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NCLEX Test
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Welcome to your NCLEX Test
A 25-year-old male is admitted in sickle cell crisis. Which of the following interventions would be of the highest priority for this client?
Taking hourly blood pressures with mechanical cuff
Encouraging fluid intake of at least 200mL per hour
Position in high Fowler’s with knee gatch raised
Administering Tylenol as ordered
None
Which of the following would be the priority nursing diagnosis for the adult client with acute leukemia?
Oral mucous membrane, altered related to chemotherapy
Risk for injury related to thrombocytopenia
Fatigue related to the disease process
Interrupted family processes related to life-threatening illness of a family member
None
A client with acute leukemia is admitted to the oncology unit. Which of the following would be most important for the nurse to inquire?
Have you noticed a change in sleeping habits recently?"
"Have you had a respiratory infection in the last 6 months?"
"Have you lost weight recently?"
"Have you noticed changes in your alertness?"
None
An African American client is admitted with acute leukemia. The nurse is assessing for signs and symptoms of bleeding. Where is the best site for examining for the presence of petechiae?
The abdomen
The thorax
The earlobes
The soles of the feet
None
A 33-year-old male is being evaluated for possible acute leukemia. Which of the following would the nurse inquire about as a part of the assessment?
The client collects stamps as a hobby.
The client recently lost his job as a postal worker.
The client had radiation for treatment of Hodgkin’s disease as a teenager.
The client’s brother had leukemia as a child.
None
The nurse is teaching the client with polycythemia vera about prevention of complications of the disease. Which of the following statements by the client indicates a need for further teaching?
"I will drink 500mL of fluid or less each day."
"I will wear support hose when I am up."
"I will use an electric razor for shaving."
"I will eat foods low in iron."
None
The nurse is conducting a physical assessment on a client with anemia. Which of the following clinical manifestations would be most indicative of the anemia?
BP 146/88
Respirations 28 shallow
Weight gain of 10 pounds in 6 months
Pink complexion
None
An African American female comes to the outpatient clinic. The physician suspects vitamin B12 deficiency anemia. Because jaundice is often a clinical manifestation of this type of anemia, what body part would be the best indicator?
Conjunctiva of the eye
Soles of the feet
Roof of the mouth
Shins
None
The nurse is conducting an admission assessment of a client with vitamin B12 deficiency. Which of the following would the nurse include in the physical assessment?
Palpate the spleen
Take the blood pressure
Examine the feet for petechiae
Examine the tongue
None
Clients with sickle cell anemia are taught to avoid activities that cause hypoxia and hypoxemia. Which of the following activities would the nurse recommend?
family vacation in the Rocky Mountains
Chaperoning the local boys club on a snow-skiing trip
Traveling by airplane for business trips
A bus trip to the Museum of Natural History
None
The nurse is instructing a client with iron-deficiency anemia. Which of the following meal plans would the nurse expect the client to select?
Roast beef, gelatin salad, green beans, and peach pie
Chicken salad sandwich, coleslaw, French fries, ice cream
Egg salad on wheat bread, carrot sticks, lettuce salad, raisin pie
Pork chop, creamed potatoes, corn, and coconut cake
None
A newly admitted client has a sickle cell crisis. The nurse is planning care based on the assessment of the client. The client is complaining of severe pain in his feet and hands. The pulse oximetry is 92. Which of the following interventions would be implemented first? Assume that there are orders for each intervention.
Adjust the room temperature
Give a bolus of IV fluids
Start O2
Administer meperidine (Demerol) 75 mg IV push
None
Which of the following foods would the nurse encourage the client in sickle cell crisis to eat?
Peaches
Cottage cheese
Popsicle
Lima beans
None
Which individual is at greatest risk for developing hypertension?
45-year-old African-American attorney
60-year-old Asian-American shop owner
40-year-old Caucasian nurse
55-year-old Hispanic teacher
None
A 30-year-old male from Haiti is brought to the emergency department in sickle cell crisis. What is the best position for this client?
Side-lying with knees flexed
Knee-chest
High Fowler’s with knees flexed
Semi-Fowler’s with legs extended on the bed
None
A 43-year-old African American male is admitted with sickle cell anemia. The nurse plans to assess circulation in the lower extremities every 2 hours. Which of the following outcome criteria would the nurse use?
Body temperature of 99°F or less
Toes moved in active range of motion
Sensation reported when soles of feet are touched
Capillary refill of < 3 seconds
None
A patient is about to undergo bone marrow aspiration and biopsy and expresses fear and anxiety about the procedure. Which of the following is the most effective nursing response?
Warn the patient to stay very still because the smallest movement will increase her pain.
Encourage the family to stay in the room for the procedure.
Stay with the patient and focus on slow, deep breathing for relaxation.
Delay the procedure to allow the patient to deal with her feelings.
None
The Hodgkin’s disease patient described in the question above undergoes a lymph node biopsy for definitive diagnosis. If the diagnosis of Hodgkin’s disease were correct, which of the following cells would the pathologist expect to find?
Lymphoblastic cells
Reed-Sternberg cells
Gaucher's cells
Rieder's cells
None
A patient is admitted to the oncology unit for diagnosis of suspected Hodgkin’s disease. Which of the following symptoms is typical of Hodgkin’s disease?
Painful cervical lymph nodes
Night sweats and fatigue
Nausea and vomiting
Weight gain
None
A nurse is caring for a patient with acute lymphoblastic leukemia (ALL). Which of the following is the most likely age range of the patient?
3-10 years
25-35 years
45-55 years
over 60 years
None
A patient is undergoing the induction stage of treatment for leukemia. The nurse teaches family members about infectious precautions. Which of the following statements by family members indicates that the family needs more education?
We will bring in books and magazines for entertainment.
We will bring in personal care items for comfort.
We will bring in fresh flowers to brighten the room.
We will bring in family pictures and get well cards.
None
A nurse is caring for patients in the oncology unit. Which of the following is the most important nursing action when caring for a neutropenic patient?
Change the disposable mask immediately after use.
Change gloves immediately after use.
Minimize patient contact.
Minimize conversation with the patient.
None
A nurse in the emergency department assesses a patient who has been taking long-term corticosteroids to treat renal disease. Which of the following is a typical side effect of corticosteroid treatment? Select all that apply.
Hypertension
Cushingoid features
Hyponatremia
Low serum albumin
Mood swings
A nurse is caring for a patient with a platelet count of 20,000/microliter. Which of the following is an important intervention?
Observe for evidence of spontaneous bleeding.
Limit visitors to family only.
Give aspirin in case of headaches
Impose immune precautions.
None
A patient is admitted to the hospital with suspected polycythemia vera. Which of the following symptoms is consistent with the diagnosis? Select all that apply.
Weight loss
Increased clotting time
Hypertension
Headaches
Polyphagia
When teaching a client with coronary artery disease about nutrition, the nurse should emphasize:
Eating three (3) balanced meals a day
Adding complex carbohydrates
Avoiding very heavy meals
Limiting sodium to 7 gms per day
None
A nurse prepares to care for a 4-year-old newly admitted for rhabdomyosarcoma. The nurse should alert the staff to pay more attention to the function of which area of the body?
All striated muscles
The cerebellum
The kidneys
The leg bones
None
The nurse is caring for a client with a serum potassium level of 3.5 mEq/L. The client is placed on a cardiac monitor and receives 40 mEq potassium chloride in 1000 ml of 5% dextrose in water IV. Which of the following EKG patterns indicates to the nurse that the infusions should be discontinued?
Narrowed QRS complex
Shortened “PR” interval
Tall peaked “T” waves
Prominent “U” waves
None
The nurse is preparing to administer an enteral feeding to a client via a nasogastric feeding tube. The most important action of the nurse is:
Verify correct placement of the tube
Check that the feeding solution matches the dietary order
Aspirate abdominal contents to determine the amount of last feeding remaining in stomach
Ensure that feeding solution is at room temperature
None
While planning care for a toddler, the nurse teaches the parents about the expected developmental changes for this age. Which statement by the mother shows that she understands the child’s developmental needs?
“I want to protect my child from any falls.”
I will set limits on exploring the house.”
“I understand the need to use those new skills.”
“I intend to keep control over our child.”
None
A triage nurse has these four (4) clients arrive in the emergency department within 15 minutes. Which client should the triage nurse send back to be seen first?
A 2-month-old infant with a history of rolling off the bed and has bulging fontanelle with crying
A teenager who got a singed beard while camping
An elderly client with complaints of frequent liquid brown colored stools
A middle-aged client with intermittent pain behind the right scapula
None
The nurse is giving discharge teaching to a client seven (7) days post myocardial infarction. He asks the nurse why he must wait six (6) weeks before having sexual intercourse. What is the best response by the nurse to this question?
“You need to regain your strength before attempting such exertion.”
“When you can climb 2 flights of stairs without problems, it is generally safe.”
“Have a glass of wine to relax you, then you can try to have sex.”
“If you can maintain an active walking program, you will have less risk.”
None
Which of the following should the nurse implement to prepare a client for a KUB (Kidney, Ureter, Bladder) radiography test?
Client must be NPO before the examination
Enema to be administered prior to the examination
Medicate client with furosemide 20 mg IV 30 minutes prior to the examination
No special orders are necessary for this examination
None
The home health nurse visits a male client to provide wound care and finds the client lethargic and confused. His wife states he fell down the stairs two (2) hours ago. The nurse should
Place a call to the client’s health care provider for instructions
Send him to the emergency room for evaluation
Reassure the client’s wife that the symptoms are transient
Instruct the client’s wife to call the doctor if his symptoms become worse
None
A child who has recently been diagnosed with cystic fibrosis is in a pediatric clinic where a nurse is performing an assessment. Which later finding of this disease would the nurse not expect to see at this time?
Positive sweat test
Bulky greasy stools
Moist, productive cough
Meconium ileus
None
The nurse is performing a neurological assessment on a client post right cerebrovascular accident. Which finding, if observed by the nurse, would warrant immediate attention?
Decrease in level of consciousness
Loss of bladder control
Altered sensation to stimuli
Emotional lability
None
The nurse is speaking at a community meeting about personal responsibility for health promotion. A participant asks about chiropractic treatment for illnesses. What should be the focus of the nurse’s response?
Electrical energy fields
Spinal column manipulation
Mind-body balance
Exercise of joints
None
Which of these findings indicate that a pump to deliver a basal rate of 10 ml per hour plus PRN for pain breakthrough for morphine drip is not working?
The client complains of discomfort at the IV insertion site
The client states “I just can’t get relief from my pain.”
The level of drug is 100 ml at 8 AM and is 80 ml at noon
The level of the drug is 100 ml at 8 AM and is 50 ml at noon
None
A patient who has received chemotherapy for cancer treatment is given an injection of Epoetin. Which of the following should reflect the findings in a complete blood count (CBC) drawn several days later?
An increase in neutrophil count
An increase in hematocrit
An increase in platelet count
An increase in serum iron
None
A registered nurse who usually works in a spinal rehabilitation unit is floated to the emergency department. Which of these clients should the charge nurse assign to this RN?
A middle-aged client who says “I took too many diet pills” and “my heart feels like it is racing out of my chest.”
A young adult who says “I hear songs from heaven. I need money for beer. I quit drinking two (2) days ago for my family. Why are my arms and legs jerking?”
An adolescent who has been on pain medications terminal cancer with an initial assessment finding pupils and a relaxed respiratory rate of 11,
An elderly client who reports having taken a “large crack hit” 10 minutes prior to walking into the emergency room.
None
A client comes to the clinic for treatment of recurrent pelvic inflammatory disease. The nurse recognizes that this condition most frequently follows which type of infection?
Trichomoniasis
Chlamydia
Staphylococcus
Streptococcus
None
In children suspected to have a diagnosis of diabetes, which one of the following complaints would be most likely to prompt parents to take their school-age child for evaluation?
Polyphagia
Dehydration
Bedwetting
Weight loss
None
A 3-year-old child was brought to the pediatric clinic after the sudden onset of findings that include irritability, thick muffled voice, croaking on inspiration, hot to touch, sit leaning forward, tongue protruding, drooling and suprasternal retractions. What should the nurse do first?
Prepare the child for X-ray of upper airways
Examine the child’s throat
Collect a sputum specimen
Notify the healthcare provider of the child’s status
None
A 25-year-old male client has been newly diagnosed with hypothyroidism and will take levothyroxine (Synthroid) 50 mcg/day by mouth. As part of the teaching plan, the nurse emphasizes that this medication:
Should be taken in the morning
May decrease the client’s energy level
Must be stored in a dark container
Will decrease the client’s heart rate
None
The hospital has sounded the call for a disaster drill on the evening shift. Which of these clients would the nurse put first on the list to be discharged in order to make a room available for a new admission?
A middle-aged client with a history of being ventilator dependent for over seven (7) years and admitted with bacterial pneumonia five days ago
A young adult with diabetes mellitus Type 2 for over ten (10) years and admitted with antibiotic-induced diarrhea 24 hours ago.
An elderly client with a history of hypertension, hypercholesterolemia, and lupus, and was admitted with Stevens-Johnson syndrome that morning.
An adolescent with a positive HIV test and admitted for acute cellulitis of the lower leg 48 hours ago.
None
At a community health fair, the blood pressure of a 62-year-old client is 160/96 mmHg. The client states “My blood pressure is usually much lower.” The nurse should tell the client to:
Go get a blood pressure check within the next 15 minutes
Check blood pressure again in two (2) months
See the healthcare provider immediately
Visit the health care provider within one (1) week for a BP check
None
What would the nurse expect to see while assessing the growth of children during their school age years?
Decreasing amounts of body fat and muscle mass
Little change in body appearance from year to year
Progressive height increase of 4 inches each year
Yearly weight gain of about 5.5 pounds per year
None
A client is admitted to the emergency room with renal calculi and is complaining of moderate to severe flank pain and nausea. The client’s temperature is 100.8 degrees Fahrenheit. The priority nursing goal for this client is:
Maintain fluid and electrolyte balance
Control nausea
Manage pain
Prevent urinary tract infection
None
Which complication of cardiac catheterization should the nurse monitor for in the initial 24 hours after the procedure?
Angina at rest
Thrombus formation
Dizziness
Falling blood pressure
None
A 15-year-old female who ingested 15 tablets of maximum strength acetaminophen 45 minutes ago is rushed to the emergency department. Which of these orders should the nurse do first?
Gastric lavage
Administer acetylcysteine (Mucomyst) orally
Start an IV Dextrose 5% with 0.33% normal saline to keep the vein open
Have the patient drink activated charcoal mixed with water
None
Which task should be assigned to the nursing assistant?
Placing the client in seclusion
Emptying the Foley catheter of the preeclamptic client
Feeding the client with dementia
Ambulating the client with a fractured hip
None
A 20-year-old patient is being treated for pneumonia. He has a persistent cough and complains of severe pain on coughing. What could you tell him to help him reduce his discomfort?
"Hold your cough as much as possible."
"Place the head of your bed flat to help with coughing."
"Restrict fluids to help decrease the amount of sputum."
"Splint your chest wall with a pillow for comfort."
None
A patient infected with human immunodeficiency virus (HIV) begins zidovudine therapy. Which of the following statements best describes this drug’s action?
It stimulates the immune system.
It destroys the outer wall of the virus and kills it.
It interferes with viral replication
It promotes excretion of viral antibodies.
