Nclex file 1
1. The nurse is caring for a 17 month-old with acetaminophen poisoning. Which of the following lab
reports should the nurse review first?
D) Liver enzymes (AST and ALT)
2. The nurse is teaching parents about diet for a 4 month-old infant with gastroenteritis and mild
dehydration. ...
Nclex file 1
1. The nurse is caring for a 17 month-old with acetaminophen poisoning. Which of the following lab
reports should the nurse review first?
D) Liver enzymes (AST and ALT)
2. The nurse is teaching parents about diet for a 4 month-old infant with gastroenteritis and mild
dehydration. In addition to oral rehydration fluids, the diet should include
A) Formula or breast milk
3. The nurse instructs the client taking dexamethasone (Decadron) to take it with food or milk. What is
the physiological basis for this instruction?
B) Stimulates hydrochloric acid production
4. The nurse is planning care for a 3 month-old infant immediately postoperative following placement
of a ventriculoperitoneal shunt for hydrocephalus.
The nurse needs to
A) Assess for abdominal distention
5. The mother of a 2 year-old hospitalized child asks the nurse's advice about the child's screaming
every time the mother gets ready to leave the hospital room. What is the best response by the nurse?
C) "Keep in mind that for the age this is a normal response to being in the hospital."
6. When caring for a client receiving warfarin sodium (Coumadin), which lab test would the nurse
monitor to determine therapeutic reponse to the drug?
C) Prothrombin time
7. The nurse is caring for a 4 year-old 2 hours after tonsillectomy and adenoidectomy.
Which of the following assessments must be reported immediately?
D) Increased restlessness
8. The nurse admits a 7 year-old to the emergency room after a leg injury. The x-rays show a femur
fracture near the epiphysis. The parents ask what will be the outcome of
injury. The appropriate response by the nurse should be which of these statements?
B) "In some instances the result is a retarded bone growth."
9. A client receiving chlorpromazine HCL (Thorazine) is in psychiatric home care.
During a home visit the nurse observes the client smacking her lips alternately with grinding her teeth.
The nurse recognizes this assessment finding as what?
D) Tardive dyskinesia
, 10. During the check up of a 2 month-old infant at a well baby clinic, the mother expresses concern to
the nurse because a flat pink birthmark on the baby's forehead and eyelid has not gone away. What is
an appropriate response by the nurse?
C) "Telangiectatic nevi are normal and will disappear as the baby grows."
11. A client has returned to the unit following a renal biopsy. Which of the following nursing
interventions is appropriate?
C) Monitor vital signs
12. A client has been admitted with a fractured femur and has been placed in skeletal traction. Which of
the following nursing interventions should receive priority?
B) Frequent neurovascular assessments of the affected leg
13. The nurse is teaching a client newly diagnosed with asthma how to use the metereddose inhaler
(MDI). The client asks when they will know the canister is empty. The best response is
A) Drop the canister in water to observe floating
14. While teaching the family of a child who will take phenytoin (Dilantin) regularly for seizure control, it
is most important for the nurse to teach them about which of the following actions?
A) Maintain good oral hygiene and dental care
15. A 7 month pregnant woman is admitted with complaints of painless vaginal bleedingover several
hours. The nurse should prepare the client for an immediate
B) Abdominal ultrasound
16. The nurse is assessing a 17 year-old female client with bulimia.
Which of the following laboratory reports would the nurse anticipate?
C) Decreased potassium
17. An 80 year-old client on digitalis (Lanoxin) reports nausea, vomiting, abdominal cramps and halo
vision. Which of the following laboratory results should the nurse analyze first?
A) Potassium levels
18. The nurse caring for a 9 year-old child with a fractured femur is told that a medication error
occurred. The child received twice the ordered dose of morphine an hour ago. Which nursing diagnosis
is a priority at this time?
C) Ineffective breathing patterns related to central nervous system depression
19. The nurse notes that a 2 year-old child recovering from a tonsillectomy has a temperature of 98.2
degrees Fahrenheit at 8:00 AM. At 10:00 AM the child's mother reports that the child "feels very warm"
to touch. The first action by the nurse should be to
C) Reassess the child's temperature
20. The nurse is teaching a newly diagnosed asthma client on how to use a peak flow meter. The nurse
explains that this should be used to
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