NCLEX NCLEX-RN - National Council Licensure Examination(NCLEX-RN)
A 5-year-old child has suffered second-degree thermal burns over 30% of her body. Forty-eight hours after the burn injury, the nurse must begin to monitor the child for which one of the following complications?
Assessment of parturient reveals the following: cervical dilation 6 cm and station 22; no progress in the last 4 hours. Uterine contractions decreasing in frequency and intensity. Marked molding of the presenting fetal head is described. The physician orders, “Begin oxytocin induction at 1 mU/min.†The nurse should:
A client is taught to eat foods high in potassium. Which food choices would indicate that this teaching has been successful?
The nurse would be concerned if a client exhibited which of the following symptoms during her postpartum stay?
Nursing interventions designed to decrease the risk of infection in a client with an indwelling catheter include:
A pregnant client comes to the office for her first prenatal examination at 10 weeks. She has been pregnant twice before; the first delivery produced a viable baby girl at 39 weeks 3 years ago; the second pregnancy produced a viable baby boy at 36 weeks 2 years ago. Both children are living and well. Using the gravida and para system to record the client’s obstetrical history, the nurse should record:
MgSO4 blood levels are monitored and the nurse would be prepared to administer the following antidote for MgSO4 side effects or toxicity:
A six-month-old infant is receiving ribavirin for the treatment of respiratory syncytial virus. Ribavirin is administered via which one of the following routes?
A nurse should carefully monitor a client for the following side effect of MgSO4:
In performing the initial nursing assessment on a client at the prenatal clinic, the nurse will know that which of the following alterations is abnormal during pregnancy?
A 30-year-old client has just been treated in the ER for bruises and abrasions to her face and a broken arm from domestic violence, which has been increasing in frequency and intensity over the last few months. The nurse assesses her as being very anxious, fearful, bewildered, and feeling helpless as she states, “I don’t know what to do, I’m afraid to go home.†The best response by the nurse to the client would be:
A baby who was diagnosed with pyloric stenosis has continued to have projectile vomiting. With prolonged vomiting, the infant is prone to:
A client is hyperactive and not sleeping. She will not remain at the table during mealtime. She is getting very limited calories and is using a lot of energy in her hyperactive state. The most therapeutic nursing action is to:
A 4-year-old child with a history of sickle cell anemia is admitted to the nursing unit with dizziness, shortness of breath, and pallor. Nursing assessment findings reveal tenderness in the abdomen. The child is most likely experiencing a/an:
A client’s transfusion of packed red blood cells has been infusing for 2 hours. She is complaining of a raised, itchy rash and shortness of breath. She is wheezing, anxious, and very restless. The nurse knows these assessment findings are congruent with:
In working with a manipulative client, which of the following nursing interventions would be most appropriate?
A 55-year-old client is admitted with a diagnosis of renal calculi. He presented with severe right flank pain, nausea, and vomiting. The most important nursing action for him at this time is:
A 27-year-old primigravida at 32 weeks’ gestation has been diagnosed with complete placenta previa. Conservative management including bed rest is the proper medical management. The goal for fetal survival is based on fetal lung maturity. The test used to determine fetal lung maturity is:
A 42-year-old client presents with a diagnosis of paranoid schizophrenia. She has become increasingly restless and verbally argumentative, and her speech has become pressured. She is exhibiting signs of:
A client is going to have a pneumonectomy in the morning. She had a previous negative surgical experience, is talking rapidly, and has an increased pulse and respiratory rate. Nursing interventions for this client should include:
