NCLEX Practice Questions RN 2/7

1. Question Tag: leukemia
Question Category: Health Promotion and Maintenance
The nurse is providing discharge teaching for the client with leukemia. The client should be told to avoid:

2. Question Tag: tracheostomy 

Question Category: Reduction of Risk Potential

The nurse is changing the ties of the client with a tracheostomy. The safest method of changing the tracheostomy ties is to:

3. Question Tag: lung resection

Question Category: Physiological Integrity, Reduction of Risk Potential

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:

4. Question Tag: Tetralogy of Fallot

Question Category: Physiological Integrity, Pharmacological and Parenteral Therapies

The infant is admitted to the unit with tetralogy of fallot. The nurse would anticipate an order for which medication?

5. Question Tag: Self-breast exam

Question Category: Health Promotion and Maintenance

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. 

6. Question Tag: ventricular septal defect

Question Category: Physiological Integrity, Physiological Adaptation

The toddler is admitted with a cardiac anomaly. The nurse is aware that the infant with a ventricular septal defect will:

7. Question Tag: nonstress test

Question Category:  Physiological Integrity, Reduction of Risk Potential

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:

8. Question Tag: labor 

Question Category: Health Promotion and Maintenance

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?

9. Question Tag: ECG, cardiac arrhythmia

Question Category: Physiological Integrity, Reduction of Risk Potential

The nurse notes the following on the ECG monitor. The nurse would evaluate the cardiac arrhythmia as:

10. Question Tag: lovenox (Enoxaparin)

Question Category: Physiological Integrity, Pharmacological and Parenteral Therapies

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:

11. Question Tag: valium (Diazepam), phenergan (Promethazine)

Question Category: Physiological Integrity, Pharmacological and Parenteral Therapies

The nurse has a preop order to administer valium (Diazepam) 10mg and phenergan (Promethazine) 25mg. The correct method of administering these medications is to:

12. Question Tag: urinary tract infection

Question Category: Health Promotion and Maintenance

A client with frequent urinary tract infections asks the nurse how she can prevent the recurrence. The nurse should teach the client to:

13. Question Tag: nursing assistant

Question Category: Safe and Effective Care Environment, Management of Care

Which task should be assigned to the nursing assistant?

14. Question Tag: thyroidectomy

Question Category: Physiological Integrity, Reduction of Risk Potential

The client has recently returned from having a thyroidectomy. The nurse should keep which of the following at the bedside?

15. Question Tag: histoplasmosis

Question Category: Physiological Integrity, Physiological Adaptation

The physician has ordered a histoplasmosis test for the elderly client. The nurse is aware that histoplasmosis is transmitted to humans by:

16. Question Tag: chest pain

Question Category: Physiological Integrity, Physiological Adaptation

What’s the first intervention for a patient experiencing chest pain and an p02 of 89%?

17. Question Tag: abdominal aortic aneurysm

Question Category: Physiological Integrity, Physiological Adaptation

Which of the following signs and symptoms usually signifies rapid expansion and impending rupture of an abdominal aortic aneurysm?

18. Question Tag: cardiomyopathy

Question Category: Physiological Integrity, Physiological Adaptation

In which of the following types of cardiomyopathy does cardiac output remain normal?

19. Question Tag: chest pain

Question Category: Physiological Integrity, Physiological Adaptation

Which of the following interventions should be your first priority when treating a patient experiencing chest pain while walking?

20. Question Tag: acute pulmonary edema

Question Category: Physiological Integrity, Physiological Adaptation 

Which of the following positions would best aid breathing for a patient with acute pulmonary edema?

21. Question Tag: abruptio placentae

Question Category: Physiological Integrity, Reduction of Risk Potential

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?

22. Question Tag: vehicle accident, fracture

Question Category: Physiological Integrity, Physiological Adaptation

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?

23. Question Tag: corticosteroids

Question Category: Physiological Integrity, Pharmacological and Parenteral Therapies

Corticosteroids are potent suppressors of the body’s inflammatory response. Which of the following conditions or actions do they suppress?

24. Question Tag: HIV, zidovudine

Question Category: Physiological Integrity, Pharmacological and Parenteral Therapies

A patient infected with human immunodeficiency virus (HIV) begins zidovudine therapy. Which of the following statements best describes this drug’s action?

