a nurse is assigned to care for a client with chro
a nurse of the telemetry unit is caring for a clie
a nurse developing a plan of care for a client wit
Written for
NGN NCLEX /NCLEX NGN RN
NGN NCLEX /NCLEX NGN RN
1
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NCLEX
NGN
Pre-Test
Questions
A
nurse
is
assigned
to
care
for
a
client
with
chronic
renal
failure
who
is
undergoing
hemodialysis
through
an
internal
AV
fistula
in
the
RA.
Which
intervention
should
the
nurse
implement
in
caring
for
the
client?
SATA
a.
Assessing
the
radial
pulse
in
the
right
extremity
b.
Using
the
LA
ti
take
BP
readings
c.
Drawing
pre-dialysis
blood
specimens
from
the
LA
d.
Assessing
the
area
over
the
AV
fistula
for
a
bruit
and
three
each
shift
e.
Placing
a
pressure
dressing
over
the
site
after
each
dialysis
treatment
f.
Administering
IV
fluids
through
the
venous
site
of
the
AV
fistula
as
needed
-
ANSA,
B,
C,
D
A
nurse
is
evaluating
outcomes
for
a
client
with
Guillain-Barre
syndrome.
Which
outcome
does
the
nurse
recognize
as
optimal
respiratory
outcomes
for
the
client?
a.
Normal
deep
tendon
reflexes
b.
Improved
skeletal
muscle
tone
c.
Absences
of
paresthesias
in
the
lower
extremities
d.
Clear
sound
in
the
lower
lung
fields
bilaterally
e.
pO2
of
85
mmHg
and
pCO2
of
40
mmHg
-
ANSD,
E
A
nurse
of
the
telemetry
unit
is
caring
for
a
client
who
has
had
a
MI
and
is
now
attached
to
a
cardiac
monitor.
The
nurse
is
monitoring
the
client's
cardiac
rhythm
and
nots
ventricular
fibrillation.
Which
nursing
intervention
should
the
nurse
take
first?
a.
Calling
the
rapid
response
team
b.
Preparing
the
client
for
cardioversion
c.
Asking
the
client
to
bear
down
and
cough
d.
Preparing
to
administer
diltiazem
-
ANSA
The
pattern
of
ventricular
fibrillation
is
identified
and
can
be
a
result
after
a
patient
with
an
MI.
VF
makes
the
patient
feel
faint,
then
loses
consciousness
and
becomes
pulseless
and
apneic
(BP
and
heart
sounds
absent).
Treatment
is
to
terminate
VF
and
covert
it
into
a
rhythm
via
defibrillation->
call
a
rapid
and
initiate
CPR.
Cardioversion
is
used
for
ventricular
or
supraventricular
tachydysrhythmias.
A
nurse
developing
a
plan
of
care
for
a
client
with
a
spinal
cord
injury
includes
measures
to
prevent
autonomic
dysreflexia
(hyperreflexia).
Which
intervention
does
the
nurse
incorporate
into
the
plan
to
prevent
this
complication?
a.
Keeping
the
fan
running
in
the
client's
room
b.
Keeping
the
linens
wrinkle
free
under
the
client
c.
Limiting
bladder
catheterization
to
once
every
12
hours
d.
Avoiding
the
administration
of
enemas
and
rectal
suppositories
-
ANSB The
most
frequent
cause
of
autonomic
dysreflexias
are
a
distended
bladder
and
impacted
feces.
Other
causes
include
stimulation
of
the
skin
by
tactile,
thermal,
or
painful
stimuli.
The
nurse
renders
care
in
such
a
way
as
to
minimize
these
risks.
A
nurse
provides
home
care
instructions
to
a
client
who
has
been
fitted
with
a
halo
device
to
treat
a
cervical
fracture.
Which
statement
by
the
client
indicates
the
need
for
further
teaching?
a.
I
need
to
get
more
fluids
and
fiber
into
my
diet
b.
I
should
cut
my
food
into
small
pieces
before
I
eat
c.
I
need
to
put
powder
under
the
vest
twice
a
day
to
prevent
sweating
d.
I
have
to
check
the
pin
sites
everyday
and
watch
for
signs
of
infection
-
ANSC
Cleanse
the
skin
under
the
wool
liner
each
day
to
prevent
rashes
and
soars.
A
nurse
is
caring
for
a
client
with
increased
intracranial
pressure.
In
which
position
should
the
nurse
maintain
the
client?
a.
Supine
with
the
head
extended
b.
Side
lying
with
the
neck
flexed
c.
Supine
with
the
head
turned
to
the
side
d.
Head
midline
and
elevated
30-45
degrees
-
ANSD
Proper
positioning
promotes
venous
drainage
from
the
cranium
to
minimize
ICP.
A
client
with
a
basilar
skull
fracture
has
clear
fluid
leaking
from
the
ears.
The
nurse
should
take
which
action
first?
a.
Asses
the
clear
fluid
for
protein
b.
Check
the
clear
fluid
for
glucose
c.
Place
cotton
calls
or
dry
gauze
loosely
in
the
ears
d.
Use
an
otoscope
to
assess
the
tympanic
membrane
for
rupture
-
ANSB
CSF
contains
glucose
not
protein.
A
nurse
is
caring
for
a
client
who
has
just
undergone
cardioversion.
Which
intervention
is
the
nurse's
priority
after
this
procedure.
a.
Administer
oxygen
b.
Monitoring
the
BP
c.
Administering
antidysrhythmic
medications
d.
Monitoring
the
client's
LOC
-
ANSA
ABC's
of
nursing.
All
other
choices
are
correct,
but
not
priority.
A
client
with
diabetes
mellitus
who
is
scheduled
to
have
blood
drawn
for
determination
of
the
glycosylated
hemoglobin
(HbA1c)
level
asks
the
nurse
why
the
test
is
necessary
if
he
is
performing
blood
glucose
monitoring
at
home.
Which
is
the
best
response
for
the
nurse
to
provide?
a.
Detect
diabetic
complications
b.
Assess
long-term
glycemic
control
c.
Determine
whether
the
client
is
at
risk
for
hypoglycemia
d
Determine
whether
the
prescribed
insulin
dosage
is
correct
-
ANSB A
nurse
caring
for
a
client
with
acquired
immunodeficiency
syndrome
is
monitoring
the
client
for
signs
of
complications.
Which
of
the
following
would
cause
the
nurse
to
suspect
infection
with
Pneumocystis
jirovec?
SATA
a.
Diarrhea
b.
Tachypnea
c.
Pedal
edema
d.
Intermittent
fever
e.
Dyspnea
with
ambulating
f.
Expectoration
of
frothy
mucus
-
ANSB,
D,
E
A
opportunistic
respiratory
infection
associated
with
AIDs
that
causes
dyspnea,
nonproductive
cough,
intermittent
fever,
fatigue,
anorexia,
tachypnea,
wt.
loss.
Zidovudine
is
prescribed
for
a
client
with
AIDS.
The
nurse
tells
the
client
that
it
is
important
to
report
back
to
the
clinic
as
scheduled
for
which
follow-up
diagnostic?
a.
Blood
glucose
checks
b.
Blood
pressure
checks
c.
Complete
blood
counts
(CBC)
d.
Electrocradiographic
studies
-
ANSC
Zidovudine
is
an
antiviral
medication
that
cause
cause
agranulocytosis
and
anemia.
After
a
non-immunocompromised
client
undergoes
a
Mantoux
test
for
TB
infection,
an
area
of
induration
6
mm
wide
developed.
The
client
asks
the
nurse
what
this
result
means.
Which
is
the
best
response?
a.
We'll
have
to
repeat
the
test
because
the
result
was
inconclusive
b.
The
swollen
area
is
small,
so
that
means
your
test
result
is
negative
c.
You've
been
exposed
to
TB
so
you
will
need
to
have
a
chest
x-ray
d.
You
need
to
get
started
on
medication
right
away
because
you
have
TB
-
ANSB
Indurations
less
than
10
mm
(non-immunocompromised)
and
5
mm
(immunocompromised)
is
considered
a
negative
result
after
48-72
hrs.
Results
greater
indicate
exposure
and
possible
TB
infection.
Morse
testing
(x-ray)
will
be
needed.
A
clients
arterial
blood
gases
are
analyzed;
pH
1.49,
paO2
97
mmHg,
HCO3-
22
mEq/L.
Which
acid
base
balance
disturbance
does
the
nurse
identify
from
these
results?
a.
Metabolic
acidosis
b.
Metabolic
alkalosis
c.
Respiratory
acidosis
d.
Respiratory
alkalosis
-
ANSD
RAcidosis:
paCo2
>45
mmHg
and
RAlkalosis
is
paCo2
<35
mmHg.
MAcidosis
is
HCO3-
is
less
than
22
mEq/L
and
MAlkalosis
is
HCO3-
greater
than
26
mEq/L.
A
client
has
recently
been
diagnosed
with
deep
vein
thrombosis
of
the
right
leg.
Which
of
the
following
interventions
of
the
nurse
immediately
implement?
a.
Elevating
the
foot
of
the
bed
6
inches
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