Physiological Adaptation NCLEX Questions
Adult Client Bowel Obstruction
The nurse is caring for a client with a bowel obstruction. The client has a nasogastric tube in place set to low intermittent suctioning (LIS). The nurse notes an output of 750 mL during the first half of the shift. The nurse reviews the client’s lab values and notes a pH of 7.48, CO2 of 35 mEq/L, and HCO3 of 28 mEq/L. Which of the following conditions does the nurse suspect?
Pediatric Patient Jaundice
A nurse is caring for a 2-day-old infant who requires phototherapy for treatment of jaundice. Which information would be included as part of the nurse’s subjective assessment?
Adult Gestational Hypertension
A nurse is educating a pregnant client on the impact of her high blood pressure during pregnancy. Which of the following is the most appropriate statement by the nurse?
Adult Ventilator
A nurse is caring for a client who is on a ventilator. The nurse checks the vent settings at the beginning of her shift and notes that the FiO2 is set at 40. Based on the nurse's knowledge of ventilation parameters, which of the following statement is correct?
Adult SIADH
A nurse is caring for a client who has been diagnosed with syndrome of inapproriate anti-diurectic hormone (SIADH). What type of electrolyte imbalance would the nurse most likely see in this situation?
Adult Labor
A nurse believes her laboring client may be experiencing hypertonic labor. Which finding would be consistent with this?
Adult Ileostomy
The nurse is caring for a client with an ileostomy. During assessment of the client, the nurse notes that the pouch opening is 1/2 inch larger than the stoma site. Which of the following poses a risk for this client?
Adult Ventilator
A nurse is caring for a client on a ventilator. The client's family is visiting, so the nurse teaches the family about what alarms mean on the ventilator. Which best decribes the rationale for this intervention?
Adult Bowel Obstruction
The nurse is caring for a client with an intestinal obstruction. Which of the following is the priority nursing intervention?
Adult Hemodialysis
A nurse is taking care of a client who has just returned from a session of hemodialysis. The physician has ordered a percutaneous nephrolithotomy for the client and the nurse does not schedule the procedure until 8 hours later. What is the rationale for this?
Adult CVP Monitoring
A nurse is working with a client who has a central catheter in place that is measuring central venous pressure (CVP). When looking at the waveform, the nurse understands that the descending portion of the wave indicates which of the following?
Adult 3rd Degree Heart Block
The telemetry nurse is reviewing a rhythm strip for a client with a 2nd degree type II heart block. The nurse notes a QRS complex of 0.16 seconds, no measurable PR interval, and a regular R to R and P to P interval. The nurse assesses the client and determines the client is responsive but dizzy with a pulse rate of 50 bpm. Which action by the nurse is most appropriate?
Adult PEA
Which of the following would be considered a non-shockable rhythm when assessing cardiac function during a cardiac arrest code?
Adult Bacterial Meningitis
The nurse is caring for a client with bacterial meningitis. Which of the following is a priority nursing intervention?
New Grad Nurse, CRRT
The new graduate nurse is training on continuous renal replacement therapy (CRRT) in the intensive care unit. The nurse correctly understands which of the following about CRRT versus regular hemodialysis?
Adult Panic Attack
A nurse working in the emergency department is assessing a client with an anxiety disorder. The client has had significant life stressors that have led to an uncontrollable panic attack and a call to 911. The nurse notes the client is breathing rapidly, complaining of dizziness, and attempting to stand up, stating "I have to leave NOW." Which of the following interventions is most appropriate for this nurse to implement?
Neonate, Weight Gain/Feeding
A mother of a 2-week-old baby calls the clinic concerned that her baby is having difficulty feeding. Which of the following statements by the mother does NOT cause concern?
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Psychosocial Integrity NCLEX Questions
Adult Diabetes
Which best describes how high stress level can impact diabetes management?
Adult Testicular Cancer
The nurse is caring for a client who was recently diagnosed with testicular cancer. The client appears anxious and asks the nurse questions about his condition. Which of the following statements by the nurse is correct?
Older Adult Depression
The nurse has received shift report and enter the room to assess an older adult client. Upon entering the room, the nurse notes that the client will not make eye contact and is unwilling to engage in a discussion. The client states, "I never sleep well, but I'm tired now, so will you let me sleep tonight?" The nurse recognize this as which common problem experienced by a client of this age?
Peds ADHD
A 14-year-old teen has been hospitalized for acute exacerbation of ADHD symptoms. The nurse tries to help the client to engage with others on the unit. Which of the following interventions would be most appropriate for supporting social interaction for this client?
Adult Undergoing Surgery
A client is concerned that they won't breathe during their surgery. Which of the following is the most appropriate response for the perioperative nurse?
Adult Colon CA
A 50-year-old client has arrived for a colonscopy, and states she is worried that gastroenterologist will find cancer. Which assessment finding would the nurse expect for a client who is in the early stages of colon cancer?
Pediatric Patient, Cancer
A nurse is working on a pediatric oncology floor and has developed a relationship with an elementary-aged child with terminal cancer. The child's parents ask the nurse how to talk to the child about the situation. Which of the following ideas should the nurse convey to the parents regarding this child's concept of death?
Adult Stomach Cancer
The hospice nurse is caring a 40-year-old client with IV stomach cancer. The nurse knows that this client will likely be most concerned with which of the following?
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Management of Care NCLEX Questions
Adult Patient, PEA/Asystole
A nurse is caring for a client with pulseless electrical activity (PEA/asystole). The nurse knows that according to the PEA/asystole algorithm, which of the following actions are expected?
Adult Testicular Cancer
The clinic nurse is performing an assessment on a 35-year-old male client who presents to the clinic with a painless testicular lump and pain in the pelvis. The nurse carefully assesses the client's lungs and asks if the client has had any trouble breathing. Which of the following explains the actions of the nurse?
Adult Chest Tube
A nurse has just received report on 4 clients who all have chest tubes in place. Which client is the priority to see first?
Adult Cerebral Angiography
A nurse is preparing a client for cerebral angiography. The nurse knows to prep and clean the site before the catheter is inserted. The nurse would be correct to prep which of the areas?
Adult Tracheostomy
A nurse is caring for a client with a new tracheostomy. The client has a pneumonia with a WBC count 4.6 x 10^9/L and is receiving morphine for pain control. Which of the following precautions is the priority at this time?
Adult TEE
A client is scheduled to have a transesophageal echocardiogram (TEE). Which of the following is an incorrect understanding by the client about the procedure?
Adult Tachycardia
A nurse enters the room and notices her client has a heart rate of 132 on the monitor. The nurse knows that which of the following is the priority nursing intervention?
Adult Meniere's Disease
The nurse is providing education to a client about Meniere's disease. Which of the following education topics should the nurse include?
Adult On A Vent
A nurse in the ICU is caring for a client that has been ventilated for 2 weeks due to Acute Respiratory Distress Syndrome (ARDS). The client's FiO2 has been at 60% for the last 48 hours. What is the nurse's immediate priority concern at this time?
Adult Chest Tube
A nurse is assisting a provider with the removal of a chest tube. Which of the following nursing interventions is the priority once the provider removes the tube from the chest?
Adult DKA
A nurse in the Intensive Care Unit (ICU) is caring for a client with diabetic ketoacidosis (DKA). Which of the following is NOT a priority nursing intervention for this patient?
Neonate SIDS
The parents of a newborn are concerned about placing their baby on it's back to sleep for fear of chocking on spit up. The nurse addresses their concern by making which of the following statements?
Adult Trauma
An unconscious client is brought in to the emergency room and needs immediate surgery for bleeding from the chest. A staff member explains that surgery cannot be done because the client cannot consent. Which of the following is the best response by the nurse?
Adult Triage
After receiving report on four clients the emergency room nurse should see the client with which of the following diagnosis first?
Adult Shock
A nurse is assessing a client. Which of the following behaviors would indicate the client is in shock?
Adult AMA PPWK
A nurse is caring for a client who wants to leave the hospital against medical advice (AMA). The nurse has notified the provider and determined that the client has the mental capacity to refuse offers the client an AMA form to sign, but the client refuses to sign it. Which of the following actions of the nurse is most appropriate?
Adult Dehydration
A client is admitted with severe diarrhea and vomiting. The client is very fatigued and weak and hasn’t urinated since early in the morning. The bladder scan reads 134 ml. Which of the following should the nurse consider regarding this client's condition?
Adult Nephrostomy Tube
The provider has ordered a nephrostomy tube for a client in the nurse's care. How should the nurse explain the procedure for nephrostomy tube placement to the client?
Adult CVC Removal
The nurse is precepting a new graduate nurse (GN). The nurse is supervising the GN who is discontinuing a central venous catheter located in client's subclavian vein. The client is sitting in a recliner comfortably. The GN has the sterile field set up apporiately, has removed the old dressing and is now ready to remove the sutures. At the moment, the precepting nurse has also just received news of an order for a STAT CBC on the vomiting, and a provider is on hold waiting to discuss another client who is going to surgery later this afternoon. The precepting nurse has also just received news of an order for a STAT CBC in the vomiting client. What is the precepting nurse's next priority?
Adult Patient Heart Disease
Before assisting with angiography for heart disease, which of the following information must the nurse determine about the client?
Adult Liver Disease
A nurse receives a client fro radiology that just underwent a liver biopsy. Which position should the nurse place the client in to decrease risk of bleeding?
Adult 1st Degree Heart Block
A student nurse is reviewing the nursing interventions for 1st degree AV block and is concerned as to why the patient needs to be monitored further. Which of the following is the best response for the nursing instructor to give the student about first degree AV heart block?
Pediatrics Pneumonia
A 5-year-old diagnosed with viral pneumonia is being discharged home with a prescription for acetaminophen to help manage the fever. Which of the following would important for the nurse to cover prior to discharge?
Adult MDRO Infection
A nurse is caring for a client who presents with a history of infection with a multi-drug resistant organism. Which type of isolation precautions should be initiated?
Pharmacology and Parenteral Therapies NCLEX Questions
Adult Coagulation Disorders
The nurse is precepting a nursing student in a pedriatric unit. The nursing student asks why it is helpful to understand Piaget's theory of cognitive development. Which of the following reponse by the nurse is correct?
Adult Tuberculosis
A client undergoing treatment for tuberculosis presents to the emergency department complaining of red-tinged discharge from the eyes. Which of the following actions is most appropriate for the nurse to take?
Adult Clotting Disorder
The nurse is precepting a nursing student in a pedriatric unit. The nursing student asks why it is helpful to understand Piaget's theory of cognitive development. Which of the following reponse by the nurse is correct?
Adult Hypertension
The provider orders an antihypertensive medication for a client whose blood pressure is 205/110 mm Hg. The nurse reviews the medication administration record and sees an order for which of the following blood pressure medications?
Adult Viral Infection
The nurse is providing first-dose medication teaching to a client who is about to begin taking an antiviral medication. The nurse teaches the client that this type of medication is most likely to affect all of the following body systems except which?
Adult Lab Values
"A nurse is checking laboratory results for a client with TPN and lipids and notes the following: Sodium: 138 mEg/L Potassium: 4.1 mEg/L Calcium: 10.1 mg/dL Albumin: 5.4 g/dL Triglycerides: 426 mg/dL Alkaline Phosphatase: 100 IU/L Based on these laboratory results, which of the following actions is most appropriate?"
Adult Dysuria
The nurse is performing an admission assessment on a client who states she has had trouble urinating ever since starting a new medication. The nurse reviews the client's medication list and suspects which of the following medications as a potential cause?
Adult Asthma Exacerbation
A nurse in the Emergency Department is admitting a client with an asthma exacerbation, headache, and fever of 101.4 F. Which of the following medication orders should the nurse question?
Adult Hypertension
Calcium channel blockers reduce high blood pressure by which of the following mechanisms?
Adult IV Fluids
The nurse is caring for a client who requires fluids for hydration. The client needs an isotonic solution to which potassium can be added. Which of the following solutions would the nurse expect to give?
Adult Migraines
A nurse is caring for a client receiving metoprolol for migraines as an off-label treatment. Which of the following would be the most important for the nurse to monitor?
Adult PVD
The nurse questions an order for beta-blocker in a client with peripheral vascular disease for which of the following reasons?
Adult HPV
A nurse is providing discharge education to a client with human papilloma virus (HPV). The nurse know that the client has a good understanding when which of the following statements is made?
Adult Opioid OD
The nurse is caring for a client who requires large amounts of opiods for pain control. The nurse will be most concerned about monitoring for which side effect?
Adult Cardiac Medication
The client is able to drink grapefruit juice with which of the following medications?
Adult Patient Cellulitis
The nurse is preparing to administer the first dose of clindamycin to a client with cellulitis. The nurse notes a client history of recurrent clostridium difficile, and confirms that the client has had this condition several times in the past 6 months. Which of the following actions by the nurse is correct?
Adult Nstemi
A client presents to the emergency department with complaints of chest pain. The EKG shows normal sinus rhythm, but the client's troponin comes back at 3.4 ng/mL. The nurse knows this client is most likely experiencing an N-STEMI and prepares which medication to give to the client?
Adult Patient Infections
The nurse is reviewing assigned clients. The nurse recognizes that each client will require antiviral medication for their medical condition except the client with which illness?
Adult Patient CHF Exacerbation
"Calcium channel blockers reduce high blood pressure by which of the following mechanisms? "
Reduction of Risk Potential NCLEX Questions
Adult Assessment
A nurse auscultates a client's heart sounds during an initial assessment. The nurse listens to sounds at the angle of Louis on the client's chest. Which best describes this location?
Adult Fall Risk
While admitting a client, the nurse has determined the client is a fall risk. What is a priority nursing intervention?
Adult Osteoporosis
A home care nurse is working with a client who has osteoporosis. Which guideline for home safety would be most appropriate in preventing fractures in this client?
Adult AIDS
A nurse is caring for a client with AIDS. The client informs the nurse about the cilent's use of acupuncture to help with the pain. The nurse should be most concerned about this practice due to which of the following factors?
Peds Surgery
A 4-year-old child requires surgery for an injury to her hand. The surgeon is considering using regional anesthesia for the procedure instead of general anesthesia. Which of the following best describes a disadvantage of using regional anesthesia in this situation
Adult Nephrotoxicity
A client receiving medication as an anti-infective starts showing signs of nephrotoxicity. The nurse knows that which of the following are signs of nephrotoxicity?
Basic Care and Comfort NCLEX Questions
Type of Crutches Necessary for a Paraplegic
A child was injured in an accident and has become a paraplegic. The child must use crutches on a permanent basis, most likely for the rest of his life. Which type of crutches would most commonly be used in this situation?
Adult Patient Gastrostomy Tube
A nurse is preparing to administer the next enteral feeding to a client with a gastrostomy tube. The client complains of nausea. The nurse checks for residual before starting the feeding and returns 200 mL. Which of the following actions of the nurse is most appropriate?
Breathing Difficulties - Scleroderma
A 36-year-old patient has been diagnosed with scleroderma and has breathing difficulties, including wheezing and dry cough. Which of the following skin changes would the nurse also expect to see upon assessment of this patient?
Hypokalemia and Cardiac Arrhythmias
A patient who has been suffering from severe diarrhea has developed hypokalemia and cardiac arrhythmias as a result. Which of the following treatments would most likely be ordered for this patient to correct the situation?
Adult Chest Tube
The nurse is caring for a client with a chest tube. The nurse will refrain from calmping the chest tube because which of the following could happen?
Impaired Physical Mobility
A nurse is teaching a client who has trouble with mobility about how best to decrease the risk of a blood clot. Which of the following statements made by the nurse is correct?
Use of a Nosey Cup in a Stroke Patient
A nurse is caring for an 80-year-old client who is in rehabilitation after having a stroke. The nurse is teaching the client about how to use a nosey cup. Which of the following best describes this device?
Spinal Cord Stimulation
A patient asks the nurse about spinal cord stimulation as a method of pain control. Which of the following describes an element of this type of pain management?
Contractures - Huntington's Disease
A 78-year-old patient with Huntington's disease has developed contractures from muscle atrophy. The nurse is reviewing his information after he has been admitted to the long-term care facility. Which best describes an appropriate outcome for this patient?
Patient with Myasthenia Gravis
The nurse helping a 47 year old female patient with getting up in the morning and peforming activities of daily living. The patient was diagonsed with Myasthenia Gravis 6 years ago. Which of the following would the nurse most likely expect the patient to find difficult because of this diagnosis?
Dyspnea
Chronic Dyspnea occurs as difficulty breathing develops over periods of weeks or months. Which of the following example of cause of Chronic Dyspnea?
Dysphagia in a Stroke Patient
A nurse is caring for a patient who is recovering from a stroke. The nurse arranges for a swallowing screening to be performed on this patient. Which best describes the purpose of this test?
Skin Breakdown after Bruising
A patient has suffered a bruise on her elbow from being assisted in bed for repositioning. Which best describes how the nurse can prevent this injury from becoming a point of skin breakdown?
DVT Prevention
A nurse is preparing to apply thigh-high anti-embolism stockings to a patient with a history of DVT. The nurse notes that the patients legs have different measurements. Which response from the nurse is appropriate?
Relaxation Therapy for Pain Management
A nurse who is caring for a patient with chronic pain and recommends the patient undergoes relaxation therapy as part of pain management. How would relaxation therapy work in this situation?
Palliative Care for and Oncology Patient
A palliative care nurse is counseling a patient who is suffering from cancer. Which statement by the patient indicates that more education is needed about the treatment he receives through palliative care?
Palliative Care in Respiratory Patient
A patient with lung disease has decided to receive palliative care at home. The patient does not want his mother to be nearby while he is recovering, even though his wife has asked him to reconsider. Which response from the nurse would best support this patients choice?
Calorie Counting for Weight Loss
A physician has ordered calorie counts for a patient who needs to lose weight. Which best describes how the nurse would instruct the client in this process?
BMI in an Overweight Patient
A 41-year-old patient is being seen at the primary care clinic for a physical exam. The patient is overweight and wants to talk to the nurse about losing weight. Choose the alternative that best explains the calculation of BMI.
Heart Failure and Sodium Intake
A patient with heart failure has been ordered to reduce her sodium intake in order to better control her condition. Which best explains why reduction in sodium intake will affect symptoms of heart failure?
Nutrition and Alzheimer's Disease
A patient with Alzheimer's Disease has had difficulties eating and is not getting enough nurtrients in his diet. The patients daughter asks the nurse if there is anything that can be done to improve his nurtition intake. Which recommendation should the nurse give?
Treatment for Urinary Incontinence
A 76-year-old patient has urinary incontinence diagnosed because of instability of the detrusor muscle. Which of the following describes a form of management of this type of incontinence? Select all that apply.
Cardiac Complications Caused by Immobility
A nurse is caring for a patient who has been immobile for the past three weeks while recovering from surgery. The patient has been deteriorating in health because of his lack of activity. Based on the nurse's knowledge of the effects of immobility, which describes the cardiovascular complications that can develop because of immobility? Select all that apply.
Intervention for Pressure Ulcer
A nurse is working with a client who has been confined to his bed for the past week because of illness. While turning this patient, the nurse notes a stage II pressure ulcer on his sacrum. Which action is most appropriate in responding to this finding? Select all that apply.
Prone Position in ARDS
A nurse must position the patient prone after his diagnosis of acute respiratory distress syndrome (ARDS). Which of the following is a benefit of using this position? Select all that apply.
TENS Device and Back Pain
A nurse is using a TENS device to help a patient with his low back pain. Which of the following considerations should the nurse keep in mind when using this type of device? Select all that apply.
Full Liquid Diet after Surgery
A patient who is recovering from surgery has been ordered to have a full liquid diet. Which foods would the nurse provide for this patient that would be consistent with this diet? Select all that apply.
Adult Patient, PEA/Asystole
A nurse is caring for a client with pulseless electrical activity (PEA/asystole). The nurse knows that according to the PEA/asystole algorithm, which of the following actions are expected?
Adult Testicular Cancer
The clinic nurse is performing an assessment on a 35-year-old male client who presents to the clinic with a painless testicular lump and pain in the pelvis. The nurse carefully assesses the client's lungs and asks if the client has had any trouble breathing. Which of the following explains the actions of the nurse?
Adult Chest Tube
A nurse has just received report on 4 clients who all have chest tubes in place. Which client is the priority to see first?
Dysphagia in a Stroke Patient
A nurse is caring for a patient who is recovering from a stroke and who has difficulties swallowing. The patient must have all liquids thickened to a nectar consistency. Which of the following is a true statement regarding this consistency of liquids? Select all that apply.
Activities of Daily Living
A nurse is assessing a patient who is being admitted to the long-term care facility where she works. The nurse is utilizing the Katz Index of Independence in Activities of Daily Living. Which activities would the nurse assess for when considering activities of daily living? Select all that apply.
Pain Management in an Oncology Patient
A patient who is dying of cancer tells the nurse that he is in extreme pain. Which of the following principles should the nurse adhere to when managing pain in a dying patient? Select all that apply.
Role of Palliative Care
The family member of a patent with lung cancer has asked the nurse about palliative care for the patient. Which describes when palliative care is appropriate for a patient? Select all that apply.
Chronic Pain in Multiple Sclerosis
A patient with chronic pain as a result of multiple sclerosis has requested music therapy for help with pain management. Which of the following describes music therapy for pain control? Select all that apply.
Nociceptive Pain
A patient has come to the healthcare clinic complaining of pain in his left arm after an injury. Which describes the characteristics of nociceptive pain? Select all that apply.
Mobility and Blood Clots
A nurse is teaching a client who has trouble with mobility about how best to decrease the risk of a blood clot. Which of the following statements made by the nurse is correct?
Pain Control After Surgery
A nurse is caring for a patient who is recovering from surgery and is in pain at the incision site. The nurse has administered some medications to help control the patients pain, but she holds off from administering more because she does not want the patients respiratory rate to drop. Which is another example of a reason why some nurses fail to utilize appropriate pain management techniques when caring for a patient in pain?
Visual Impairment
A nurse is caring for a patient who is visually impaired. Which of the following interventions is most appropriate when working with this client?
Cataplexy and Sleeping Disorders
Which sleep disorder is associated with cataplexy?
Prosthesis in amputation patient
A patient with a hand deformity requires a prosthesis following a surgical procedure. Which factor would be considered that would best help determine the type of prosthesis needed.
Communication - Patient with Hearing Loss
A nurse is caring for a patient with hearing loss who has forgotten his hearing aids at home. Which method of communication would the nurse most likely use to communicate with this patient?
Urinary Incontinence in Spinal Cord Injury
A patient with a spinal cord injury has difficulty determining when he needs to empty his bladder. The nurse teaches him about tapping to stimulate voiding. How would the nurse describe tapping to this patient?
Stress Incontinence
A patient with stress incontinence is undergoing treatment through rehabilitation of the pelvic floor muscles. Which statement by the patient suggests that he is responding to the treatment?
Skin Breakdown Related to Immobility
A nurse is caring for a patient with reduced mobility following hip surgery. Which best describes how the nurse would intervene to prevent skin breakdown from immobility?
Nutrition and COPD
A nurse is reviewing the principles of good nutrition with a patient with COPD to support his overall health. Which of the following suggestions regarding patient nutrition would most likely support the health of a patient with COPD?
Lab Values in a Patient with Dehydration
A nurse is caring for a client who is at high risk of dehydration. Which parameter would the nurse use for assessment if this patient were to become dehydrated?
Irrigation of NG Tube
A nurse is preparing to irrigate a patients nasogastric tube. She has assessed the patients abdomen and determined that the tip of the tube is located in the stomach. After drawing up 30 mL of normal saline into a syringe, the nurse prepares for the next step. Which best describes the next step in this process?
Tumors and Sleep
A 37-year-old patient with a spinal tumor has been having a difficult time sleeping. Which best explains how a tumor can make sleep more difficult for a patient with cancer?
Ambulation After Knee Surgery
A 16-year-old patient needs to get up to ambulate after having knee surgery. A nurse assigns a nursing assistant to ambulate the patient. Which of the following should the nurse consider when delegating this task to the nursing assistant?
Diagnosis of Sleep Apnea
A patient tells the nurse that she is afraid that she has sleep apnea. She says that she does not feel rested in the morning and that she snores. Her husband says that he notices that she seems to stop breathing on several occasions during the night. The client asks the nurse how sleep apnea is diagnosed. Which answer from the nurse is correct?
Narcolepsy in a Traumatic Brain Injury
A patient who suffered a traumatic brain injury last year has developed narcolepsy and excessive daytime sleepiness. Which of the following side effects of this condition should the nurse most likely expect to see in this patient?
Breathing Difficulties - Spinal Cord Injury
A 36-year-old male patient is being seen in the emergency department after a spinal injury; the patient states that he cannot feel anything below the level of his shoulders. Which point best describes the time that the patient would need to be intubated with an endotracheal tube?
Diabetic Peripheral Neuropathy
A 59-year-old patient is suffering from severe pain, numbness, and tingling in the lower legs as a result of diabetic peripheral neuropathy. Which type of non-pharmacological intervention would be most appropriate for pain management in this patient.
Dysphagia in a Patient with ALS
A 38-year-old patient has been diagnosed with amyotrophic lateral schlerosis (ALS) and subsequently has developed breathing difficulties including shortness of breath and an inability to cough. Which best descrbes a nutritional challenge associated with this?
General Adaptation Syndrome
Which of the following descriptions best defines general adaptation syndrome?
Comforting a Preschool-Age Child
Which of the following is an example of a non-pharmacological comfort measure that may be developmentally appropriate for a preschool-age child? Select all that apply.
Health Promotion and Maintenance NCLEX Questions
Adult prostate exam
The nurse is preparing a male client who is about to have a digital rectal exam to check the prostate. The nurse asks the client if the lab has drawn a blood sample yet. What is the reason for the nurse to ask about a blood draw at this time?
Pediatric developmental milestone
The nurse enters the clinic room and observes the mother of a 2-week-old holding a rattle in front of the neonate's face. The neonate is looking at the rattle. The nurse recognizes that this neonate is in which of the following behavioral states?
Neonate Developmental Milestones
The nurse enters the clinic room and observes the mother of a 2-week-old holding a rattle in front of the neonate's face. The neonate is looking at the rattle. The nurse recognizes that this neonate is in which of the following behavioral states?
Adult Thyroid
Which best describes how pregnancy affects thyroid function?
Nurse Practice Act
A nurse is reviewing the nurse practice. The nurse understands that the concept of being responsible and answerable for one's own behavior is known as which of the following?
Adult Guillain Barre
While preparing to give a bed bath to a client with Guillain-Barre syndrome, the nurse knows that this client will likely have which of the following deficits?
Peds Growth and Development
The nurse is assessing for environmental influences on growth and development of a pediatric client. The nurse recognizes that which of the following is NOT an environmental influence?
Acromegaly and Pituitary Gland Tumor
An 18-year-old patient is seen at the healthcare center with swelling of the hands and face. The patient is diagnosed with acromegaly. The nurse knows that this condition is typically caused by?
Tantrums in a 3-year-old
A family with a 3 1/2 year old child comes in to the clinic for a well-child visit. The parents tell the nurse that their child often has tantrums, even though they try to ignore the behavior. Select all of the following appropriate information that the nurse should provide as education to the family about potential causes of tantrums in children this age.
Method of Change
A patient has admitted to the nurse that he thinks he has a problem with drinking too much alcohol. The nurse talks with the patient about substance abuse and the negative effects of alcoholism. Which describes how personal engagement with a patient is effective as a method of change.
Blood Pressure / Pulse on Cardiogenic Shock
A nurse is performing an initial exam on a patient who presents for care of acute coronary syndrome. The patient is in cardiogenic shock and the physician has placed a central line. During the physical assessment, which sign or symptom would the nurse most likely expect to see?
Impaired Infant/Child Attachment
A nurse is working with a family that has adopted a child from another country. The family has difficulty getting the child to listen to instructions or interact with family members at all. The nurse has given this a nursing diagnosis of Risk for Impaired Infant/Child Attachment. Which of the following interventions are appropriate for this diagnosis. Select all that apply.
Risk Factors for Pancreatic Cancer
A 48-year-old patient has been diagnosed with pancreatic cancer. The patient talks to the nurse about his diagnosis and says, How could this have happened to me? Which of the following has been shown to be a risk factor for the development of pancreatic cancer? Select all that apply.
Hypovolemic Shock and Proper Position
A nurse is caring for a 35-year-old patient who has been diagnosed with hypovolemic shock as a result of severe hemorrhage. In which position should the nurse place this patient to promote optimal circulation.
Social Isolation
A nurse believes that the 71-year-old widow she is working with is at risk of social isolation. Which of the following behaviors would this client most likely demonstrate with a nursing diagnosis of Social Isolation? Select all that apply.
Self-Care Deficit in a Stroke Patient
A 66-year=old patient who is recovering from a stroke has developed a self-care deficit related to dressing and grooming. Select all of the following appropriate outcomes for this nursing diagnosis.
Preventing Coronary Artery Disease
A 40-year-old patient is being seen for a health check-up and the nurse is providing information to him about prevention of coronary artery disease. Which best describes an appropriate goal for this patient that would be applied after teaching?
Prevention of Anaphylactic Shock
A nurse is teaching a patient about self-care at home after he has experienced an anaphylactic reaction to shellfish. For future reference for the patient, after exposure to shellfish, in order to best manage an allergic reaction and prevent anaphylactic shock, the nurse should counsel the patient to do what as an initial intervention?
Nerve Damage From Continuous Vibration
A 61-year-old patient is being treated in the care clinic. The patient has been a school bus driver for 40 years and is asking the nurse about work-related injuries. Which symptoms would most likely develop in a person who works in conditions in which continuous vibration are present?
Compensated vs Decompensated Shock
A child is brought to the hospital for care after falling down some stairs and is in a state of neurogenic shock. The nurse performs an initial assessment on the patient. Which parameter best identifies whether the patient is in a state of compensated or decompensated shock?
Musculoskeletal Symptoms in Pregnancy
A patient who is 16 weeks' pregnant is at the healthcare provider's office for a routine prenatal exam. The nurse is educating the patient about pregnancy-related body changes that will most likely occur in the next several months. Which best describes a condition that affects the musculoskeletal system that occurs during pregnancy?
Exercise and Aging
A 67-year-old patient complains to the nurse that while he used to run long distances and participate in marathons, he no longer has the stamina to run very far. Select all of the following that are associated with changes in exercise tolerance as a result of aging.
Stress Reduction in Pregnancy
A nurse is caring for a 35-year-old patient who has been diagnosed with hypovolemic shock as a result of severe hemorrhage. In which position should the nurse place this patient to promote optimal circulation.
Position to assess Posterior Lung Sounds
A nurse needs to assess a patients back and listen to posterior lung sounds. In which position would it be most appropriate to place this patient?
Cardiac Changes Related to Aging
An 80-year-old patient is being seen at the primary care clinic for routine care. The nurse performs a physical assessment on the patient. Based on the potential changes in the cardiac system associated with aging, which instructions would the nurse most likely give to this patient?
Hypothermia in an Infant
A nurse working in the newborn nursery is caring for an infant who was born 3 hours ago. The infant's axillary temperature is 97.0F and the nurse notes that his respiratory rate is 60/minute. Which action of the nurse is most appropriate?
Assessment of Pain
A nurse is caring for a 15-year-old girl who is recovering from an appendectomy. The nurse is trying to assess the patients level of pain. Which question from the nurse would be most appropriate for determining the intensity of pain the patient is experiencing?
Adult Patient, PEA/Asystole
A nurse is caring for a client with pulseless electrical activity (PEA/asystole). The nurse knows that according to the PEA/asystole algorithm, which of the following actions are expected?
Adult Testicular Cancer
The clinic nurse is performing an assessment on a 35-year-old male client who presents to the clinic with a painless testicular lump and pain in the pelvis. The nurse carefully assesses the client's lungs and asks if the client has had any trouble breathing. Which of the following explains the actions of the nurse?
Adult Chest Tube
A nurse has just received report on 4 clients who all have chest tubes in place. Which client is the priority to see first?
Complications of Gestational Diabetes
A pregnant client is in labor to deliver her baby. The mother is 39 weeks' gestation and has had gestational diabetes during pregnancy. The mother has missed many prenatal appointments and admits that she has not checked her blood glucose levels or controlled her diet well, despite her diagnosis. Which of the following are risks to the infant as a result of uncontrolled gestational diabetes? Select all that apply.
Dehydration in the Elderly
An 86-year-old male patient is transferred from the long-term care facility where he lives to the hospital for treatment after falling in the hallway. The staff tell the nurse that he normally is not a fall risk and has been healthy and active, with little to no cognitive impairments. Upon admission, the patients laboratory workup indicates that he is severely dehydrated. Which of the following manifestations of dehydration would more likely develop in an older adult? Select all that apply.
Heart Sounds
A nurse is performing an initial assessment on a 35-year-old patient with heart disease. The nurse hears a systolic click, which sounds like a high-pitched sound during the late part of systole. The systolic click heard on auscultation most likely indicates:
Hemoglobin A1c and Diabetes
A nurse is working with a patient who is being tested for diabetes. The physician has ordered a hemoglobin A1C test and the nurse checks the results. The patient asks, "What is the homoglobin A1C test?" Which response from the nurse is correct?
Blended Families
A nurse is working at a family care clinic in the community. The nurse sees many different tyes of family structuresamong the patients who come into the clinic. Select the followng aspects associated with blended families.
Authoritarian Parenting Style
A nurse is caring for a family when she notes that the parents have an authoritarian parenting style. Which of the following aspects are associated with this tye of parenting? Select all that apply.
Dehydration in an Athlete
A 19-year-old college student is seen in the university heallth clinic for symptoms of dehydration and weight loss.The patient is a member of the university's track team and spends several hours a day training. Which information should the nurse give to this patient to prevent dehydration associated with excessive exercise.
Palpation
A nurse is palpating a patient's abdomen to check for an abdominal aordic aneurysm during a physical assessment. Which part of the hand would the nurse most likely use to palpate for this finding?
Palpation and Percussion of Abdomen
Which best describes the order in which the nurse should assess a patient's abdomen?
Precontemplation
A nurse is talking with a patient who is a smoker; the nurse wants to provide some information to the patient about quitting smoking for his health. Which situation would describe the patient as being in the pre-contemplation phase of change?
Peds Transitioning to Adult Care - Asthma
The clinic nurse is assessing a 17-year-old client’s management of asthma. The nurse notes that the client is NOT ready to transition out of pediatric care and into adult care based on which of the following?
Management of Care NCLEX Questions
Adult Renal Angiogram
A nurse is caring for a client who is scheduled for a renal angiogram. Which of the following items is appropriate to teach the client regarding this procedure?
Adult MI Signs
A nurse assistant tells the nurse that four of the clients had complaints when morning vitals were being done. Of the following four client complaints, which is the priority for the nurse to see first?
Adult Bradycardia
A student nurse is observing a client's heart rate and notices a regular rhythm, heart rate of 45, 1 p wave followed by 1 QRS, PR interval of 0.16 seconds and a QRS comlpex of 0.06 seconds. The student nurse identifies this rhythm as which of the following?
Adult Hearing Loss
A nurse is caring for a client who needs an MRI for a back injury. The client is deaf. The nurse has provided written information for the client but needs to find out if there are any questions. In which way would the nurse most likely act as the client's advocate?
Peds Growth and Development
A nurse assessing a four-year-old's language development knows to be concerned by which one of the following assessment findings?
Adult Heart Failure
The nurse is caring for a client who is suffering from heart failure. The client has been experiencing weight gain and peripheral edema. Which of the following interventions should the nurse employ?
Adult Esophageal Varices
A nurse is caring for a client just admitted with esophageal varices. Which of the following nursing interventions is the highest priority?
Neonate APGAR
A baby is born and at 1 minute the baby has blue hands and feet, is actively crying and moving his extremeties. The heart rate us 110 and he is pulling away stimulus. What is the APGAR score?
Adult HIPAA
A client is being admitted to the hospital for medical care upon admission, he signs a general release of medical information. Which of the following entities can receive client information from signing this release?
Adult Liver Biopsy
A nurse is caring for a client who just had a liver biopsy due to a history of cirrhosis. Which of the following is a priority nursing intervention for this patient?
Implementing Evidence-Based Practice
A nurse who works as a manager on a general medical unit has implemented a new policy about using a standard of care developed by her recent research as part of evidence-based practice. Which action best demonstrates that the nurse is appropriately evaluating the impact of this implementation on the nursing unit?
Privacy and Confidentiality
A nurse is helping to admit a patient to the nursing unit of a hospital. The nurse gives the patient some written information about his rights to privacy while he is in the hospital. Which statement by the patient indicates that more teaching is needed in this area?
Adult Heart Block
The nurse receives report on an adult client with pneumonia. During report the nurse notes that the client has a new-onset heart block on the EKG (prior EKGs showed normal sinus rhythm) and has been running a temperature. Which vital sign is the most important to monitor for this client?
Adult SBAR
After the nurse gives assessment findings on a client to the provider, the nurse lets the provider know it would be prudent to come evaluate the client. What part of SBAR communication is this?
Safety and Infection Control NCLEX Questions
Adult TB
While caring for a client who is recovering from surgery, the nurse finds out that the client is infected with active tuberculosis. Prior to this discovery, the nurse had only been using standards precautions. Which action of the nurse is most appropriate for providing proper precautions in this situation?
Adult Organ Rejection
A client has had a kidney transplant and develops acute organ rejection approximately one month after the surgery. Based on the nurse's knowledge of transplant rejection, the nurse knows the client will most likely exhibit which of the following symptoms?
Peds Neutropenia
The charge nurse on a pedriatric ward is making assignments for the shift. One of the clients admitted to the ward is a five-year-old with severe neutropenia and a fever. Which of the following clients would be most appropriate to assign with this client?
Adult Liver Biopsy
A nurse is caring for a client who just had a liver biopsy due to a history of cirrhosis. Which of the following is a priority nursing intervention for this patient?
Implementing Evidence-Based Practice
A nurse who works as a manager on a general medical unit has implemented a new policy about using a standard of care developed by her recent research as part of evidence-based practice. Which action best demonstrates that the nurse is appropriately evaluating the impact of this implementation on the nursing unit?
Privacy and Confidentiality
A nurse is helping to admit a patient to the nursing unit of a hospital. The nurse gives the patient some written information about his rights to provacy while he is in the hospital. Which statement by the patient indicates that more teaching is needed in this area?