentesis 1
hour ago. Which of the following findings would require
immediate follow-up?
1. respirations of 24
2. tenderness at the puncture site
3. temperature of 99.6° F (37.6° C)
4. small amount of bleeding at the puncture site
The nurse is caring for a client who has right-sided
hemiplegia and is ambulating using a walker. It would
indicate a correct understanding of how to use the walker if
the client is observed
1. moving the walker forward 12 in (30 cm) then swinging
both legs forward together
2. taking a step forward with the left leg and then advancing
the right leg and the walker
3. moving the walker and the right leg forward 6 in (15 cm)
and then moving the left leg forward
4. placing the rear legs of the walker and the right leg forward
and then moving the left leg forward
The nurse is contributing to a staff education program about
clients who are pregnant and rubella nonimmune. Which of
the following information should the nurse suggest
including? Select all that apply.
1. "Fetal effects from the mother's exposure to rubella tend
to be mild."
2. "Clients who are not immune to rubella should be
vaccinated postpartum."
3. "Exposure to rubella during pregnancy is only harmful in
the first trimester." 4. "Pregnancy should be prevented for 4
weeks after receiving the rubella vaccine."
5. "Anti-infectives administered after exposure eliminate the
risks of rubella for the fetus."
The nurse is caring for a client with persistent depressive
disorder. Which of the following behaviors would the nurse
expect to observe?
1. grandiose actions
2. expansive, pressured speech
3. reports of auditory hallucinations
4. inability to experience joy or pleasure in life
The nurse is caring for a client who has just returned from
the radiology department after having an upper
gastrointestinal (UGI) series. Which of the following actions
should the nurse take first?
1. Administer the enema.
2. Verify the preliminary test results.
3. Determine whether follow-up x-rays are to be taken.
4. Give the multivitamin that was withheld prior to the
procedure.
The nurse is measuring a client for crutches. Which of the
following actions should the nurse take?
1. Measure the client's height and subtract 8 in (20 cm) to
obtain the correct crutch length.
2. Ask the client to stand upright and position the shoulder
rest of the crutch 6 in (15 cm) below the axilla.
3. Adjust the crutches so the client's elbows are at a 30-
degree angle while the client's hands are resting on the hand
grips.
4. Measure from the posterior fold of the axillae to the toes
of the client's feet and add 2 in (5 cm) while the client is in a
supine position.
The nurse in an outpatient care facility has received the
following telephone messages from clients who were
previously seen at the facility. The nurse should first
telephone the client who is reporting
1. no memory of the postprocedure instructions following an
esophagogastroduodenoscopy (EGD)
2. a sore throat following a endoscopic retrograde
cholangiopancreatography (ERCP)
3. shortness of breath following a bronchoscopy
4. abdominal cramping following a colonoscopy
The nurse in a rehabilitation facility is caring for a client who
had a right knee arthroplasty 8 days ago and has been
diagnosed with pneumonia. The client is being transferred to
an acute care facility. It would be essential for the nurse to
communicate in the transfer report that
1. the client lives in a ranch home that requires climbing 2
stairs to get into the house
2. the client's spouse will be visiting the client at the hospital
later today after leaving work
3. the discharge to home is anticipated for the client after 1
more week of physical therapy
4. the most recent focused data collection reveals bilateral
crackles (rales) auscultated in the client's lungs
The nurse is caring for a client who is experiencing new-
onset profuse epistaxis. Which of the following actions
should the nurse take? Select all that apply.
1. Check the client's vital signs.
2. Apply a warm compress to the client's nose.
3. Assist the client to apply pressure to the nares.
4. Encourage the client to spit out blood instead of
swallowing it.
5. Place the client in an upright position with the head tilted
forward.
6. Encourage the client to blow the nose periodically until
the epistaxis resolves
The nurse is talking with the spouse of a client who has
malignant melanoma and is terminally ill. Which of the
following statements by the spouse would be essential to
follow up?
1. "I feel as though there is so much happening now and I
have been relying on my adult children to help care for my
spouse."
2. "I give my spouse the pain medication regularly even
though the medication causes my spouse to become
drowsy."
3. "I try to keep my spouse's window open when the weather
is nice because my spouse enjoys listening to the birds."
4. "I sometimes feel bad because I often have 1 or 2 glasses
of wine to help me relax and sleep at night."
Day 1: Client reports pain in left ear for the past 2 days.
Client is febrile with small amount of cerumen observed in
left ear canal. Prescribed azithromycin 500 mg, p.o., today,
then 250 mg, p.o., daily for 4 days.
Day 13: Yesterday, client observed drops of blood on pillow
case. Reports having no oral intake today. Client states, "I
have not had an appetite for over a week." Client is febrile
and experiencing dizziness, vertigo, and tenderness over the
left mastoid process. Tympanic membrane is dull and
bulging on otoscopic examination. Client reports decreased
hearing in the left ear and onset of a headache. Abdomen
soft with hypoactive bowel sounds. 12-lead
electrocardiogram (ECG) reveals normal sinus rhythm.
Which of the following findings require immediate follow-
up? Select all that apply.
1. vertigo
2. appetite
3. vomiting
4. headache
5. bowel sounds
6. cardiac rhythm
Which of the following complications is the client at risk for
experiencing? Select all that apply.
1. leukopenia
2. paralytic ileus
3. fluid imbalance
4. injury from falling
5. venous thrombosis
Day 1: Client reports pain in left ear for the past 2 days.
Client is febrile with small amount of cerumen observed in
left ear canal. Prescribed azithromycin 500 mg, p.o., today,
then 250 mg, p.o., daily for 4 days.
Day 13: Yesterday, client observed drops of blood on pillow
case. Reports having no oral intake today. Client states, "I
have not had an appetite for over a week." Client is febrile
and experiencing dizziness, vertigo, and tenderness over the
left mastoid process. Tympanic membrane is dull and
bulging on otoscopic examination. Client reports decreased
hearing in the left ear and onset of a headache. Abdomen
soft with hypoactive bowel sounds. 12-lead
electrocardiogram (ECG) reveals normal sinus rhythm.
Complete the following sentence by choosing from the list of
options. The client is at highest risk for developing
______________________________
meningitis
otosclerosis
Ménière disease
Day 1: Client reports pain in left ear for the past 2 days.
Client is febrile with small amount of cerumen observed in
left ear canal. Prescribed azithromycin.
Day 13: Yesterday, client observed drops of blood on pillow
case. "I have not had an appetite for over a week." Client is
febrile and experiencing dizziness, vertigo, and tenderness
over the left mastoid process. Tympanic membrane is dull
and bulging on otoscopic examination. Client reports
decreased hearing
1000: Client admitted for recurring otitis media and
worsening of symptoms.
Which of the following health care orders should the nurse
anticipate? SATA
1. lumbar puncture
2. indwelling urethral catheter
3. airborne isolation precautions
4. culture and sensitivity (C & S) testing of ear drainage
5. psychiatric consultation for evaluation of abnormal grief
6. computed tomography (CT) scan of the head and left ear
Day 1: Client reports pain in left ear for the past 2 days.
Client is febrile with small amount of cerumen observed in
left ear canal. Prescribed azithromycin

