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1. A client exposed to Mycobacterium tuberculosis starts on chemoprophylaxis. The nurs provides what instruction to the client?
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4. The clinic nurse is conducting health screenings. Which of the following client assessment findings indicates that client teaching is needed about the risk for stroke? Select all that apply
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NCLEX-final
nclex questions for final med-surg exam
| Question | Answer |
|---|---|
| 1. A client exposed to Mycobacterium tuberculosis starts on chemoprophylaxis. The nurs provides what instruction to the client? | You will take a single drug such as isoniazid (INH) by mouth every day for 6-12 months |
| 4. The clinic nurse is conducting health screenings. Which of the following client assessment findings indicates that client teaching is needed about the risk for stroke? Select all that apply | Weight 205 lbs. and height 5'4", blood pressure 164/92, smokes 1/2 pack of cigarettes per day |
| 8 The nurse places highest priority on taking which of the following actions to reduce the spread of microoganisms when caring for a client at risk for infection? | Wash hands before and after client care |
| 9. The nurse would report to the physician which of the following abnormal lab values for a 58-year-old client newly admitted to the nursing unit with fever and diarrhea? Select all that apply | White blood cell count 12,260/mm3, Blood urea nitrogen 38 mg/dL |
| 11. A postoperative client who has an order for 5,000 units of heparin SubQ for three doses wants to know why this drug is being ordered. What information would the nurse provide to the client to best answer the question? | Heparin is being used to prevent blood clots from forming as a result of surgery or decreased mobility |
| 17. The nurse is assigned to a client diagnosed with head & neck cancer who is receiving enteral feedings via gastrostomy tube. When the nurse is called away to care for another client, which task for this client could be appropriately delegated to a UAP | Administering a bath and changing bed linens |
| 18. A client with metabolic acidosis is admitted. Which of the following lab values would the nurse expect to find with this client? | pH 7.2; serum potassium 6.2 mEq/L |
| 19. A client has a BUN of 68 mg/dL and a creatinine level of 6.0 mg/dL. The IV fluid is 5% dextrose in 0.9% sodium chloride with 40 mEq KCL @ 100 mL/hr. Which action would be most appropriate for the nurse to take? | Question the use of Potassium in IV fluids |
| 23. The nurse is working with a client suffering from chronic diarrhea. In teaching ways to reduce diarrhea, the nurse would encourage the client to avoid which of the following that contribute to the development of diarrhea? | anxiety or anger |
| 25. The nurse notices that an elderly nursing home resident has not been eating or drinking as much as usual. Which assessment finding would best indicate the presence of fluid volume deficit? | Increased drowsiness, mild confusion, and concentrated urine |
| 27. The nurse would place highest priority on which of the following nursing interventions when planning to prevent atelectasis in the newly admitted postoperative client? | hourly coughing and deep breathing |
| 29. A client's hemoglobin level is 14 grams/dL. Which interpretation of the laboratory value by the nurse is most accurate? | Client has a normal laboratory value and has not nutritional risk |
| 32. After correctly positioning a client for a wound drsg change, the nurse sets up a sterile field, placing would supplies in the field. The nurse hears a page to respond to a fallen client. Which is the most appropriate action for the nurse to take? | Ensure the client's safety, cover the field with a sterile towel, and respond to another client. |
| 39. When giving directions to a 24-year-old female with abdominal pain who is about to undergo a pelvic sonogram, which statement should the nurse make to the client? | Drink plenty of liquids so you will have a full bladder |
| 43. When a female client preparing for surgery suddenly bursts into tears, the preoperative holding unit nurse should take which of the following actions? | Ask the client to share what she is feeling |
| 44. After reviewing the client's health history, the nurse concludes that which of the following is the most significant factor related to the development of bronchogenic carcinoma for this client? | cigarette smoking |
| 48. Which of the following actions would the nurse institute that is specific to the care of the assigned client who has tuberculosis | wearing a particulate respirator mask when taking vital signs |
| 49. A client has a potassium level of 6.8 mEq/L. Which sign or symptom would the nurse expect to find when assessing this client? | Peaking of T wave on the telemetry monitor |
| 52. The nurse is assigned to the care of an obese client who has GERD. Which of the following activities could the nurse appropriately delegate to a UAP? | Instruct the client to remain upright for at least 2 hours after eating |
| 53. The nurse is admitting a client with thermal burns to both arms and anterior trunk. The client asks for a drink of water. What is the most appropriate response for the nurse to make? | I'm sorry, you cannot drink anything right now; let me moisten your mouth instead |
| 55 A client who has pancreatitis is experiencing pain. After administering an analgesic, the nurse should place the client in which of the following positions to promote comfort? | sitting up and leaning forward |
| 58 The nurse believes a client has slight one-sided weakness. Tests muscle strength by asking the client to hold the arms up with supinated hands- as if holding a tray, eyes closed. The clients right hand moves down slightly and turns. The nurse documents | pronator drift |
| 61. A client who is receiving IV heparin by protocol orders has an activated partial thromboplastin time (aPTT) level of 140 seconds (control time is 36 seconds) What is the priority action that the nurse should institute? | Stop the heparin therapy for 1 hour. Decrease the rate of infusion per protocol and restart the medication in 1 hour. Obtain a repeat PTT in 2-4 hours from the restart of the infusion |
| 62. The nurse has admitted to the intermediate care unit a client who sustained a SCI at T1 in a motor vehicle accident. Which of the following nursing care activities can the nurse delegate to the UAP when working with this client?Select all that apply | Measure O2 sat levels every hour, provide mouth care |
| 63 The nurse has been instructed to have a surgical consent form signed by a client who will be undergoing a surgical procedure. What is the most essential information to include in the discussion prior to the client signing the permission? | right to withdraw consent |
| 65 a client is scheduled to have a transverse colostomy performed. While doing client teaching, the nurse points to which stoma on the diagram to show the client the location of the stoma? | the correct stoma is on the transverse part of colon |
| 67 The nursing unit is understaffed and a nurse from the surgical intermediate care unit has been floated to the unit for the day shift. Which of the following two clients should the nurse assign to this RN float nures? | a client who underwent emergency appendectomy during the night, a client with nephrolithiasis scheduled for lithotripsy later in the morning. |
| 68 The nurse would conclude that hypomagnesemia has not resolved if which of the following neuromuscular signs is still present after treatment. | tetany |
| 69 A client presents to the ED with a complaint of chest pain. Which serum lab test does the nurse check off on the laboratory slip as part of a protocol order to rule out an acute MI? | troponin |
| 74 A client has a strong family tendency toward HTN. He denies that he will get HTN because he watches what he eats, gets plenty of exercise, and keeps his weight within a normal range. When implementing the plan of care, the nurse should do which: | Recognize the client's efforts towards a healthy lifestyle and emphasis that early detection is essential to prevent complications |
| 78 A client presents to the ED with a stab wound to the abdominal RUQ. Vitals are bp 85/60, pulse 125, RR 28. The nurse should immediately suspect damage to what organ? | liver |
| 82 As part of the ongoing assessment of a client who has an electrical burn, a CBC, electrolyte panel, and renal panel were ordered. The nurse would expect to find which of the following results? | potassium level of 5.9 mEq/L |
| 83 A client with CHF has been advised to follow a low sodium diet. Which statement by the client indicates to the nurse that diet teaching has been effective? | "I need to avoid eating processed foods and canned meats and vegetables." |
| 85 While talking with a client the nurse notes that the client rapidly becomes more uncomfortable and anxious. What action should the nurse take? | refocus the conversation on a less threatening topic. |
| 92. The nurse in the ED is caring for a client who has fallen 20 feet from a roof. While performing the primary assessment, the most important nursing intervention will be which of the following? | maintain cervical spine precautions |
| 93 Which breakfast option indicates to the nurse that the client with coronary artery disease requires further diet instruction | canned peaches, egg omelet, whole milk, fruited yogurt |
| 97 The nursing unit is short staffed for the shift and an RN from the pediatric unit has been floated to the nursing unit. Which of the following clients should the nurse assign to the float nurse? | a 32-year-old client newly diagnosed with diabetes who needs dietary and medication teaching |
| 99 the nurse has just read the results of a clients TB test at a health fair. An induration is apparent. The client asks what this means. The nurse's best response would be: | A positive test means that you have been exposed to the TB organism. It does not mean that you currently have active bacteria. Further testing will be needed. |
| 101 The nurse suspects that hepatotoxicity is developing in a dark-skinned client who is on an antibiotic. In what area of the body should the nurse assess for jaundice? | hard palate of oral cavity |
| 103 Which nutritional measure would help a client with GERD to reduce the risk of symptoms? | Limiting intake of coffee drinks to 2 or few cups per day |
| 107 While assessing the chest tube drainage system of client,the nurse observes a slight rise and fall in the water level in the water seal. The nurse should take which of the following actions? | continue to monitor the system |
| 109 A client with cancer has a calcium level of 11.8 mg/dL. Which of the following symptoms would indicate a need for the nurse to call the physician for treatment orders? | muscle weakness |
| 112 a client with a history of heart failure suddenly exhibits shortness of breath, a respiratory rate of 30, crackles auscultated bilaterally, and frothy sputum. After telephoning the physician for medical orders, which should the nurse delegate to LPN? | insert a urinary catheter |
| 113 An 86 yo client will be undergoing a surgical procedure. Which of the following changes would the nurse make in the informed consent process for this elderly client? | Provide adequate time for the client to process the information |
| 115 The nurse is caring for a client who is recovering from partial thickness burns. Which of the following breakfast options indicates the client understands the recommended diet? | two poached eggs, hash brown potatoes, whole milk |
| 116 A client with diabetes insipidus who has been taking vasopressin intranasally comes to the clinic. On assessment the nurse notes some disorientation and behavior changes. Significant pedal edema is present. What should be the nurses next action? | check vital signs and notify the physician |
| 117 the nurse is assigned to the care of a client receiving radiation therapy for cancer. Which of the following activities needed in the care of a client receiving external beam radiation therapy could be safely delegated to a UAP? Select all that apply | document intake from the meal trays, assist the client to ambulate in the hall |
| 119 A female client states that will not undergo any invasive testing for her "stomach pain." The nurse explains that which of the following tests could be completed to assess the abdomen and still meet the client's wishes? | Abdominal ultrasound |
| 129 A female client has been successfully resuscitated after cardiac arrest. Her arterial blood gas reveals a pH of 7.6. The nurse attributes this result to which of the following | excess sodium bicarbonate, which was administered during the resuscitation |
| 134 The nurse would assess a 76-year-old client for which common problem that most increases the risk for major complications of heart and lung disease | polypharmacy resulting from visits to multiple doctors |
| 135 A client with ARDS show no improvement despite increases in the concentration of oxygen administered. What intervention should the nurse attempt which may improve ventilation-perfusion matching? | prone positioning |
| 136 The nurse is giving general information about antihypertensives to a young female client with a hx of HTN. The nurse includes that which antihypertensive should not be used if the client becomes pregnant | ACE inhibitors |
| 139 A client has been admitted to the nursing unit with a 3-day history of severe nausea and vomiting with diarrhea. The client is experiencing fatigue, anorexia, and muscle weakness. Based on this hx, which lab finding would the nurse expect? | potassium 2.9 mEq/L |
| 142 During a scheduled exam, the client's glycolysated hemoglobin was found to be 9%. The client has had diabetes mellitus for 3 years. The nurse should do which of the following? | Explore the clients general dietary pattern for the past 4 months |
| 149 The nurse examines the WBC differential for a client who experienced a severe allergic reaction. The nurse anticipates that which of the following values will be elevated? | eosinophils |
| 152 In a child with acute renal failure, the nurse would help to prevent hyperkalemia by limiting which of the following foods in the diet? | potatoes, tomatoes, and oranges |
| 158 While making rounds, the nurse observes a client receiving oxygen by this mode. The nurse concludes the client is using this mode of oxygen therapy because of which primary benefit? | oxygen concentration can be regulated |
| 165 A client admitted with exacerbation of COPD has a respiratory rate 18, dry cough, abg reveals pH of 7.29, CO2 of 50 mm Hg, O2 of 72 mmHg. The nurse identifies which nursing diagnosis as the priority? | impaired gas exchange |
| 167 The nurse has delegated to a UAP the care of a client who had a right hemisphere thrombotic stroke with hemiplagia. The nurse would give further direction to the UAP after noting that the UAP did which of the following? | placed a chair for a visitor on the let of the bed |
| 169 The nurse is reviewing the results of a male clients recent lipid profile. The nurse notes that the client is experiencing beneficial effects of a heart healthy diet and exercise after noting elevations in which laboratory value? | high density lipoprotein |
| 179 A client with bone cancer receiving chemotherapy has developed bone marrow suppression. Which laboratory report is of highest priority for the nurse to monitor at this time? | White blood cell count |
| 182 The client is admitted with all of the following orders to treat DKA with severe metabolic acidosis. Which order would the nurse determine to be the first priority in managing this client? | start IV fluid infusion for rehydration |
| 186 The home health care nurse is visiting an elderly client who is taking a prescribed calcium channel blocker. In conducting dietary teaching, the nurse instructs the client that what food is contraindicated to take with a calcium channel blocker? | grapefruit |
| 188 The nurse must assess the temperature and blood pressure of a client on contact precautions for wound infection every shift. Which is the appropriate nursing action to minimize the spread of microorganisms | keep the equipment in the client's room |
| 193 A client is receiving radiation to the head and neck area for the treatment of cancer. What interventions would you use to help the client's complaint of a dry mouth? | suggest the use of sugar free candies |
| 195 The nurse would expect to find a diminished pCO2 level in the assigned client who has which of the following physical assessment findings? | hyperventilation |
| 198 An adult client arrives to the ED with complaints of chest pain and shortness of breath. The nurse concludes that which of the following points, if present in the client's history, would indicate that this pain may be related to cardiac disease? | history of diabetes and smoking, the pain increases with activity, the client is experiencing sweating and nausea when the pain is severe |
| 201 The nurse is administering nitrogen mustard (Mustargen) and notes swelling at the IV site. The nurse should take which of the following actions initially? | stop administration and attempt to aspirate |
| 211 A client has been admitted to the hospital with chest pain. Pain has not been relieved after one dose of nitro. Vital signs: bp dropped to 126/84 from 130/90. Which of the following actions should the nurse take next? | give another dose of nitro |
| 213 The nurse anticipates which of the following regarding sodium restriction for a client diagnosed with ascites secondary to cirrhosis? | If the client experiences resistance to diuretic therapy, there may need to be more stringent sodium restrictions |
| 223 When assessing the genitourinary system of a 75 year old male client, the nurse questions the client about symptoms of which of the following conditions that is common in older men? | benign prostatic hyperplasia |
| 228 The nurse would implement which of the following as the most important measure on the surgical unit on the first postopertive day following surgical repair of an abdominal aneurysm? | palpate peripheral pulses every 2-4 hours |
| 233 A client with venous stasis ulcers is being treated with an Unna boot. The nurse should include which of the following additional interventions in the plan of care? | elevating legs and assessment of peripheral pulses |
| 237 Which of these statements if made by a client receiving dietary instruction for atherosclerosis would indicate a need for furthur discussion | Margarine has less fat than butter, so I will no longer use butter |
| 253 The nurse is caring for a 68 yo male diagnosed with BPH. Which of the following statements by the client indicates the need for further teaching? | "I should cut down on the fluids I drink so I won't have to urinate so often" |
| 262 The nurse concludes client teaching about infection control measures has been effective when a client with tuberculosis states. | "I need to wear a particulate respiratory mask when I got to x-ray." |
Created by:
ekelley10