Mid-Term Transitions Seminar Nclex review (LATEST EXAM UPDATE) COMPLETE SOLUTION

Mid-Term Transitions Seminar Nclex review (LATEST EXAM UPDATE) COMPLETE SOLUTION1. A nurse enters a client’s room and finds that the wastebasket is on fire. The nurse immediately assists the client out of the room. The next nursing action would be to: A. Confine the fire by closing the room door. B. Activate the fire alarm. C. Call for help. D. Extinguish the fire. 2. A nurse enters the nursing lounge and discovers that a chair is on fire. She activates the alarm, closes the lounge door, and obtains the fire extinguisher to extinguish the fire. The nurse pulls the pin on the fire extinguisher. The next appropriate action in the use of the fire extinguisher is to: A. Squeeze the handle on the extinguisher. B. Aim at the base of the fire. C. Sweep the fire from side to side with the extinguisher D. Sweep the fire from top to bottom with extinguisher. 3. A home care nurse performs a home safety assessment and discovers that a client is using a space heater to heat her apartment. Which of the following instructions would the nurse provide to the client regarding the use of the space heater? A. A space heater should not be used in an apartment B. The space heater needs to be placed at least 3 feet from anything that can burn. C. The space heater should be placed in the hallway at night. D. The space heater should be kept at a low setting at all times. 4. A nurse is preparing to initiate an intravenous line containing a high dose of potassium chloride and plans to use an intravenous infusion pump. The nurse brings the pump to the bedside, prepares to plug the pump cord into the wall, and notes the receptacle is available in the wall socket. Which of the following is the most appropriate nursing action? A. Use an extension cord from the nurses’ lounge for the pump plug. B. Initiate the intravenous line without the use of a pump. C. Plugin the pump cord in the available plug above the room sink. D. Contact the electrical maintenance department for assistance. 5. A nurse obtains an order from a physician to restrain a client by using a jacket restraint. The nurse instructs a nursing assistant to apply the restraint to the client. Which of the following observations, if made by the nurse, would indicate inappropriate application of the restraints by the nursing assistant? A. A safety knot in the restraint straps. B. Restraint straps that are safely secured to the side rails. C. The jacket restraint secured such that two fingers can slide easily between the restraint and the client’s skin D. Jacket restraint straps that do not tighten when force is applied against them. 6. A nurse is giving report to a nursing assistant who will be caring for a client who has hand restraints. The nurse instructs the nursing assistant to assess the skin integrity of the retrained hands A. Every 30 minutes B. Every 2 hours C. Every 3 hours D. Every 4 hours 7. A nurse is planning care for a client with an internal radiation implant. Which of the following is an inappropriate component for the nurse to include in the plan of care? A. Placing the client in a semiprivate room at the end of the hallway B. Wearing gloves when emptying the client’s bedpan C. Keeping all linens in the room until the implant is removed. D. Wearing a lead apron when providing direct care to the client. 8. A mother calls the home the home care nurse and tells the nurse that her 3-yearold child has just ingested liquid furniture polish. The home care nurse would direct the mother immediately A. Induce vomiting B. Bring the child to the emergency room. C. Call an ambulance. D. Call the Poison Control Center 9. An emergency room nurse receives a telephone call and is informed that a tornado has hit a local residential area and that numerous casualties have occurred. The victims will be brought to the emergency room. The initial nursing action is which of the following? A. Prepare the triage room B. Obtain additional supplies from the central supply department. C. Activate the agency disaster plan. D. Obtain additional nursing staff to assist in treating the casualties 10. A nurse is caring for a client with a nosocomial infection caused by methicillinresistant Staphylococcus aureus. Contact precautions are initiated. The nurse prepares to provide colostomy care to the client. The nurse obtains which of the following protective items required to perform this procedure? A. Gloves, gown, and goggles. B. Gloves, and goggles. C. Gloves, gown, and shoe protectors D. Gloves and gown. 11. A client has just returned to a nursing unit after an above –the –knee amputation of the right leg. A nurse places the client in which of the following most appropriate positions? a. Supine with the stump flat on the bed b. Supine with the stump supported with pillows c. Reverse Trendelenburg’s d. Prone 12. A nurse is caring for a client with a severe burn. The client is scheduled for an autograft to be placed on the lower extremity. The nurse develops a post- operative plan of care for the client and includes witch of the following in the plan? a. Maintain surgical extremity in a flat position. b. Keep surgical extremity covered with a blanket. c. Maintain the client in prone position. d. Elevate and immobilize the grafted extremity. 13. A nurse is preparing to care for a client who has returned to the nursing unit following cardiac catheterization performed through the femoral artery. The nurse plans to place the client in which most appropriate client position/ activity following the procedure? a. Bed rest with head elevation at 60 degrees b. Bed rest with head elevation no greater than 30 degrees c. Bed rest with bathroom privileges only d. Bed rest in high Fowler’s Position 14. A nurse is providing instructions to a client and the family regarding home care after light eye cataract removal. Which statement by the client would indicate an understanding of the instructions? a. “I will not sleep on my right side.” b. “ I will not sleep on my left side.” c. “ I will not sleep with my head elevated.” d. “I will not wear glasses until my physician says it is okay.” 15. A nurse assists a physician in performing a liver biopsy. Ager the biopsy the nurse plans to place the client in which of the following positions? a. Supine b. Prone c. A left side-lying position with a small pillow or folded towel under the puncture side. d. Right side-laying position with a small pillow or folded towel under the puncture site 16. A nurse has conducted preoperative teaching for a client scheduled for surgery in 1 week. The client has a history of arthritis and has been taking acetylsalicylic acid (aspirin). The nurse determines that the client need additional teaching if the client states: a. “I need to continue to take the aspirin as prescribed until the day of surgery.” b. “Aspirin can cause bleeding after surgery.” c. “Aspirin can cause my ability to clot blood to be abnormal.” d. “I need to discontinue the aspirin 48 hours before the scheduled surgery.” 17. A nurse is preparing a preoperative client for transfer to the operating room. The nurse should take which of the following actions in the care of this client at this time? a. Administer all the daily medications. b. Ensure that the client has voided. c. Verify that the client has not eaten for the last 24 hours. d. Practice post operative breathing exercises 18. The nurse educator is providing an information session to nursing assistants regarding caring for the older adult. The nurse educator tells the nursing assistant that which of the following situations portrays ageism? a. Accepting differences among older adults b. Allowing older adults to make decisions c. Informing the older adult of their rights d. Advising older adults to forego aggressive treatment 19. The nurse is performing an assessment on an older client who is having difficulty sleeping at night. Which statement, if made by the client, indicates that the teaching concerning improving sleep is necessary? a. “I drink hot chocolate before bedtime” b. “ I have stopped smoking cigars” c. “I swim 3 times a week” d. “ I read for 40 minutes before bedtime” 20. The nurse is teaching a client who has iron deficiency anemia about foods she should include in her diet. The nurse determines that the client understands the dietary modifications if she selects which of the following from her menu? a. Nuts and milk b. Coffee and tea c. Cooked rolled oats and fish d. Oranges and dark green leafy vegetables 21. A client with hypertension has been told to maintain a diet low in sodium. A nurse who is teaching this client about foods that are allowed includes which food item in a list provided to the client? a. Tomato soup b. Boiled shrimp c. Instant oatmeal d. Summer squash 22. A nurse on the day shift walks into a client’s room and finds the client unresponsive. The client is not breathing and does not have a pulse, and the nurse immediately calls out for help. The next nursing action is which of the following? a. Open the airway. b. Give the client oxygen. c. Start chest compressions. d. Ventilate with a mouth-to-mask device. 23. A home health care nurse is visiting a client with elevated triglyceride levels and a serum cholesterol level of 398 mg/dL. The client is taking cholestyramine (Questran). Which of the following statements, if made by the client, indicates the need for further education? a. “Constipation and bloating might be a problem.” b. “I’ll continue to watch my diet and reduce my fats.” c. “Walking a mile each day will help the whole process.” d. “I’ll continue my nicotinic acid from the health food store.” 24. A nurse is providing instructions to the parents of a child with scoliosis regarding the use of a brace. Which statement by the parents indicates a need for further instructions? a. “I will encourage my child to perform prescribed exercises.” b. “I will have my child wear soft fabric clothing under the brace.” c. “I should apply lotion under the brace to prevent skin breakdown.” d. “I should avoid the use of powder because it will cake under the brace.” 25. The nurse employed in a long-term care facility is caring for an older male client. Which nursing action contributes to encouraging autonomy in the client? a. Planning his meals b. Decorating his room c. Scheduling his barber appointments d. Allowing him to choose social activities 26. The home care nurse is visiting an older female client whose husband died 6 months ago. Which behavior by the client indicates ineffective coping? a. Neglecting her personal grooming b. Looking at old snapshots of her family c. Participating in a senior citizens program d. Visiting her husband’s grave once a month 27. The nurse is providing instructions to a nursing assistant regarding care of an older client with hearing loss. The nurse tells the assistant that clients with a hearing loss: a. Are often distracted b. Have middle ear changes c. Respond to low-pitched tones d. Develop moist cerumen production 28. The nurse is providing an educational session to new employees, and the topic is abuse of the older client. The nurse helps the employees identify that which client is most typical of a victim of abuse? a. A 75-year-old man who has moderate hypertension b. A 68-year-old man who has newly diagnosed cataracts c. A 90-year-old woman who has advanced Parkinson’s disease d. A 70-year-old woman who has early diagnosed Lyme disease 29. A nurse is preparing to insert a nasogastric tube into a client. The nurse places the client in which position for insertion? a. Right side b. Low Fowler’s c. High Fowler’s d. Supine with the head flat 30. A nurse develops a plan of care for a client with deep vein thrombosis. Which client position or activity in the plan will be included? a. Out-of-bed activities as desired b. Bedrest with the affected extremity kept flat c. Bedrest with elevation of the affected extremity d. Bedrest with the affected extremity in a dependent position 31. A nurse is administering a cleansing enema to a client with a fecal impaction. Before administering the enema, the nurse places the client in which position? a. Left Sims’ position b. Right Sims’ position c. On the left side of the body, with the head of the bed elevated 45 degrees d. On the right side of the body, with the head of the bed elevated 45 degrees 32. A nurse educator asks a student to list the five categories of complementary and alternative medicine (CAM), developed by the National Center for Complementary and Alternative Medicine (NCCAM). Which of the following, if stated by the nursing student, would indicate an understanding of the five categories of CAM? a. Herbology, hydrotherapy, acupuncture, nutrition, and chiropractic care b. Mind-body medicine, traditional Chinese medicine, homeopathy, naturopathy, and healing touch c. Biologically based practices, body-based practices, magnetic therapy, massage therapy, and aromatherapy d. Whole medical systems, mind-body medicine, biologically based practices, manipulative and body-based practices, and energy medicine 33. An antihypertensive medication has been prescribed for a client with hypertension. The client tells a clinic nurse that she would like to take an herbal substance to help lower her blood pressure. The nurse should take which appropriate action? a. Tell the client that herbal substances are not safe and should never be used. b. Encourage the client to discuss the use of an herbal substance with the physician. c. Teach the client how to take her blood pressure so that it can be monitored closely. d. Tell the client that if she takes the herbal substance she will need to have her blood pressure checked frequently. 34. A nurse hears a client calling out for help, hurries down the hallway to the client’s room, and finds the client lying on the floor. The nurse performs a thorough assessment, assists the client back to bed, notifies the physician of the incident, and completes an incident report. Which of the following should the nurse document on the incident report? a. The client fell out of bed. b. The client climbed over the side rails. c. The client was found lying on the floor. d. The client became restless and tried to get out of bed. 35. A client is brought to the emergency department by emergency medical services (EMS) after being hit by a car. The name of the client is unknown, and the client has sustained a severe head injury and multiple fractures and is unconscious. An emergency craniotomy is required. Regarding informed consent for the surgical procedure, which of the following is the best action? a. Obtain a court order for the surgical procedure. b. Ask the EMS team to sign the informed consent. c. Transport the victim to the operating room for surgery. d. Call the police to identify the client and locate the family. 36. A nurse has just assisted a client back to bed after a fall. The nurse and physician have assessed the client and have determined that the client is not injured. After completing the incident report, the nurse implements which action next? a. Reassess the client. b. Conduct a staff meeting to describe the fall. c. Document in the nurse’s notes that an incident report was completed. d. Contact the nursing supervisor to update information regarding the fall. 37. A registered nurse arrives at work and is told to report (float) to the intensive care unit (ICU) for the day because the ICU is understaffed and needs additional nurses to care for the clients. The nurse has never worked in the ICU. The nurse should take which action first? a. Call the hospital lawyer. b. Refuse to float to the ICU. c. Call the nursing supervisor. d. Report to the ICU and identify tasks that can be performed safely. 38. A nurse who works on the night shift enters the medication room and finds a co worker with a tourniquet wrapped around the upper arm. The co-worker is about to insert a needle, attached to a syringe containing a clear liquid, into the antecubital area. The appropriate initial action by the nurse is which of the following? a. Call security. b. Call the police. c. Call the nursing supervisor. d. Lock the co-worker in the medication room until help is obtained. 39. A hospitalized client tells the nurse that a living will is being prepared and that the lawyer will be bringing the will to the hospital today for witness signatures. The client asks the nurse for assistance in obtaining a witness to the will. The appropriate response to the client is which of the following? a. “I will sign as a witness to your signature.” b. “You will need to find a witness on your own.” c. “Whoever is available at the time will sign as a witness for you.” d. “I will call the nursing supervisor to seek assistance regarding you request.” 40. A nurse has made an error in a narrative documentation of an assessment finding on a client and obtains the client’s record to correct the error. The nurse corrects the error by: a. Documenting a late entry into the client’s record b. Trying to erase the error for space to write in the correct data c. Using whiteout to delete the error to write in the correct data d. Drawing one line through the error, initialing and dating the line, and then documenting the correct information 41. A nurse employed in a hospital is waiting to receive a report from the laboratory via the facsimile (fax) machine. The fax machine activates and the nurse expects the report, but instead receives a sexually oriented photograph. The appropriate initial nursing action is to: a. Call the police. b. Cut up the photograph and throw it away. c. Call the nursing supervisor and report the incident. d. Call the laboratory and ask for the individual’s name who sent the photograph. 42. A nursing instructor delivers a lecture to nursing students regarding the issue of client’s rights and asks a nursing student to identify a situation that represents an example of invasion of client privacy. Which of the following, if identified by the student, indicates an understanding of a violation of this client right? a. Performing a procedure without consent b. Threatening to give a client a medication c. Telling the client that he or she cannot leave the hospital d. Observing care provided to the client without the client’s permission 43. Nursing staff members are sitting in the lounge taking their morning break. A nursing assistant tells the group that she thinks that the unit secretary has acquired immunodeficiency syndrome (AIDS) and proceeds to tell the nursing staff that the secretary probably contracted the disease from her husband, who is supposedly a drug addict. Which legal tort has the nursing assistant violated? a. Libel b. Slander c. Assault d. Negligence 44. An 87-year-old woman is brought to the emergency department for treatment of a fractured arm. On physical assessment, the nurse notes old and new ecchymotic areas on the client’s chest and legs and asks the client how the bruises were sustained. The client, although reluctant, tells the nurse in confidence that her son frequently hits her if supper is not prepared on time when he arrives home from work. Which of the following is the appropriate nursing response? a. “Oh, really. I will discuss this situation with your son.” b. “This is a legal issue, and I must tell you that I will need to report it.” c. “Let’s talk about the ways you can manage your time to prevent this from happening.” d. “Do you have any friends that can help you out until you resolve these important issues with your son?” 45. A nurse calls the physician regarding a new medication prescription because the dosage prescribed is higher than the recommended dosage. The nurse is unable to locate the physician, and the medication is due to be administered. Which action should the nurse implement? a. Contact the nursing supervisor. b. Administer the dose prescribed. c. Hold the medication until the physician can be contacted. d. Administer the recommended dose until the physician can be located. 46. A nurse is assigned to care for four clients. In planning client rounds, which client should the nurse assess first? a. A client scheduled for a chest x-ray b. A client requiring daily dressing changes c. A postoperative client preparing for discharge d. A client receiving nasal oxygen who had difficulty breathing during the previous shift 47. A nurse employed in an emergency department is assigned to triage clients coming to the emergency department for treatment on the evening shift. The nurse should assign highest priority to which of the following clients? a. A client complaining of muscle aches, a headache, and malaise b. A client who twisted her ankle when she fell while rollerblading c. A client with a minor laceration on the index finger sustained while cutting an eggplant d. A client with chest pain who states that he just ate pizza that was made with a very spicy sauce 48. A new nursing graduate is attending an agency orientation regarding the nursing model of practice implemented in the health care facility. The nurse is told that the nursing model is a team nursing approach. The nurse understands that planning care delivery will be based on which characteristic of this type of nursing model of practice? a. A task approach method is used to provide care to clients. b. Managed care concepts and tools are used in providing client care. c. A single registered nurse is responsible for providing care to a group of clients. d. A registered nurse leads nursing personnel in providing care to a group of clients. 49. A registered nurse has received the assignment for the day shift. After making initial rounds and checking all of the assigned clients, which client will the registered nurse plan to care for first? a. A client who is ambulatory b. A client scheduled for physical therapy at 1 PM c. A client with a fever who is diaphoretic and restless d. A postoperative client who has just received pain medication 50. A nurse is giving a bed bath to an assigned client when a nursing assistant enters the client’s room and tells the nurse that another assigned client is in pain and needs pain medication. The appropriate nursing action is which of the following? a. Finish the bed bath and then administer the pain medication to the other client. b. Ask the nursing assistant to find out when the last pain medication was given to the client. c. Ask the nursing assistant to tell the client in pain that medication will be administered as soon as the bed bath is complete. d. Cover the client, raise the side rails, tell the client that you will return shortly, and administer the pain medication to the other client. 51. A nurse manager has implemented a change in the method of the nursing delivery system from functional to team nursing. A nursing assistant is resistant to the change and is not taking an active part in facilitating the process of change. Which of the following is the best approach in dealing with the nursing assistant? a. Ignore the resistance. b. Exert coercion with the nursing assistant. c. Provide a positive reward system for the nursing assistant. d. Confront the nursing assistant to encourage verbalization of feelings regarding the change. 52. A registered nurse is planning the client assignments for the day. Which of the following is the most appropriate assignment for a nursing assistant? a. A client requiring a colostomy irrigation b. A client receiving continuous tube feedings c. A client who requires urine specimen collections d. A client with difficulty swallowing food and luids 53. A new unit nurse manager is holding her first staff meeting. The manager greets the staff and comments that she has been employed to bring about quality improvement. The manager provides a plan that she developed and a list of tasks and activities for which each staff member must volunteer to perform. In addition, she instructs staff members to report any problems directly to her. What type of leadership style do the new manager’s characteristics suggest? a. Autocratic b. Situational c. Democratic d. Laissez-faire 54. A registered nurse employed in a long-term care facility is planning assignments for the clients on a nursing unit. The registered nurse needs to assign four clients and has a licensed practical (vocational) nurse and three nursing assistants on a nursing team. Which of the following clients would the registered nurse most appropriately assign to the licensed practical (vocational) nurse? a. A client who requires a bed bath b. An older client requiring frequent ambulation c. A client who requires a 24-hour urine collection d. A client requiring abdominal wound irrigations and dressing changes every 3 hours 55. The visiting nurse observes that the older male client is confined by his daughter-inlaw to his room. When the nurse suggests that he walk to the den and join the family, he says, “I’m in everyone’s way; my daughter-in-law needs me to stay here.” The most important action for the nurse to take is to: a. Say nothing, because it is best for the nurse to remain neutral and wait to be asked for help. b. Suggest to the client and daughter-in-law that they consider a nursing home for the client. c. Say to the daughter-in-law, “Confining your father-in-law to his room is inhuman.” d. Suggest appropriate resources to the client and daughter-in-law, such as respite care and a senior citizens’ center. 56. The nurse is performing an assessment on an older adult client. Which assessment data would indicate a potential complication associated with the skin of this client? a. Crusting b. Wrinkling c. Deepening of expression lines d. Thinning and loss of elasticity in the skin 57. The home health nurse is visiting a client for the first time. While assessing the client’s medication, it is noted that there are at least 19 prescription and several over-thecounter medications that the client has been taking. Which intervention should the nurse take first? a. Check for drug-drug interactions. b. Determine whether there are any adverse side effects. c. Determine whether there are medication duplications. d. Call the prescribing physician and report any polypharmacy. 58. The nurse is caring for a client with a diagnosis of influenza who first began to experience symptoms yesterday. Antiviral therapy is prescribed and the nurse provides instructions to the client about the therapy. Which statement by the client indicates an understanding of the instructions? a. “I must take the medication exactly as prescribed.” b. “Once I start the medication, I will no longer be contagious.” c. “I will not get any colds or infections while taking this medication.” d. “This medication has minimal side effects and I can return to normal activities.” 59. A client has been started on long-term therapy with rifampin (Rifadin). A nurse teaches the client that the medication: a. Should always be taken with food or antacids b. Should be double-dosed if one dose is forgotten c. Causes orange discoloration of sweat, tears, urine, and feces d. May be discontinued independently if symptoms are gone in 3 months 60. A client with tuberculosis is being started on antituberculosis therapy with isoniazid (INH). Before giving the client the first dose, a nurse ensures that which of the following baseline studies has been completed? a. Electrolyte levels b. Liver enzyme levels c. Serum creatinine level d. Coagulation times