None
Corticosteroids are potent suppressors of the body’s inflammatory response. Which of the following conditions or actions do they suppress?
Cushing syndrome
Pain receptors
Immune response
Neural transmission
None
A 16-year-old patient involved in a motor vehicle accident arrives in the ED unconscious and severely hypotensive. He’s suspected to have several fractures of his pelvis and legs. Which of the following parenteral fluids is the best choice for his current condition?
Packed red blood cells
0.9% sodium chloride solution
Lactated Ringer’s solution
Fresh frozen plasma
None
A pregnant woman arrives at the emergency department (ED) with abruptio placentae at 34 weeks’ gestation. She’s at risk for which of the following blood dyscrasias?
Heparin-associated thrombosis and thrombocytopenia (HATT)
Idiopathic thrombocytopenic purpura (ITP)
Thrombocytopenia
Disseminated intravascular coagulation (DIC)
None
Which of the following positions would best aid breathing for a patient with acute pulmonary edema?
Lying flat in bed
Left side-lying position
High Fowler’s position
Semi-Fowler’s position
None
Which of the following interventions should be your first priority when treating a patient experiencing chest pain while walking?
Have the patient sit down.
Get the patient back to bed.
Obtain an ECG.
Administer sublingual nitroglycerin.
None
In which of the following types of cardiomyopathy does cardiac output remain normal?
Obliterative
Restrictive
Dilated
Hypertrophic
None
Which of the following signs and symptoms usually signifies rapid expansion and impending rupture of an abdominal aortic aneurysm?
Abdominal pain
Absent pedal pulses
Chest pain
Lower back pain
None
What’s the first intervention for a patient experiencing chest pain and a p02 of 89%?
Administer morphine
Administer oxygen
Administer sublingual nitroglycerin
Obtain an electrocardiogram (ECC)
None
The physician has ordered a histoplasmosis test for the elderly client. The nurse is aware that histoplasmosis is transmitted to humans by:
Cats
Dogs
Turtles
Birds
None
The client has recently returned from having a thyroidectomy. The nurse should keep which of the following at the bedside?
A tracheostomy set
A padded tongue blade
An endotracheal tube
An airway
None
A 19-year-old patient comes to the ED with acute asthma. His respiratory rate is 44 breaths/minute, and he appears to be in acute respiratory distress. Which of the following actions should you take first?
Take a full medical history.
Give a bronchodilator by nebulizer.
Apply a cardiac monitor to the patient.
Provide emotional support for the patient.
None
A client with frequent urinary tract infections asks the nurse how she can prevent the recurrence. The nurse should teach the client to:
Douche after intercourse
Void every 3 hours
Obtain a urinalysis monthly
Wipe from back to front after voiding
None
The nurse has a preop order to administer valium (Diazepam) 10mg and phenergan (Promethazine) 25mg. The correct method of administering these medications is to:
Administer the medications together in one syringe
Administer the medication separately
Administer the Valium, wait 5 minutes, and then inject the Phenergan
Question the order because they cannot be given at the same time
None
A client with clotting disorder has an order to continue lovenox (Enoxaparin) injections after discharge. The nurse should teach the client that lovenox injections should:
Be injected into the deltoid muscle
Be injected into the abdomen
Aspirate after the injection
Clear the air from the syringe before injections
None
The nurse notes the following on the ECG monitor. The nurse would evaluate the cardiac arrhythmia as:
Atrial flutter
A sinus rhythm
Ventricular tachycardia
trial fibrillation
None
The nurse is evaluating the client who was admitted 8 hours ago for induction of labor. The following graph is noted on the monitor. Which action should be taken first by the nurse?
Instruct the client to push
Perform a vaginal exam
Turn off the Pitocin infusion
Place the client in a semi-Fowler’s position
None
The nurse is monitoring a client with a history of stillborn infants. The nurse is aware that a nonstress test can be ordered for this client to:
Determine lung maturity
Measure the fetal activity
Show the effect of contractions on fetal heart rate
Measure the wellbeing of the fetus
None
The toddler is admitted with a cardiac anomaly. The nurse is aware that the infant with a ventricular septal defect will:
Tire easily
Grow normally
Need more calories
Be more susceptible to viral infections
None
The nurse is educating the lady’s club in a self-breast exam. The nurse is aware that most malignant breast masses occur in the Tail of Spence. On the diagram below, select where the Tail of Spence is.
A
B
C
D
None
The nurse is educating the lady’s club in a self-breast exam. The nurse is aware that most malignant breast masses occur in the Tail of Spence. On the diagram below, select where the Tail of Spence is.
A
B
C
D
None
The nurse is monitoring a client following a lung resection. The hourly output from the chest tube was 300mL. The nurse should give priority to:
Turning the client to the left side
Milking the tube to ensure patency
Slowing the intravenous infusion
Notifying the physician
None
The nurse is changing the ties of the client with a tracheostomy. The safest method of changing the tracheostomy ties is to:
Apply the new tie before removing the old one.
Have a helper present.
Hold the tracheostomy with the nondominant hand while removing the old tie.
Ask the doctor to suture the tracheostomy in place.
None
On a follow-up visit after having a vaginal hysterectomy, a 32-year-old patient has a decreased hematocrit level. Which of the following complications does this suggest?
Hematoma
Hypovolemia
Infection
Pulmonary embolus (PE)
None
A hospitalized patient is receiving packed red blood cells (PRBCs) for treatment of severe anemia. Which of the following is the most accurate statement?
Transfusion reaction is most likely immediately after the infusion is completed.
PRBCs are best infused slowly through a 20g. IV catheter.
PRBCs should be flushed with a 5% dextrose solution.
A nurse should remain in the room during the first 15 minutes of infusion.
None
A clinic patient has a hemoglobin concentration of 10.8 g/dL and reports sticking to a strict vegetarian diet. Which of the following nutritional advice is appropriate?
The diet is providing adequate sources of iron and requires no changes.
The patient should add meat to her diet; a vegetarian diet is not advised.
The patient should use iron cookware to prepare foods, such as dark-green, leafy vegetables, and legumes, which are high in iron.
A cup of coffee or tea should be added to every meal
None
A patient received surgery and chemotherapy for colon cancer, completing therapy three (3) months previously, and she is now in remission. At a follow-up appointment, she complains of fatigue following activity and difficulty with concentration at her weekly bridge games. Which of the following explanations would account for her symptoms?
The symptoms may be the result of anemia caused by chemotherapy.
The patient may be immunosuppressed.
The patient may be depressed.
The patient may be dehydrated.
None
A clinic patient has recently been prescribed nitroglycerin for treatment of angina. He calls the nurse complaining of frequent headaches. Which of the following responses to the patient is correct?
"Stop taking the nitroglycerin and see if the headaches improve."
Go to the emergency department to be checked because nitroglycerin can cause bleeding in the brain."
"Headaches are a frequent side effect of nitroglycerine because it causes vasodilation."
"The headaches are unlikely to be related to the nitroglycerin, so you should see your doctor for further investigation."
None
A patient with a history of congestive heart failure arrives at the clinic complaining of dyspnea. Which of the following actions is the first the nurse should perform?
Ask the patient to lie down on the exam table.
Draw blood for chemistry panel and arterial blood gas (ABG).
Send the patient for a chest x-ray.
Check blood pressure.
None
A patient arrives in the emergency department with symptoms of myocardial infarction, progressing to cardiogenic shock. Which of the following symptoms should the nurse expect the patient to exhibit with cardiogenic shock?
Hypertension
Bradycardia
Bounding pulse
Confusion
None
Following myocardial infarction, a hospitalized patient is encouraged to practice frequent leg exercises and ambulate in the hallway as directed by his physician. Which of the following choices reflects the purpose of exercise for this patient?
Increases fitness and prevents future heart attacks
Prevents bedsores
Prevents DVT (deep vein thrombosis)
Prevent constipations
None
Tissue plasminogen activator (t-PA) is considered for the treatment of a patient who arrives in the emergency department following the onset of symptoms of myocardial infarction. Which of the following is a contraindication for treatment with t-PA?
Worsening chest pain that began earlier in the evening
History of cerebral hemorrhage
History of prior myocardial infarction
Hypertension
None
There are a number of risk factors associated with coronary artery disease. Which of the following is a modifiable risk factor?
Gender
Age
Obesity
Heredity
None
A nurse is administering IV furosemide to a patient admitted with congestive heart failure. After the infusion, which of the following symptoms is not expected?
Increased urinary output
Decreased edema
Decreased pain
Decreased blood pressure
None
Which of the following techniques is correct for obtaining a wound culture specimen from a surgical site?
Thoroughly irrigate the wound before collecting the specimen.
Use a sterile swab and wipe the crusty area around the outside of the wound.
Gently roll a sterile swab from the center of the wound outward to collect drainage.
Use a sterile swab to collect drainage from the dressing.
None
A patient has partial-thickness burns to both legs and portions of his trunk. Which of the following I.V. fluids are given first?
Albumin
D5W
Lactated Ringer’s solution
0.9% sodium chloride solution with 2 mEq of potassium per 100 ml
None
The nurse is providing discharge teaching for the client with leukemia. The client should be told to avoid:
Using oil or cream-based soaps
Flossing between the teeth
The intake of salt
Using an electric razor
None
Patients with Type 1 diabetes mellitus may require which of the following changes to their daily routine during periods of infection?
No changes
Less insulin
More insulin
Oral diabetic agents
None
Adequate fluid replacement and vasopressin replacement are objectives of therapy for which of the following disease processes?
Diabetes mellitus
Diabetes insipidus
Diabetic ketoacidosis
Syndrome of inappropriate antidiuretic hormone secretion (SIADH)
None
Which of the following potentially serious complications could occur with therapy for hypothyroidism?
Acute hemolytic reaction
Angina or cardiac arrhythmia
Retinopathy
Thrombocytopenia
None
After a liver biopsy, place the patient in which of the following positions?
Left side-lying, with the bed flat
Right side-lying, with the bed flat
Left side-lying, with the bed in semi-Fowler’s position
Right side-lying, with the bed in semi-Fowler’s position
None
Which of the following factors should be the primary focus of nursing management in a patient with acute pancreatitis?
Nutrition management
Fluid and electrolyte balance
Management of hypoglycemia
Pain control
None
After surgical repair of a hip, which of the following positions is best for the patient’s legs and hips?
Abduction
Adduction
Prone
Subluxated
None
When giving intravenous (I.V.) phenytoin, which of the following methods should you use?
Use an in-line filter.
Withhold other anticonvulsants.
Mix the drug with saline solution only.
Flush the I.V. catheter with dextrose solution
None
Which of the following signs of increased intracranial pressure (ICP) would appear first after head trauma?
Bradycardia
Large amounts of very dilute urine
Restlessness and confusion
Widened pulse pressure
None
Which of the following nursing interventions should you use to prevent footdrop and contractures in a patient recovering from a subdural hematoma?
High-top sneakers
Low-dose heparin therapy
Physical therapy consultation
Sequential compressive device
None
Which of the following measures best determines that a patient who had a pneumothorax no longer needs a chest tube?
You see a lot of drainage from the chest tube.
Arterial blood gas (ABG) levels are normal.
The chest X-ray continues to show the lung is 35% deflated.
The water-seal chamber doesn’t fluctuate when no suction is applied.
None
A firefighter who was involved in extinguishing a house fire is being treated for smoke inhalation. He developed severe hypoxia 48 hours after the incident, requiring intubation and mechanical ventilation. Which of the following conditions has he most likely developed?
Atelectasis
Pneumonia
Bronchitis
Acute respiratory distress syndrome (ARDS)
None
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