25. Question Tag: pneumonia

Question Category: Physiological Integrity, Basic Care and Comfort

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?

26. Question Tag: asthma, acute respiratory distress

Question Category: Physiological Integrity, Physiological Adaptation

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?

27. Question Tag: smoke inhalation, hypoxia

Question Category: Physiological Integrity, Physiological Adaptation

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?

28. Question Tag: pneumothorax

Question Category: Physiological Integrity, Reduction of Risk Potential

Which of the following measures best determines that a patient who had a pneumothorax no longer needs a chest tube?

29. Question Tag: subdural hematoma

Question Category: Physiological Integrity, Physiological Adaptation

Which of the following nursing interventions should you use to prevent foot drop and contractures in a patient recovering from a subdural hematoma?

30. Question Tag: increased intracranial pressure

Question Category: Physiological Integrity, Physiological Adaptation

Which of the following signs of increased intracranial pressure (ICP) would appear first after head trauma?

31. Question Tag: phenytoin

Question Category: Physiological Integrity, Physiological Adaptation

When giving intravenous (I.V.) phenytoin, which of the following methods should you use?

32. Question Tag: hip repair

Question Category: Physiological Integrity, Physiological Adaptation

After surgical repair of a hip, which of the following positions is best for the patient’s legs and hips?

33. Question Tag: acute pancreatitis

Question Category: Physiological Integrity, Physiological Adaptation

Which of the following factors should be the primary focus of nursing management in a patient with acute pancreatitis?

34. Question Tag: liver biopsy

Question Category: Physiological Integrity, Reduction of Risk Potential

After a liver biopsy, place the patient in which of the following positions?

35. Question Tag: hypothyroidism

Question Category: Physiological Integrity, Reduction of Risk Potential

Which of the following potentially serious complications could occur with therapy for hypothyroidism?

36. Question Tag: diabetes insipidus

Question Category: Physiological Integrity, Physiological Adaptation

Adequate fluid replacement and vasopressin replacement are objectives of therapy for which of the following disease processes?

37. Question Tag: type 1 diabetes mellitus

Question Category: Physiological Integrity, Physiological Adaptation

Patients with Type 1 diabetes mellitus may require which of the following changes to their daily routine during periods of infection?

38. Question Tag:decreased hematocrit

Question Category: Physiological Integrity, Reduction of Risk Potential

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?

39. Question Tag: partial-thickness burn

Question Category: Physiological Integrity, Pharmacological and Parenteral Therapies

A patient has partial-thickness burns to both legs and portions of his trunk. Which of the following I.V. fluids are given first?

40. Question Tag: wound culture

Question Category: Health Promotion and Maintenance

Which of the following techniques is correct for obtaining a wound culture specimen from a surgical site?

41. Question Tag: furosemide, congestive heart failure

Question Category: Physiological Integrity, Pharmacological and Parenteral Therapies

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?

42. Question Tag: coronary artery disease

Question Category: Health Promotion and Maintenance

There are a number of risk factors associated with coronary artery disease. Which of the following is a modifiable risk factor?

43. Question Tag: myocardial infarction, tissue plasminogen activator

Question Category: Physiological Integrity, Physiological Adaptation

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?

44. Question Tag: myocardial infarction

Question Category: Health Promotion and Maintenance

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?

45. Question Tag: cardiogenic shock

Question Category: Physiological Integrity, Physiological Adaptation

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?

46. Question Tag: congestive heart failure

Question Category: Physiological Integrity, Physiological Adaptation

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?

47. Question Tag: nitroglycerin, angina

Question Category: Physiological Integrity, Pharmacological and Parenteral Therapies

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?

48. Question Tag: colon cancer, chemotherapy

Question Category: Physiological Integrity, Reduction of Risk Potential

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?

49. Question Tag: hemoglobin

Question Category: Basic Care and Comfort

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?

50. Question Tag: anemia

Question Category: Physiological Integrity, Physiological Adaptation

A hospitalized patient is receiving packed red blood cells (PRBCs) for treatment of severe anemia. Which of the following is the most accurate statement?

51. Question Tag: Epoetin

Question Category: Physiological Integrity, Reduction of Risk Potential

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?

52. Question Tag: polycythemia vera

Question Category: Physiological Integrity, Physiological Adaptation

A patient is admitted to the hospital with suspected polycythemia vera. Which of the following symptoms is consistent with the diagnosis? Select all Select all that apply.

53. Question Tag: platelet count

Question Category: Physiological Integrity, Reduction of Risk Potential

A nurse is caring for a patient with a platelet count of 20,000/microliter. Which of the following is an important intervention?

54. Question Tag: corticosteroid

Question Category: Physiological Integrity, Pharmacological and Parenteral Therapies

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.

55. Question Tag: neutropenia

Question Category: Physiological Integrity, Physiological Adaptation

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?

56. Question Tag: leukemia

Question Category: Health Promotion and Maintenance

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?

57. Question Tag: acute lymphoblastic leukemia

Question Category: Health Promotion and Maintenance

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?

58. Question Tag: Hodgkin’s disease

Question Category: Physiological Integrity, Physiological Adaptation

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?

59. Question Tag: Hodgkin’s disease

Question Category: Physiological Integrity, Physiological Adaptation

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?

60. Question Tag: bone marrow aspiration

Question Category: Physiological Integrity, Physiological Adaptation

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?

61. Question Tag: sickle cell anemia

Question Category: Physiological Integrity, Reduction of Risk Potential

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?

62. Question Tag: sickle cell crisis

Question Category: Physiological Integrity, Physiological Adaptation

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?

63. Question Tag: sickle cell crisis

Question Category: Physiological Integrity, Physiological Adaptation

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?

64. Question Tag: sickle cell crisis

Question Category: Physiological Integrity, Basic Care and Comfort

Which of the following foods would the nurse encourage the client in sickle cell crisis to eat?

65. Question Tag: sickle cell crisis

Question Category: Physiological Integrity, Physiological Adaptation

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.

66. Question Tag: iron-deficiency anemia

Question Category: Physiological Integrity, Basic Care and Comfort

The nurse is instructing a client with iron-deficiency anemia. Which of the following meal plans would the nurse expect the client to select?

67. Question Tag: sickle cell anemia

Question Category: Health Promotion and Maintenance

Clients with sickle cell anemia are taught to avoid activities that cause hypoxia and hypoxemia. Which of the following activities would the nurse recommend?

68. Question Tag: vitamin B12 deficiency

Question Category: Physiological Integrity, Physiological Adaptation

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?

69. Question Tag: vitamin B12 deficiency

Question Category: Health Promotion and Maintenance 

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?

70. Question Tag: anemia

Question Category:  Physiological Integrity, Physiological Adaptation 

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?

71. Question Tag: polycythemia vera

Question Category: Health Promotion and Maintenance

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?

72. Question Tag: acute leukemia

Question Category: Health Promotion and Maintenance

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?

73. Question Tag: acute leukemia

Question Category: Health Promotion and Maintenance

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 the presence of petechiae?

74. Question Tag: acute leukemia 

Question Category: Health Promotion and Maintenance

A client with acute leukemia is admitted to the oncology unit. Which of the following would be most important for the nurse to inquire?

75. Question Tag: acute leukemia

Question Category: Physiological Integrity, Reduction of Risk Potential

Which of the following would be the priority nursing diagnosis for the adult client with acute leukemia?

76. Question Tag: Hodgkin’s lymphoma

Question Category: Physiological Integrity

A 21-year-old male with Hodgkin’s lymphoma is a senior at the local university. He is engaged to be married and is to begin a new job upon graduation. Which of the following diagnoses would be a priority for this client?

77. Question Tag: thrombocytopenic purpura

Question Category: Physiological Integrity

A client has autoimmune thrombocytopenic purpura. To determine the client’s response to treatment, the nurse would monitor:

78. Question Tag: thrombocytopenic purpura

Question Category: Physiological Integrity

The home health nurse is visiting a client with autoimmune thrombocytopenic purpura (ATP). The client’s platelet count currently is 80, it will be most important to teach the client and family about:

79. Question Tag: transsphenoidal hypophysectomy

Question Category: Physiological Integrity

A client with a pituitary tumor has had transsphenoidal hypophysectomy. Which of the following interventions would be appropriate for this client?

80. Question Tag: diabetes

Question Category: Physiological Integrity

The client with a history of diabetes insipidus is admitted with polyuria, polydipsia, and mental confusion. The priority intervention for this client is:

81. Question Tag: hemophilia

Question Category: Physiological Integrity

A client with hemophilia has a nosebleed. Which nursing action is most appropriate to control the bleeding?

82. Question Tag: unilateral adrenalectomy

Question Category: Physiological Integrity

A client has had a unilateral adrenalectomy to remove a tumor. To prevent complications, the most important measurement in the immediate postoperative period for the nurse to take is:

83. Question Tag: Addison’s disease, glucocorticoids

Question Category: Physiological Integrity

A client with Addison’s disease has been admitted with a history of nausea and vomiting for the past 3 days. The client is receiving IV glucocorticoids (Solu-Medrol). Which of the following interventions would the nurse implement?

84. Question Tag: total thyroidectomy

Question Category: Physiological Integrity

A client had a total thyroidectomy yesterday. The client is complaining of tingling around the mouth and in the fingers and toes. What would the nurse’s next action be?

85. Question Tag: hypothyroidism

Question Category: Physiological Integrity

A 32-year-old mother of three is brought to the clinic. Her pulse is 52, there is a weight gain of 30 pounds in 4 months, and the client is wearing two sweaters. The client is diagnosed with hypothyroidism. Which of the following nursing diagnoses is of highest priority?

86. Question Tag: arteriogram

Question Category: Physiological Integrity

The client is having an arteriogram. During the procedure, the client tells the nurse, “I’m feeling really hot.” Which response would be best?

87. Question Tag: healthcare workers

Question Category: Physiological Integrity

The nurse is observing several healthcare workers providing care. Which action by the healthcare worker indicates a need for further teaching?

88. Question Tag: electroconvulsive therapy, depression

Question Category: Physiological Integrity

The client is having electroconvulsive therapy for treatment of severe depression. Which of the following indicates that the client’s ECT has been effective?

89. Question Tag: enterobiasis

Question Category: Physiologic Integrity

The 5-year-old is being tested for enterobiasis (pinworms). To collect a specimen for assessment of pinworms, the nurse should teach the mother to:

90. Question Tag: enterobiasis 

Question Category: Physiological Integrity

The nurse is teaching the mother regarding treatment for enterobiasis. Which instruction should be given regarding the medication?

91. Question Tag: pregnancy

Question Category: Safe and Effective Care Environment

The registered nurse is making assignments for the day. Which client should be assigned to the pregnant nurse?

92. Question Tag: room assignments 

Question Category: Safe and Effective Care Environment

The nurse is planning room assignments for the day. Which client should be assigned to a private room if only one is available?

93. Question Tag: Digitalis

Question Category: Safe and Effective Care Environment 

The nurse caring for a client in the neonatal intensive care unit administers adult-strength Digitalis to the 3-pound infant. As a result of her actions, the baby suffers permanent heart and brain damage. The nurse can be charged with:

94. Question Tag: licensed practical nurse

Question Category: Safe and Effective Care Environment

Which assignment should not be performed by the licensed practical nurse?

95. Question Tag: surgery

Question Category: Physiological Integrity

The client returns to the unit from surgery with a blood pressure of 90/50, pulse 132, and respirations 30. Which action by the nurse should receive priority?

96. Question Tag: preeclampsia

Question Category: Safe and Effective Care Environment

Which nurse should be assigned to care for the postpartum client with preeclampsia?

97. Question Tag: Board of Nursing

Question Category: Safe and Effective Care Environment

Which information should be reported to the state Board of Nursing?

98. Question Tag: medication administration

Question Category: Safe and Effective Care Environment

The nurse is suspected of charting medication administration that he did not give. After talking to the nurse, the charge nurse should:

99. Question Tag: home health care

Question Category: Safe and Effective Care Environment

The home health nurse is planning for the day’s visits. Which client should be seen first?

100. Question Tag: emergency department

Question Category: Safe and Effective Care Environment

The emergency room is flooded with clients injured in a tornado. Which clients can be assigned to share a room in the

101. Question Tag: conjunctivitis

Question Category: Physiological Integrity

The nurse is caring for a 6-year-old client admitted with a diagnosis of conjunctivitis. Before administering eye drops, the nurse should recognize that it is essential to consider which of the following?

102. Question Tag: meal planning

Question Category: Health Promotion and Maintenance

The nurse is discussing meal planning with the mother of a 2-year-old toddler. Which of the following statements, if made by the mother, would require a need for further instruction?

103. Question Tag: toddler

Question Category: Physiological Integrity

A 2-year-old toddler is admitted to the hospital. Which of the following nursing interventions would you expect?

104. Question Tag: hearing aid

Question Category: Health Promotion and Maintenance

Which instruction should be given to the client who is fitted for a behind-the-ear hearing aid?

105. Question Tag: tonsillectomy

Question Category: Physiological Integrity

A priority nursing diagnosis for a child being admitted from surgery following a tonsillectomy is:

106. Question Tag: bacterial pneumonia

Question Category: Physiological Integrity

A client with bacterial pneumonia is admitted to the pediatric unit. What would the nurse expect the admitting assessment to reveal?

107. Question Tag: epiglottitis

Question Category: Safe and Effective Care Environment

The nurse is caring for a client admitted with epiglottitis. Because of the possibility of complete obstruction of the airway, which of the following should the nurse have available?

108. Question Tag: Grave’s disease

Question Category: Physiological Integrity

A 25-year-old client with Grave’s disease is admitted to the unit. What would the nurse expect the admitting assessment to reveal?

109. Question Tag: celiac disease

Question Category: Health Promotion and Maintenance

The nurse is providing dietary instructions to the mother of an 8-year-old child diagnosed with celiac disease. Which of the following foods, if selected by the mother, would indicate her understanding of the dietary instructions?

110. Question Tag: chronic bronchitis

Question Category: Physiological Integrity

The nurse is caring for an 80-year-old with chronic bronchitis. Upon the morning rounds, the nurse finds an O2 sat of 76%. Which of the following actions should the nurse take first?

111. Question Tag: amniotomy

Question Category: Physiological Integrity

A gravida 3 para 0 is admitted to the labor and delivery unit. The doctor performs an amniotomy. Which observation would the nurse be expected to make after the amniotomy?

112. Question Tag: vaginal exam

Question Category: Physiological Integrity

The client is admitted to the unit. A vaginal exam reveals that she is 2cm dilated. Which of the following statements would the nurse expect her to make?

113. Question Tag: labor

Question Category: Physiological Integrity 

The client is having fetal heart rates of 90–110 bpm during the contractions. The first action the nurse should take is:

114. Question Tag: pitocin, dystocia

Question Category: Physiological Integrity

In evaluating the effectiveness of IV Pitocin for a client with secondary dystocia, the nurse should expect:

115. Question Tag: footling breech presentation

Question Category: Physiological Integrity

A vaginal exam reveals a footling breech presentation. The nurse should take which of the following actions at this time?

116. Question Tag: vaginal exam

Question Category: Physiological Integrity

A vaginal exam reveals that the cervix is 4cm dilated, with intact membranes and a fetal heart tone rate of 160–170 bpm. The nurse decides to apply an external fetal monitor. The rationale for this implementation is:

117. Question Tag: labor, primigravida

Question Category: Physiological Integrity

The following are all nursing diagnoses appropriate for a gravida 1 para 0 in labor. Which one would be most appropriate for the primigravida as she completes the early phase of labor?

118. Question Tag: late decelerations

Question Category: Physiological Integrity

As the client reaches 8 cm dilation, the nurse notes late decelerations on the fetal monitor. The FHR baseline is 165–175 bpm with variability of 0–2bpm. What is the most likely explanation of this pattern?

119. Question Tag: variable decelerations

Question Category: Physiological Integrity

The nurse notes variable decelerations on the fetal monitor strip. The most appropriate initial action would be to:

120. Question Tag: fetal heart rate 

Question Category: Physiological Integrity

Which of the following is a characteristic of a reassuring fetal heart rate pattern?

121. Question Tag: epidural anesthesia

Question Category: Physiologic Integrity

The rationale for inserting a French catheter every hour for the client with epidural anesthesia is:

122. Question Tag: conception

Question Category: Health Promotion and Maintenance

A client in the family planning clinic asks the nurse about the most likely time for her to conceive. The nurse explains that conception is most likely to occur when:

123. Question Tag: rhythm method

Question Category: Health Promotion and Maintenance

A client tells the nurse that she plans to use the rhythm method of birth control. The nurse is aware that the success of the rhythm method depends on the:

124. Question Tag: diabetes, birth control

Question Category: Health Promotion and Maintenance

A client with diabetes asks the nurse for advice regarding methods of birth control. Which method of birth control is most suitable for the client with diabetes?

125. Question Tag: ectopic pregnancy

Question Category: Physiological Integrity

The doctor suspects that the client has an ectopic pregnancy. Which symptom is consistent with a diagnosis of ectopic pregnancy?

126. Question Tag: nutrition, pregnancy

Question Category: Health Promotion and Maintenance

The nurse is teaching a pregnant client about nutritional needs during pregnancy. Which menu selection will best meet the nutritional needs of the pregnant client?

127. Question Tag: hyperemesis gravidarum

Question Category: Physiological Integrity

The client with hyperemesis gravidarum is at risk for developing:

128. Question Tag: pregnancy

Question Category: Health Promotion and Maintenance

A client tells the doctor that she is about 20 weeks pregnant. The most definitive sign of pregnancy is:

129. Question Tag: diabetes, neonate

Question Category: Physiologic Integrity

The nurse is caring for a neonate whose mother is diabetic. The nurse will expect the neonate to be:

130. Question Tag: oral contraceptives

Question Category: Health Promotion and Maintenance

Which of the following instructions should be included in the nurse’s teaching regarding oral contraceptives?

131. Question Tag: breastfeeding

Question Category: Health Promotion and Maintenance

The nurse is discussing breastfeeding with a postpartum client. Breastfeeding is contraindicated in the postpartum client with:

132. Question Tag: vaginal bleeding 

Question Category: Physiological Integrity

A client is admitted to the labor and delivery unit complaining of vaginal bleeding with very little discomfort. The nurse’s first action should be to:

133. Question Tag: labor

Question Category: Physiological Integrity 

A client telephones the emergency room stating that she thinks that she is in labor. The nurse should tell the client that labor has probably begun when:

134. Question Tag: fetal development, smoking

Question Category: Health Promotion and Maintenance

The nurse is teaching a group of prenatal clients about the effects of cigarette smoke on fetal development. Which characteristic is associated with babies born to mothers who smoked during pregnancy?

135. Question Tag: RhoGam

Question Category: Physiological Integrity

The physician has ordered an injection of RhoGam for the postpartum client whose blood type is A negative but whose baby is O positive. To provide postpartum prophylaxis, RhoGam should be administered:

136. Question Tag: amniotomy 

Question Category: Physiological Integrity

After the physician performs an amniotomy, the nurse’s first action should be to assess the:

137. Question Tag: effacement, labor and delivery 

Question Category: Physiological Integrity

A client is admitted to the labor and delivery unit. The nurse performs a vaginal exam and determines that the client’s cervix is 5 cm dilated with 75% effacement. Based on the nurse’s assessment the client is in which phase of labor?

138. Question Tag: narcotic abstinence syndrome

Question Category: health

A newborn with narcotic abstinence syndrome is admitted to the nursery. Nursing care of the newborn should include:

139. Question Tag: epidural anesthesia 

Question Category: 

A client elects to have epidural anesthesia to relieve the discomfort of labor. Following the initiation of epidural anesthesia, the nurse should give priority to:

140. Question Tag: postoperative wound infection

Question Category: Safe and Effective Care Environment

The nurse is aware that the best way to prevent postoperative wound infection in the surgical client is to:

141. Question Tag: fractured hip

Question Category: Physiological Integrity

The elderly client is admitted to the emergency room. Which symptom is the client with a fractured hip most likely to exhibit?

142. Question Tag: osteoporosis

Question Category: Health Promotion and Maintenance

The nurse knows that a 60-year-old female client’s susceptibility to osteoporosis is most likely related to:

143. Question Tag: Bryant’s traction 

Question Category: Physiological Integrity

A 2-year-old is admitted for repair of a fractured femur and is placed in Bryant’s traction. Which finding by the nurse indicates that the traction is working properly?

144. Question Tag: Buck’s traction

Question Category: Physiological Integrity

A client with a fractured hip has been placed in Buck’s traction. Which statement is true regarding balanced skeletal traction? Balanced skeletal traction:

145. Question Tag: open reduction internal fixation

Question Category: Safe and Effective Care Environment

The client is admitted for an open reduction internal fixation of a fractured hip. Immediately following surgery, the nurse should give priority to assessing the:

146. Question Tag: percutaneous gastrostomy tube

Question Category: Health Promotion and Maintenance

Which statement made by the family member caring for the client with a percutaneous gastrostomy tube indicates an understanding of the nurse’s teaching?

147. Question Tag: total knee replacement 

Question Category: Physiological Integrity

The nurse is assessing the client with a total knee replacement 2 hours postoperative. Which information requires notification of the doctor?

148. Question Tag: plumbism 

Question Category: Health Promotion and Maintenance

The nurse is caring for the client with a 5-year-old diagnosis of plumbism. Which information in the health history is most likely related to the development of plumbism?

148. Question Tag: plumbism 

Question Category: Health Promotion and Maintenance

The nurse is caring for the client with a 5-year-old diagnosis of plumbism. Which information in the health history is most likely related to the development of plumbism?

149. Question Tag: total hip replacement

Question Category: Safe and Effective Care Environment

A client with a total hip replacement requires special equipment. Which equipment would assist the client with a total hip replacement with activities of daily living?

150. Question Tag: abdominal surgery 

Question Category: Physiologic Integrity

An elderly client with an abdominal surgery is admitted to the unit following surgery. In anticipation of complications of anesthesia and narcotic administration, the nurse should:

151. Question Tag: room assignments

Question Category: Physiological Integrity, Basic Care and Comfort

Which roommate would be most suitable for the 6-year-old male with a fractured femur in Russell’s traction?

152. Question Tag: celebrex (Celecoxib)

Question Category: Health Promotion and Maintenance

A client with osteoarthritis has a prescription for celebrex (Celecoxib). Which instruction should be included in the discharge teaching?

153. Question Tag: fracture, cast

Question Category: Safe and Effective Care Environment,,  Safety and Infection Control

A client with a fractured tibia has a plaster-of-Paris cast applied to immobilize the fracture. Which action by the nurse indicates an understanding of a plaster-of-Paris cast? The nurse:

154. Question Tag: fiberglass cast

Question Category: Physiological Integrity, Basic Care and Comfort

The teenager with a fiberglass cast asks the nurse if it will be okay to allow his friends to autograph his cast. Which response would be best?

155. Question Tag: Steinmann pin 

Question Category: Safe and Effective Care Environment, Management of Care

The nurse is assigned to care for the client with a Steinmann pin. During pin care, she notes that the LPN uses sterile gloves and Q-tips to clean the pin. Which action should the nurse take at this time?

156. Question Tag: scoliosis, spica cast

Question Category: Physiological Integrity, Reduction of Risk Potential

A child with scoliosis has a spica cast applied. Which action specific to the spica cast should be taken?

157. Question Tag: fracture, traction

Question Category: Safe and Effective Care Environment,,  Safety and Infection Control

The client with a cervical fracture is placed in traction. Which type of traction will be utilized at the time of discharge?

158. Question Tag: continuous passive motion device 

Question Category: Physiological Integrity, Physiological Adaptation

A client with a total knee replacement has a CPM (continuous passive motion device) applied during the postoperative period. Which statement made by the nurse indicates an understanding of the CPM machine?

159. Question Tag: walker, fracture

Question Category: Safe and Effective Care Environment,,  Safety and Infection Control

A client with a fractured hip is being taught correct use of the walker. The nurse is aware that the correct use of the walker is achieved if the:

160. Question Tag: prolapsed cord

Question Category: Physiological Integrity, Physiological Adaptation

When assessing a laboring client, the nurse finds a prolapsed cord. The nurse should:

161. Question Tag: rosuvastatin

Question Category: Physiological Integrity, Pharmacological and Parenteral Therapies

The client presents to the clinic with a serum cholesterol of 275 mg/dL and is placed on rosuvastatin (Crestor). Which instruction should be given to the client?

162. Question Tag: diazoxide, hypertensive crises 

Question Category: Physiological Integrity, Pharmacological and Parenteral Therapies

The client is admitted to the hospital with hypertensive crises. Diazoxide (Hyperstat) is ordered. During administration, the nurse should: