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NCLEX Review Study Guide Comprehensive Questions and Answers 100% Accuracy |Updated 2024.
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NCLEX Review Study Guide Comprehensive Questionsand Answers 100% Accuracy |Updated 2024.
A client with diabetes mellitus calls the clinic nurse and reports that she has been vomiting during the
night and now has diarrhea. Which question does the nurse make a priority of asking the client?
"Have you tested your blood glucose?"
A client's oral intake of liquids includes 120 mL on the night shift, 800 mL on the day shift, and 650 mL
on the evening shift. The client is receiving an intravenous (IV) antibiotic every 12 hours, diluted in 50
mL of normal saline solution. The nurse empties 700 mL of urine from the client's Foley catheter at the
end of the day shift. Thereafter, 500 mL of urine is emptied at the end of the evening shift and 325 mL
at the end of the night shift. Nasogastric tube drainage totals 155 mL for the 24-hour period, and the
total drainage from the Jackson-Pratt device is 175 mL. What is the client's total intake during the 24-
hour period?
1670mL
A client with heart failure suddenly experiences profound dyspnea, pallor, audible wheezing, and
cyanosis, and the nurse suspects pulmonary edema. The nurse would first:
Raise the head of the client's bed
A client with cervical cancer who is undergoing chemotherapy with cisplatin (Platinol). For which
adverse effect of cisplatin will the nurse assess the client?
Hearing loss
Alendronate (Fosamax) is prescribed for a client with postmenopausal osteoporosis. The nurse
provides information on the medication to the client. When does the nurse tell the client to take the
alendronate?
Every morning before breakfast, with a full glass of water
A client with emphysema is receiving theophylline (Theo-24). While providing dietary instructions, the
nurse tells the client that it is acceptable to consume:
Apple juice
A nurse is reviewing the record of a client scheduled for electroconvulsive therapy (ECT). Which of the
following diagnoses, if noted on the client's record, would indicate a need to contact the physician
who is scheduled to perform the ECT?
Recent stroke
An emergency department nurse is assessing a client with acute closed-angle glaucoma. Which of the
following characteristics of the disorder does the nurse expect the client to exhibit? Select all that
apply.
,Nausea
Eye pain
Vomiting
Headache
The nurse administers intravenous morphine sulfate to a client in pulmonary edema. For which
intended effect of the medication does the nurse monitor the client?
Relief of anxiety
An emergency department nurse is told that a client with carbon monoxide poisoning resulting from a
suicide attempt is being brought to the hospital by emergency medical services. Which intervention
will the nurse carry out as a priority upon arrival of the client?
Administering 100% oxygen
A client with agoraphobia will undergo systematic desensitization through graduated exposure. In
explaining the treatment to the client, the nurse tells the client that this technique involves:
Gradually introducing the client to a phobic object or situation in a predetermined sequence of least to
most frightening
A client with a medical history of diabetes mellitus is found to have sarcoidosis, and oral prednisone is
prescribed. The nurse provides instructions to the client about the medication and tells the client to:
Closely monitor the blood glucose level
Enalapril maleate (Vasotec) is prescribed for a hospitalized client. Which assessment does the nurse
perform as a priority before administering the medication?
Checking the client's blood pressure
A client who has undergone abdominal hysterectomy asks the nurse when she will be able to resume
sexual intercourse. The nurse tells the client that sexual intercourse may be resumed:
In about 6 weeks, when the vaginal vault is satisfactorily healed
A nurse on the evening shift checks a physician's prescriptions and notes that the dose of a prescribed
medication is higher than the normal dose. The nurse calls the physician's answering service and is
told that the physician is off for the night and will be available in the morning. The nurse should:
Ask the answering service to contact the on-call physician
A hospitalized female client with mania enters the unit community room and says to a client who is
wearing a blue shirt, "Boys in blue are fun to do! Boys in blue are fun to do!" What is the appropriate
response by the nurse?
"Don't say that. If you can't control yourself, we'll help you."
A client with HIV infection who has been found to have histoplasmosis is being treated with
intravenous amphotericin B (Fungizone). Which parameter does the nurse check to detect the most
common adverse effect of this medication?
,Intake and output
A nurse is gathering subjective and objective data from a client with suspected rheumatoid arthritis
(RA). Which early manifestations of RA would the nurse expect to note? Select all that apply.
Fatigue
Low-grade fever
Phenelzine sulfate (Nardil) is prescribed for a client with depression. The nurse provides information
to the client about the adverse effects of the medication and tells the client to contact the physician
immediately if she experiences:
Neck stiffness or soreness
A client is receiving an intravenous infusion of oxytocin (Pitocin) to stimulate labor. The nurse
monitoring the client notes uterine hypertonicity and immediately:
Stops the oxytocin infusion
A nurse is assessing a pregnant woman for the presence of edema. The nurse places a thumb on the
top of the client's foot, then exerts pressure and releases it and notes that the thumb has left a
persistent depression. On the basis of this finding, the nurse concludes that:
Pitting edema is present
A nurse is caring for a client with community-acquired pneumonia who is being treated with
levofloxacin (Levaquin). For which of the following findings, indicating an adverse reaction to the
medication, does the nurse monitor the client?
Fever
A client receiving parenteral nutrition (PN) suddenly experiences chest pain and dyspnea, and the
nurse suspects an air embolism. The nurse immediately places the client in a lateral Trendelenburg
position, on the left side. What action does the nurse take next?
Clamping the intravenous catheter
A nurse is preparing a poster for a health fair booth promoting primary prevention of skin cancer.
Which of the following recommendations does the nurse include on the poster? Select all that apply.
Seek medical advice if you find a skin lesion.
A nurse is providing instructions to a client with glaucoma who will be using acetazolamide (Diamox)
daily. Which of the following findings, an adverse effect, does the nurse instruct the client to report to
the physician?
Dark urine
A nurse is providing morning care to a client who has undergone surgery to repair a fractured left hip.
Which item is most important for the nurse to use in turning the client from side to side to change the
bed linens?
, Abduction device
A nurse is performing an assessment of a client being admitted to the hospital with a diagnosis of
multiple sclerosis. The client tells the nurse that she took baclofen (Lioresal) for the past 9 months but
completely stopped the medication 2 days ago because it was making her feel weak. On the basis of
this information, the nurse notes in the plan of care that the client should be monitored most closely
for:
Seizure activity
A nurse administers nitroglycerin sublingually to a client with angina pectoris who complains of chest
pain. The medication is ineffective, so the nurse prepares to administer a second dose. Before
administering the nitroglycerin, which action does the nurse make a priority?
Checking the client's blood pressure
A nurse provides information to a client with coronary artery disease (CAD) about smoking-cessation
measures. Which statement by the client indicates a need for further information?
"I should drink a cup of coffee if I feel the urge to smoke."
A client with myasthenia gravis who has been taking pyridostigmine bromide (Mestinon) for the
treatment of the disorder comes to the emergency department complaining of severe muscle
weakness, and cholinergic crisis is diagnosed. Which medication does the nurse prepare for immediate
use in treating the crisis?
Atropine sulfate
A rape victim being treated in the emergency department says to the nurse, "I'm really worried that
I've got HIV now." What is the appropriate response by the nurse?
"Let's talk about the information that you need to determine your risk of contracting HIV."
A nurse is providing instruction to a client with osteoporosis regarding appropriate foods to include in
the diet. The nurse tells the client that one food item high in calcium is:
Sardines
A nurse prepares to administer digoxin (Lanoxin) to a client with congestive heart failure. Which vital
sign must be checked before the medication is administered?
Apical pulse
A nurse provides home care instructions to a client with coronary artery disease (CAD) who is being
discharged from the hospital. Which statement by the client indicates a need for further instruction?
"I need to participate in aerobic and weightlifting exercise three times a week."
A nurse is caring for a client with a cuffed endotracheal tube who is undergoing mechanical
ventilation. Which intervention to prevent a tracheoesophageal fistula, a complication of this type of
tube, does the nurse implement?
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