Day 13: Yesterday, client observed drops of blood on pillow

case. Reports having no oral intake today. Client states, “I
have not had an appetite for over a week.” Client is febrile
and experiencing dizziness, vertigo, and tenderness over the
left mastoid process. Tympanic membrane is dull and
bulging on otoscopic examination. Client reports decreased
hearing in the left ear and onset of a headache. Abdomen
soft with hypoactive bowel sounds. 12-lead
electrocardiogram (ECG) reveals normal sinus rhythm.
Specify: indicated or not indicated for the postoperative care
of the client.

Keep the client supine for 24 hours.

Assess for bleeding from the left ear.

Administer antiemetics to prevent vomiting.

Reinforce the importance of coughing to clear the airway

Keep the client supine for 24 hours.

Assess for bleeding from the left ear.
Administer antiemetics to prevent vomiting.
Reinforce the importance of coughing to clear the airway
The nurse has assisted with the orientation of new staff
members to the care of clients in the postpartum period.
Which of the following statements by a staff member would
indicate a correct understanding of the orientation?
1. "I will offer a client gloves to wear during formula feedings
if the client's newborn develops a fine white rash over the
nose and chin."
2. "I should encourage a client to wear gloves when the
client applies a medicated cream to hemorrhoids."
3. "I should wear gloves to assist a client who is
breastfeeding her newborn."
4. "I must wear a surgical mask when checking a client's
lochia."
The nurse is caring for a client who has just been told the
client's cancer has metastasized. The nurse enters the room
and observes the client crying. Which of the following
responses would be appropriate for the nurse to make first?
1. "You seem upset. May I sit with you for a while?"
2. "I will give you some time alone and will come back soon."
3. "I can telephone a family member to come and stay with
you."
4. "Do you have a spiritual advisor that you would like me to
notify?"
A client is admitted with severe pain in the left lower
extremity. The client is scheduled for a complete blood
count (CBC), urinalysis, chest x-ray, and x-ray of the lower
extremities. The client asks the nurse, "Why do I have to have
all these tests? The pain is in my leg." Which of the following
responses would be most appropriate for the nurse to
make?
1. "The tests will not take long to complete."
2. "These tests are part of the admission procedure."
3. "It must be difficult not understanding what is happening
to you."
4. "Perhaps that is something you need to discuss with your
primary health care provider."
The nurse has received the following information about
assigned clients. The nurse should first check the client
1. who has right-sided heart failure and is reporting frequent
urination
2. with active pulmonary tuberculosis (TB) who is reporting
expectorating blood-tinged mucus
3. who has a fractured femur and received a dose of pain
medication 1 hour ago and is reporting that the pain has not
been relieved
4. with benign prostatic hyperplasia (BPH) who is reporting
having no bowel movement for the past 3 days and is
requesting a dose of a prescribed laxative
The nurse is caring for a client with pertussis. Which of the
following infection control precautions should the nurse
implement?
1. Wear gloves when checking the client's pulse.
2. Wear a protective gown when bathing the client.
3. Wear a surgical mask when assisting the client to eat.
4. Place a stethoscope in the client's room to be used with
that client only.
The nurse is contributing to a staff education program about
fall prevention. Which of the following information should
the nurse suggest including?
1. "Raise the side rails for a client with memory impairment."
2. "Encourage a client with impaired balance to avoid
ambulation."
3. "Instruct a client with orthostatic hypotension to
ambulate slowly."
4. "Place a commode at the bedside of a client with urinary
frequency."
The nurse is caring for a client with pneumococcal
pneumonia. Which of the following statements by the client
would require follow-up?
1. "I have 4 cats."
2. "I usually swim twice a week."
3. "I stopped smoking 4 years ago."
4. "I live with my 89-year-old mother."
The nurse is reinforcing teaching with a client who is at risk
for coronary artery disease (CAD). Which of the following
information should the nurse reinforce? Select all that apply.
1. "Exercising once a week will prevent the risk of CAD."
2. "You should avoid exposure to environmental tobacco
smoke."
3. "You should maintain a body mass index (BMI) of less than
25."
4. "You may continue to consume alcoholic beverages as
you desire."
5. "A diet high in fruits, vegetables, and unsaturated fats will
decrease your risk of CAD."
The nurse is collecting data on a 4-month-old client with
gastroenteritis. The nurse observes an irregular area of dark
blue pigmentation on the client's sacral area. The nurse
should next
1. determine whether this finding is normal for an infant of
the client's ethnic background
2. ask the client's parent whether the child has shown any
tendency toward bleeding
3. report the finding to the registered nurse as evidence of
possible child abuse
4. apply gentle pressure to the area to check for tenderness
The nurse has reinforced teaching with a client who has an
ileal conduit. Which of the following statements by the client
would indicate a correct understanding of the teaching?
1. "I will need to awaken several times at night to empty the
pouch."
2. "The stoma should be a dark purple color."
3. "I can expect to have mucus in my urine."
4. "I will need to limit my fluid intake."
The nurse is talking with the parent of a 3-month-old client.
The parent expresses concern that the infant is unable to roll
over. Which of the following would be an appropriate
response for the nurse to make?
1. "We should inform your child's primary health care
provider about this delay."
2. "Most infants are able to roll over between the ages of 4
and 6 months."
3. "Does your infant smile in response to your smile?"
4. "Is your infant able to pick up objects?"
The nurse is collecting data from an 85-year-old male client.
Which of the following statements would be essential to
follow up?
1. "I have a problem starting a strong stream of urine."
2. "I feel stomach discomfort after eating a large meal."
3. "I have awakened from sleep because of shortness of
breath."
4. "I find that it takes longer to do tasks such as balancing
my checkbook."
The nurse is caring for assigned clients. The nurse should
recognize that the client at highest risk for developing
peritonitis is a client who had
1. an appendectomy for a ruptured appendix 12 hours ago
2. a nasogastric (NG) tube inserted 6 hours ago for
gastrointestinal bleeding
3. a subtotal gastrectomy 8 hours ago and is reporting pain
rated 7 on a scale of 0 (no pain) to 10 (severe pain)
4. an abdominal cholecystectomy 16 hours ago and has 300
mL of greenish brown drainage in the biliary drainage tube (T-
tube)
The nurse has reinforced teaching with the parent of a child
about prevention of Lyme disease. Which of the following
statements by the parent would indicate a correct
understanding of the teaching?
1. "I will make sure my child is bathed after being outside."
2. "I will keep my child away from other children who have
Lyme disease."
3. "I will ensure that potato salads and macaroni salads are
kept at 39.9° F (4.4° C)."
4. "I will make sure that my child wears long sleeves and long
pants when playing in wooded areas."
The nurse has reinforced discharge teaching with the parent
of a newborn. Which of the following statements by the
parent would require follow-up?
1. "I will leave my baby's diaper off when possible if the
diaper area starts to become red."
2. "I should give my baby a pacifier at bedtime to reduce the
risk of sudden infant death syndrome (SIDS)."
3. "I will secure my baby in a rear-facing car seat in the front
seat of the car since there is an airbag there."
4. "I should squeeze the bulb syringe before inserting it into
my baby's mouth when I suction excess secretions."
The nurse has received the following information about
assigned clients. The nurse should first check the client who
1. has gastroenteritis, is reporting nausea, and vomited 100
mL of green liquid
2. has a long leg cast and is sitting in a chair with the casted
leg elevated on a stool
3. had a thyroidectomy 2 days ago and has muscle spasms
in the wrist when the blood pressure is taken
4. had an appendectomy 1 day ago and has a 0.8 in (2 cm)
area of serosanguineous drainage on the incision dressing
The nurse is talking with a client who has schizophrenia. The
client states. "I just returned from Mars." Which of the
following responses would be appropriate for the nurse to
make?
1. "I need to tell you that you cannot talk about silly things
here."
2. "Why do you think you made that trip?"
3. "I am here to listen to your concerns."
4. "How does it feel to be back?"
The nurse has reinforced teaching with a client who is
receiving vardenafil. Which of the following statements by
the client would indicate a correct understanding of the
teaching? Select all that apply.
1. "I may experience a headache and facial flushing."
2. "I can continue to take prescribed isosorbide
mononitrate."
3. "I will take the medication 1 hour before I engage in sexual
activity."
4. "I should notify my primary health care provider if I have
pain in my jaw."
5. "I can take an additional dose of the medication if I do not
experience the desired effects within 3 hours."
The nurse is talking with the spouse of a client with left-
sided hemiplegia. The spouse tells the nurse, "I scheduled
this appointment because I noticed an area of redness had
developed on my spouse's hip. I feel so guilty because I
caused this to happen. I do not know what to do." Which of
the following would be an appropriate initial response for the
nurse to make?
1. "How often do you change your spouse's position?"
2. "The type of care that you have undertaken is not easy." '
3. "We will make sure that you have help if this requires
special care."
4. "Have you been offering your spouse fluids at regular time
intervals?"
The nurse is contributing to a staff education program about
electronic medical records. Which of the following
information should the nurse suggest including? Select all
that apply.
1. "An issue surrounding electronic medical records is
access to secure information."
2. "The nurse should log off the computer system before
leaving a computer terminal."
3. "An advantage of using electronic medical records is
improved legibility in documentation."
4. "The nurse should refrain from sharing security passwords
for the electronic medical record system."
5. "A disadvantage of the use of electronic medical records
is that departments are unable to interact within the
system."
6. "A nurse with experience documenting in 1 electronic
medical record system can use another system without
training."
The nurse is preparing to insert an indwelling urethral
catheter for an assigned client. Which of the following
statements by the client would be a priority to follow up?
1. "I have had a catheter before and felt pressure when the
catheter was placed."
2. "I developed a rash on my neck when I ate shrimp several
months ago."
3. "I just urinated so I won't need a catheter placed."
4. "I haven't been drinking many fluids lately."
The nurse is caring for a 17-year-old client with Guillain-
Barré syndrome who is beginning to have return of sensation
and motor function. The client states, "I'm going to miss my
senior dance. It's not fair." Which of the following responses
would be appropriate for the nurse to make?
1. "You should be happy that you are getting some
movement back." '
2. "You will be able to have your friends visit and tell you
about the dance."
3. "You are sad because you will miss something you have
looked forward to for a long time."
4. "You will graduate from high school soon, and there will be
dances at the college you plan to attend."
The nurse is caring for an adolescent client who was recently
diagnosed with diabetes mellitus (type 1). The client states,
"You don't understand what it is like to have to give yourself
injections every day!" Which of the following responses
would be appropriate for the nurse to make?
1. "I have cared for many clients who are the same age as
you, and they have adjusted."
2. "There are many athletes who have the same diagnosis
and are very healthy."
3. "It must be difficult to self-administer an injection every
day."
4. "I can teach one of your parents how to give the
injections."
The nurse is caring for a client with panic disorder. Which of
the following findings would the nurse expect to observe?
1. dry skin
2. chest pain
3. decreased pulse
4. delusional thinking
The nurse is assisting with the plan of care for a client with
moderate Alzheimer's disease (AD). Which of the following
interventions should the nurse suggest including in the
client's plan of care? Select all that apply.
1. Avoid the use of restraints.
2. Avoid reminiscing about happy times in the client's life.
3. Use distraction when the client becomes anxious or
agitated.
4. Provide the client with a wide selection of food choices at
mealtimes.
5. Speak slowly and use short, simple sentences when
providing the client with information.
6. Provide family members with information about
community support services for respite care.
The nurse is caring for a client with disseminated herpes
zoster (shingles) who is in a private room. The nurse should
understand the client may be developing sensory isolation if
the client reports the onset of
1. photophobia
2. headaches
3. tremors
4. anxiety
The nurse is contributing to a staff education program about
the stages of grief in clients with terminal illnesses. Which of
the following information should the nurse suggest
including?
1. "The client avoids making plans during the acceptance
phase."
2. "The nurse should confront the client in the denial phase
and emphasize that the client's diagnosis will indeed result
in death."
3. "The client may openly express feelings of sadness during
the depression phase or withdraw from friends and family
members."
4. "The nurse should leave the client alone as much as
possible if feelings are misdirected toward the nurse during
the anger phase."
The nurse is contributing to the plan of care for a client who
sustained a spinal cord injury at T1 five days ago. Which of
the following interventions should the nurse recommend
including in the client's plan of care?
1. Limit the client's fluid intake to 1 L daily.
2. Encourage the client to increase the intake of foods high in
carbohydrates.
3. Request a prescription for a stool softener to be
administered to the client daily.
4. Perform lower extremity passive range-of-motion (ROM)
exercises for the client once daily.
The nurse is caring for a client who is receiving long-term
glucocorticoid therapy. The nurse should encourage the
client to select a diet that is high in
1. calcium
2. vitamin K
3. magnesium
4. thiamine (vitamin B1 )
The nurse is collecting data from a client with sickle cell
anemia. Which of the following statements by the client
would be essential to follow up?
1. "I usually drink 4 L of water or juice daily."
2. "I am scheduled to receive the influenza vaccine."
3. "I may need to receive an anti-infective if I develop a fever."
4. "I have been applying cold packs daily to help relieve the
pain in my knees."
The nurse is contributing to the plan of care for a client who
has a nasogastric (NG) tube for feeding. Which of the
following interventions should the nurse recommend
including in the client's plan of care?
1. Raise the head of the client's bed 15 degrees.
2. Apply sterile gloves to irrigate the client's NG tube.
3. Use pH paper to measure the pH of the client's aspirate.
4. Encourage the client to cough while removing the NG
tube.
The nurse is preparing to assist a client who has recently
developed a visual impairment to ambulate. To ensure the
client's safety, it would be appropriate for the nurse to
1. hold the client's hand while walking next to the client
2. place 1 hand on the client's shoulder and walk in front of
the client
3. apply a gait belt around the client's waist and walk at the
client's side
4. instruct the client to hold on to the nurse's upper arm
while the nurse walks slightly ahead of the client
The nurse is reinforcing discharge instructions with a client
taking isosorbide dinitrate. The nurse should reinforce that
the client should avoid
1. sudden position changes
2. exposure to sunlight
3. vigorous exercise
4. taking antacids
The nurse is reinforcing teaching with a client who has iron-
deficiency anemia. Which of the following information
should the nurse reinforce? Select all that apply.
1. "Take the iron supplement with a glass of milk if you
experience gastric upset."
2. "Continue to take your iron supplement after your
symptoms resolve."
3. "Consult with a genetic counselor to establish inheritance
patterns."
4. "Alternate periods of activity and rest throughout the day."
5. "Increase your dietary intake of foods such as legumes."
The nurse has reinforced teaching with a female client who
sustained a spinal cord injury at T5 three weeks ago. Which
of the following statements by the client would indicate a
correct understanding of the teaching? Select all that apply.
1. "I need to maintain a fluid intake of at least 2 L daily."
2. "I will need to perform range-of-motion (ROM) exercises
several times each day."
3. "I will be able to ambulate with crutches once I have
completed physical therapy."
4. "I should see a fertility specialist if I want to conceive a
child because I may be infertile."
5. "I should notify my primary health care provider if I
experience a pounding headache."
The nurse is contributing to the plan of care for a client who
sustained full-thickness (third-degree) burns on 30% of the
body 3 days ago. Which of the following interventions should
the nurse suggest including in the client's plan of care?
Select all that apply.
1. Discourage movement of the affected body parts.
2. Offer the client opioid analgesics prior to providing wound
care.
3. Use ice and other cold therapy as an adjunct to
pharmaceutical pain relief.
4. Wear a hair covering and a surgical mask when the burn
wounds are exposed.
5. Stress the importance of strict intake and output
recording for the client with unlicensed assistive personnel
(UAP).
Client is transferred from (ED) to the pediatric unit via
wheelchair, admitted, and accompanied by the parent.
Reports frequent nausea, vomiting, anorexia, periumbilical
and (RLQ) pain rated 8/10. States, “Pain began around 4am,
and then I started to throw up.” Respirations are shallow.
Skin is dry. Posture is stooped, mood and affect are irritable.
Last meal was 20 hours ago.

Actions to Take: Request an order to administer

corticosteroids, reinforce teaching insulin administration,
Prepare for a (CT) scan of the abdomen, Reinforce teaching
folic acid supplementation. Ensure peripheral (VAD) for fluid
and electrolyte correction.

Potential Conditions: appendicitis, ulcerative colitis, new

onset diabetes mellitus (type 1), regional enteritis (Crohn’s
disease)

Parameters to Monitor: rectal bleeding, growth restriction,

sudden pain relief, glycosylated hemoglobin (HgbA1 C) every
3 months, CBC

Potential Conditions:

Actions to Take:

Parameters to Monitor:

The nurse and unlicensed assistive personnel (UAP) are

caring for assigned clients. Which of the following activities
would be appropriate for the nurse to assign to UAP?
1. obtaining vital signs from the client with major depression
2. providing medication teaching to the client with
schizophrenia
3. monitoring medication side effects of the client with
bipolar I disorder
4. telephoning the primary health care provider to report the
intake and output information from the client with anorexia
nervosa (AN)
The nurse has reinforced teaching with a female client who
will receive oxytocin for induction of labor. Which of the
following statements by the client would indicate a correct
understanding of the teaching?
1. "I will have my blood pressure checked every 60 minutes."
2. "The breathing exercises that I learned will not help
manage labor pain."
3. "The oxytocin infusion can result in uterine
hyperstimulation and fetal harm."
4. "I can expect to have a headache and vomiting because of
the oxytocin infusion."
The nurse is contributing to a staff education program about
atenolol. Which of the following information should the
nurse suggest including?
1. "Atenolol blocks the vasoconstrictor and aldosterone-
producing effects of angiotensin II."
2. "Atenolol blocks the conversion of angiotensin I to
angiotensin II."
3. "Atenolol blocks the stimulation of beta-1 adrenergic
receptors."
4. "Atenolol blocks the postsynaptic alpha-1 adrenergic
receptors."
The nurse is caring for a client with disseminated
intravascular coagulation (DIC). Which of the following
statements by the client would be essential to follow up?
1. "I prefer to receive my medication subcutaneously rather
than intramuscularly."
2. "I have avoided blowing my nose today because I have had
2 episodes of epistaxis."
3. "I have been taking 1 aspirin every day since I had a
myocardial infarction (MI) 1 year ago."
4. "I held pressure on the puncture site for 5 minutes after
the nurse drew blood from my arm."
The nurse is reinforcing teaching with a client who is
scheduled for a thoracentesis. Which of the following
information should the nurse reinforce?
1. "You should lie on the affected side for 4 hours after the
procedure."
2. "You will be given a dose of a sedative/hypnotic before the
procedure."
3. "You should not have anything to eat or drink for 24 hours
before the procedure."
4. "You will be placed in a sitting position with your arms
resting on a bedside table during the procedure."
The nurse has reinforced teaching with a client who is
scheduled for electroconvulsive therapy (ECT). Which of the
following statements by the client would indicate a correct
understanding of the teaching?
1. "Common side effects of ECT are diarrhea and a low-
grade fever."
2. "I will experience a tonic-clonic seizure for approximately
15 minutes during the ECT procedure."
3. "ECT is commonly used to treat depression when several
antidepressants have not been effective."
4. "ECT is effective because it decreases the level of
neurotransmitters in the central nervous system."
The nurse is reinforcing teaching with a client with chronic
lymphocytic leukemia who is at risk for developing
thrombocytopenia. Which of the following information
should the nurse reinforce?
1. ''You should use a disposable razor rather than an electric
razor when shaving."
2. "Frequent deep-breathing exercises should be performed,
but avoid coughing and blowing your nose."
3. "Frequent oral hygiene should be performed, including
flossing your teeth and using alcohol-based mouthwashes."
4. ''You may take over-the-counter (OTC) ibuprofen for any
discomfort, but avoid using OTC acetaminophen."
The nurse is preparing a client for emergency surgery to
repair a depressed skull fracture. Which of the following
actions would be essential for the nurse to take?
1. checking the client's corneal reflex
2. determining the time that the client last ate
3. telling the client what will occur in the postanesthesia
care unit (PACU)
4. showing the client a picture of the postoperative wound
drainage system
The nurse and unlicensed assistive personnel (UAP) are
caring for assigned clients. Which of the following activities
would be appropriate to assign to UAP? Select all that apply.
1. bathing the client who has altered mental status
2. assisting the client who uses a walker to ambulate
3. checking the vital signs of the client who has a peripheral
venous access device (VAD)
4. adjusting the prescribed oxygen flow rate for the client
based on oxygen saturation levels
5. measuring the oral intake and urine output for the client
who has an indwelling urethral catheter
The nurse is collecting data from a client with Guillain-Barré
syndrome. The client is experiencing paralysis and
paresthesia of the lower extremities and has a respiratory
rate of 18. Which of the following actions should the nurse
take?
1. Pad the side rails of the client's bed.
2. Massage the client's legs every 2 hours.
3. Monitor the client's respiratory rate frequently.
4. Keep the head of the client's bed elevated at 30 degrees.
The nurse is caring for a client who had an abdominal
paracentesis 1 hour ago. Which of the following statements
by the client would be a priority to follow up?
1. "The urine in my drainage bag looks pink."
2. "I will avoid sleeping on my left side for 2 days."
3. "I feel dizzy when I change positions in bed too quickly."
4. "It is easier for me to breathe when I am sitting up in bed."
The nurse is contributing to the plan of care for a client with
gestational hypertension who is at 32 weeks gestation.
Which of the following should the nurse recommend be
included in the plan of care?
1. monitoring the client's urine output
2. instructing the client to report any increase in fetal activity
3. minimizing the client's dietary intake of high-calcium
foods
4. instructing the client to use relaxation techniques to
relieve a headache
The nurse is collecting data from a client with chronic
obstructive pulmonary disease (COPD). Which of the
following findings would be a priority to report to the
registered nurse?
1. The client reports having increased sputum production in
the morning.
2. The client reports getting tired easily.
3. The client's breathing is shallow.
4. The client's sputum is yellow.
The nurse and unlicensed assistive personnel (UAP) are
caring for assigned clients. Which of the following activities
would be appropriate for the nurse to assign to UAP?
1. removing a condom catheter for the male client who has a
fractured pelvis
2. evaluating the pain level for the client who had an
abdominal hysterectomy several hours ago
3. providing discharge teaching to the client with chronic
obstructive pulmonary disease (COPD)
4. determining the effectiveness of an antianxiety
medication for the client with moderate Alzheimer's disease
(AD)
The nurse is collecting data from a client with a suspected
diagnosis of abdominal aortic aneurysm. Which of the
following findings would be consistent with an abdominal
aortic aneurysm?
1. back pain
2. dysphagia
3. urinary retention
4. neck vein distention
The nurse is observing a coworker who is suctioning a
tracheostomy for a client. The nurse should intervene if the
coworker
1. wears a face shield throughout the procedure
2. applies suction as the catheter is being withdrawn
3. wears clean, nonsterile gloves throughout the procedure
4. applies suction for 10 seconds at each pass of the
catheter
The nurse in the maternity unit is talking with a staff member
from another unit. The staff member asks the nurse about a
mutual friend who had a baby at the health care facility.
Which of the following would be an appropriate response for
the nurse to make? Select all that apply.
1. "I cannot give you any information about her condition." '
2. "I understand the delivery went well and her spouse is
with her."
3. ''You should give her a call on the telephone to see how
she is doing."
4. "I saw her this morning, and she is going to be discharged
home today."
5. "Take a look in the computer system to find out which
room she is in so you can visit."
The nurse has reinforced teaching with a client who had a
colostomy created 5 days ago. Which of the following
statements by the client would indicate a correct
understanding of the teaching?
1. "I should avoid emptying the pouch more than 2 times a
day so that I do not loosen the seal around the appliance."
2. "I will notify my primary health care provider if I develop a
fever or redness and drainage from the incision."
3. "I can expect to experience a burning sensation around
the stoma until the incision is completely healed."
4. "I will begin an aerobic exercise program because I will not
be able to go swimming."
The nurse is collecting data from a client who has
hypovolemic shock. Which of the following findings would
be consistent with hypovolemic shock? Select all that apply.
1. confusion
2. hypertension
3. decreased urine output
4. elevated respiratory rate
5. jugular vein distention (JVD)
The nurse is collecting data from a client with right-sided
heart failure. Which of the following findings would be
consistent with right-sided heart failure? Select all that
apply.
1. edema
2. dyspnea
3. dry cough
4. weight gain
5. jugular vein distention (JVD)
The nurse in a rehabilitation facility is admitting a client who
had a stroke. The client has an advance directive. Which of
the following actions should the nurse take? Select all that
apply.
1. Obtain a do-not-resuscitate (DNR) order for the client.
2. Make the health care team aware of the advance directive.
3. Notify the client's family that emergency care will not be
given.
4. Witness the client's signature on the advance directive,
and have it notarized.
5. Document in the medical record that the client has an
advance directive.
T 99.0° F (37.2° C)
P 72
RR 18
BP 98/60
Pulse oximetry reading 96% on 2 L/min of oxygen

Of which of the following scheduled medications should the

nurse withhold the dose?
1. captopril
2. albuterol
3. sennosides/docusate sodium
4. hydrocodone/acetaminophen
The charge nurse in a long-term care facility has just
completed client care assignments for unlicensed assistive
personnel (UAP). Which of the following statements by the
charge nurse would provide the best direction to UAP about
the assignment?
1. "The client with paraplegia should have a monthly safety
check completed on the wheelchair."
2. "You will need to assist the client with mild Alzheimer's
disease (AD) with activities of daily living (ADL)."
3. "The client with heart failure should be weighed and have
vital signs checked before breakfast is served."
4. ''You need to follow proper infection control precautions
when assisting the client with active pulmonary tuberculosis
(TB)."
The nurse is caring for a client who has been diagnosed with
a hookworm infection. The client's parent asks, "How can I
prevent my other children from getting hookworms?" Which
of the following would be an appropriate response for the
nurse to make?
1. "Cook all meats thoroughly."
2. "Wash all clothing in hot water."
3. "Have your pets treated for worms."
4. "Encourage your children to wear shoes when outside."
The nurse has reinforced teaching with clients about
preventing skin cancer. Which of the following statements by
a client would indicate a correct understanding of the
teaching?
1. "I will gradually increase the amount of time I am exposed
to the sun to prevent sunburn."
2. "I do not need to wear sunscreen on cloudy days because
clouds provide natural protection."
3. "I can wear a wide-brimmed hat rather than sunscreen if I
am outdoors for a short period of time."
4. "I will wear sunscreen with a sun protection factor (SPF) of
at least 15 when spending time in the sun."
The charge nurse in a long-term care facility has been
advised that the following clients will be admitted during the
shift. The charge nurse should assign the only available
private room to the client with
1. scabies
2. salmonellosis
3. hepatitis B (HBV)
4. cytomegalovirus (CMV)
The nurse is contributing to the plan of care for a client who
had a stroke 3 days ago and has right-sided hemiplegia and
dysphagia. Which of the following nutritional outcomes
would be most appropriate for the nurse to recommend
including in the client's plan of care?
1. The client will eat 90% of each meal.
2. The client will drink liquids without drooling.
3. The client will eat without episodes of coughing. '
4. The client will drink 4 oz (120 mL) of juice or water with
each meal.
The nurse is reinforcing teaching with a client who had a
renal transplant 3 days ago and is receiving cyclosporine.
Which of the following information should the nurse
reinforce?
1. "You should increase your intake of grapefruit juice while
you are taking cyclosporine."
2. ''You should notify your primary health care provider if you
experience a sore throat."
3. ''You may experience decreased urine output while you
are taking cyclosporine."
4. ''You will need to take this medication until your new
kidney is functioning."
The nurse is reinforcing teaching with a client who is
receiving insulin glargine. Which of the following information
should the nurse reinforce? 1. After administering the insulin
glargine the same syringe can be used to administer regular
insulin. 2. Insulin glargine should be administered 3 times
each day 15 minutes before meals. 3. Extra vials of insulin
glargine that have not been opened can be stored in the
freezer. 4. Insulin glargine does not have a peak action time.
The nurse is assisting with the admission of a client with
active pulmonary tuberculosis (TB).
Which of the following actions should the nurse take? Select
all that apply.
1. Provide a supply of sterile gloves outside of the client's
room.
2. Inform visitors that plants are restricted from the client's
room.
3. Keep the client in the room and the door to the client's
room closed.
4. Place the client in a private room with monitored negative
air pressure.
5. Place a surgical mask on the client when preparing the
client for transport to the radiology department.