NCLEX FILE 2
1. A nurse is auscultating heart sounds of an adult client experiencing dyspnea. The nurse hears a soft,
turbulent sound between beats at the left midclavicular line in the fifth intercostal space. Which of the
following is an appropriate documentation of the findings?
b. Murmur at...
NCLEX FILE 2
1. A nurse is auscultating heart sounds of an adult client experiencing dyspnea. The nurse hears a soft,
turbulent sound between beats at the left midclavicular line in the fifth intercostal space. Which of the
following is an appropriate documentation of the findings?
b. Murmur at the mitral area
2. A nurse is teaching a client who has a newly documented latex allergy. Which of the following
statements by the clients indicates an understanding of the teaching?
c. I will remove bananas from my diet
3. A nurse is obtaining a medical history from a client who has a new diagnosis of type 2 diabetes
mellitus. The nurse should report which of the following conditions is a contraindication for the use of
metformin?
c. Renal insufficiency
4. A nurse is caring for a client who is at 33 weeks of gestation following an amniocentesis.
The nurse should monitor the client for which of the following complications?
a. Contractions -
5. A nurse on a surgical pediatric care unit receives report prior to providing care for a group of clients.
Which of the following clients should the nurse assess first?
d. I will determine which muscles to contract by stopping and starting my stream of urine
6. A nurse is teaching a client how to perform kegel exercises. Which of the following client statements
indicates understanding of the teaching?
I will determine which muscles to contract by stopping and starting my stream of urine
7. A nurse is providing prenatal teaching for a client who is scheduled for an amniocentesis.
Which of the following statements indicates that the client understands the teaching?
b. I should urinate before the test
, 8. A nurse in an emergency department is caring for a client who reports cocaine use 1 hr ago.
Which of the following findings should the nurse expect?
c. Elevated temperature
9. A nurse is assessing the heart sounds of a client who has acute pericarditis. Which of the following
clinical manifestations is an expected finding for this client?
b. Scratchy, high pitched sound upon chest auscultation
10. A nurse is providing dietary teaching to a client who has a new diagnosis of irritable bowel
syndrome. Which of the following recommendations should the nurse include?
b. Consume food high in bran fiber
11. A nurse is admitting an older adult client who is transferring from another facility. The nurse notes
pressure ulcers on the client’s coccyx and abrasions around the wrists. Which of the following actions
should the nurse take to address the suspicions of elder abuse?
b. Privately interview the client about her condition.
12. A nurse is caring for a client following a stroke. The client has right-sided weakness and facial
drooping. Which of the following nursing actions is the priority?
a. Maintain NPO status for client(ABC)
13. A community health nurse is teaching a client who has type 1 diabetes mellitus and is 10 weeks of
gestation about managing diabetes during pregnancy. Which of the following statements by the client
indicates an understanding of the teaching?
b. “I will need to increase my insulin doses later in my pregnancy”
14. A home health nurse is preparing to assess a client who reports tingling around the mouth and
laxative use at least once daily. Which of the following assessments should the nurse perform first?
a. Test the client for Trousseau’s sign
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