NCLEX NCLEX-RN - National Council Licensure Examination(NCLEX-RN)
A client was admitted to the hospital for a TURP. Within 48 hours of admission and 12 hours postoperatively, both the blood pressure and pulse increased. He became agitated, thought snakes were crawling on his arms and legs, and generally became unmanageable. He pulled out his IV and urinary catheter in attempt to rid himself of the snakes. He was sweating profusely. The admission nurse’s notes indicated that the client admitted to “having a few drinks now and then.†He is probably experiencing which of the following?
A client takes warfarin (Coumadin) 15 mg po daily. To evaluate the medication’s effectiveness, the nurse should monitor the:
A 58-year-old client on a general surgery unit is scheduled for transurethral resection of the prostate (TURP) in 2 hours. The nurse explains to the client that this procedure means:
Prior to administering digoxin to a client with congestive heart failure, the nurse needs to assess:
Primary nursing diagnoses for the antisocial client are:
A 74-year-old client seen in the emergency room is exhibiting signs of delirium. His family states that he has not slept, eaten, or taken fluids for the past 24 hours. The planning of nursing care for a delirious client is based on which of the following premises?
A 71-year-old client fell and injured her left leg while cooking in the kitchen. Her husband calls the ambulance, and she is taken to the emergency department at a local hospital. X-ray reports confirm that she has an intertrochanteric fracture of the left femur. Her left leg will require skeletal traction initially and then surgery. The nurse knows that this type of traction will be used:
The 4th of July holiday comes while a client is in the hospital being treated for schizophrenia. She is taking chlorpromazine and has improved to the point of being allowed to go with a group to the park for a picnic. The side effect of chlorpromazine that the nurse needs to keep in mind during this outing is:
A 1000-mL dose of lactated Ringer’s solution is to be infused in 8 hours. The drop factor for the tubing is 10 gtt/mL. How many drops per minute should the nurse administer?
The nurse should facilitate bonding during the postpartum period. What should the nurse expect to observe in the taking-hold phase?
The nurse instructs a client on the difference between true labor and false labor. The nurse explains, “In true labor:
A 40-year-old client is admitted to the hospital for tests to diagnose cancer. Since his admission, he has become dependent and demanding to the nursing staff. The nurse identifies this behavior as which defense mechanism?
A client experiencing delusions states, “I came here because there were people surrounding my house that wanted to take me away and use my body for science.†The best response by the nurse would be:
A 55-year-old man has recently been diagnosed with hypertension. His physician orders a low-sodium diet for him. When he asks, “What does salt have to do with high blood pressure?’’ the nurse’s initial response would be:
A client has a chest tube placed in his left pleural space to re-expand his collapsed lung. In a closed-chest drainage system, the purpose of the water seal is to:
After an infant is delivered by cesarean delivery and placed on the warmer, the RN dries and assesses the infant. At 1 and 5 minutes after birth, the RN does the Apgar scoring of the infant. The RN knows that because this infant was delivered by cesarean section, he is at increased risk for having which one of the following:
A client has consented to have a central venous catheter placed. The best position in which to place the client is the Trendelenburg position. The reason is that the Trendelenburg position:
A nurse is performing a vaginal exam on a client in active
labor. An important landmark to assess during labor
and delivery are the ischial spines because:
A male client has been hospitalized with congestive heart failure. Medical management of heart failure focuses on improving myocardial contractility. This can be achieved by administering:
A client is diagnosed with organic brain disorder. The nursing care should include:
