NCLEX addition question Posted: 26 Dec 2010 02:52 AM PST 1.

A client has an arteriovenous (AV) fistula in place in the right upper extremity for hemodialysis treatments. When planning care for this client, which of the following measure should the nurse implement to promote client safety? a. Take blood pressures only on the right arm to ensure accuracy. b. Use the fistula for all venipunctures and intravenous infusions. c. Ensure that small clamps are attached to the AV fistula dressing. d. Assess the fistula for the presence of a bruit and thrill every 4 hours. 2. A client is due in hydrotherapy for a burn dressing change. To ensure that the procedure is the most tolerable for the client, the nurse takes which of the following actions? a. Ensure that the client has a robe and slippers b. Administers an analgesic 20 minutes before therapy c. Sends dressing supplies with the client to hydrotherapy d. Administers the intravenous abtibiotic 30 minutes before therapy 3. The nurse is caring for a client with heart failure who has a magnesium level of 1.4 mg/dL. The nurse should: a. Monitor the client for irregular heart rhythms. b. Teach the client to avoid food high in magnesium. c. Encourage the intake of antacids with phosphates. d. Provide a diet of ground beef, eggs, and chicken breast. 4. A nurse is preparing to care for a client following parathyroidectomy. The nurse plans care anticipating which postoperative order? a. Maintain the endotracheal tube for 36 hours. b. Take a rectal temperature only until discharge. c. Ensure that intravenous calcium preparations are available. d. Place the client in a flat position with the head and neck immobilized. 5. A client with a wound infection and osteomyelitis is to receive hyperbaric oxygen therapy. During the therapy, the nurse implements which priority intervention? a. Maintains an intravenous access b. Ensures that oxygen is being delivered. c. Administers sedation to prevent claustrophobia.

d. Provides emotional support to the clients family. 6. The nurse is caring for a client with a herniated lumbar intervertebral disk. The nurse plans to place the client in which position to minimize the pain? a. Flat with a knees raised b. High fowlers position with the foot of the bed flat c. Semi-fowlers position with the foot of the bed flat. d. Semi-Fowlers position with the knees slightly raised. 7. A mother arrives at the emergency department with her child, stating that she just found the child sitting on the floor next to an empty bottle of aspirin. On assessment, the nurse notes that the child is drowsy but conscious. The nurse anticipates that the physician will prescribe which of the following? a. Ipecac syrup b. Activated charcoal c. Magnesium citrate d. Magnesium sulfate 8. A client with myasthenia gravis is admitted to the hospital, and the nursing history reveals that the client is taking pyridostigmine (Mestinon). The nurse assesses the client for side effects of the medication and asks the client about the presence of a. Mouth ulcers b. Muscles cramps c. Feeling of depression d. Unexplained weight gain. 9. A client with a fractured right ankle has a short leg cast applied in the emergency department. During discharge teaching, the nurse provides which information to the client to prevent complications? a. Trim the rough edges of the cast after it is dry. b. Weight-bearing on the right leg is allowed once the cast feels dry. c. Expect burning and tingling sensations under the cast for 3 to 4 days. d. Keep the right ankle elevated above the heart level with pillows for 24 hours. 10. An older adult female client with a fractured left tibia has a long leg cast and is using crutches to ambulate. In caring for the client, the nurse assesses for which sign or symptom that indicates a complication associated with crutch walking? a. Left leg discomfort b. Weak biceps brachii

c. Triceps muscle spasms d. Forearm muscle weakness 11. A client with myasthenia gravis is experiencing prolonged periods of weakness, and the physician orders an endophonium (Tensilon) test. A test dose is administered and the client becomes weaker. The nurse interprets that this test result as: a. Normal b. Positive c. Myasthenic crisis d. Cholinergic crisis 12. The nurse notes an isolated premature ventricular contraction (PVC) on the cardiac monitor. The appropriate nursing action is to: a. Prepare for defibrillation. b. Continue to monitor the rhythm. c. Notify the physician immediately. d. Prepare to administer lidocaine hydrochloride (Xylocaine) 13. The nurse is caring for a client admitted to a hospital with the diagnosis of active tuberculosis. The nurse determines that the diagnosis was confirmed by a: a) Tine Test b) Chest X-ray c) Mantoux text d) Sputum culture 14. A clinic nurse prepares to assess the fundal height on a client who is in the second trimester of pregnancy. When measuring the fundal height, the nurse will most likely expect the measure to: a) Correlate with gestational age b) Be less that gestational age c) Be greater than gestational age. d) Have no correlation to gestational age. 15. A pregnant client tells a nurse that she felt wetness on her peri-pad and found some clear fluid. The nurse immediately inspects the perineum and notes the presence of the umbilical cord. The nurses initial action is to: a) Notify the physician. b) Monitor the fetal heart rate. c) Transfer the client to the delivery room.

d) Place the client in the Trendelenburg position 16. A nurse admits a newborn infant to the nursery. On assessment of the infant, the nurse palpates the anterior fontanel and notes that it feels soft. The nurse determines that this finding indicates: a. Dehydration b. A normal finding c. Increased intracranial pressure d. Decreased intracranial pressure 17. A client with acquired immunodeficiency syndrome (AIDS) is admitted to the hospital for chills, fever, nonreproductive dough, and pleuritic chest pain. A diagnosis of Pneumocystic Jiroveci pneumonia is made and the client is started on intravenous (IV) pentamidine (Pentam-300). Which of the following should the nurse plan to carry out to safely administer the medication? a) Infuse over 1 hour and allow the client to ambulate. b) Infuse over 1 hour with the client in a supine position. c) Administer over 30 minutes with the client in a reclining position. d) Administer an IV push over 15 minutes with the client in a supine position. 18. The nurse is caring for a client who has been transferred to the surgical unit after having a pelvic exenteration. During the postoperative period, the client complains of pain the calf area. What action should the nurse take? a) Ask the client to walk and observe the gait. b) Lightly massage the calf area to relieve the pain. c) Check the calf area for temperature, color, and size. d) Administer prn morphine as prescribed for postoperative pain. 19. A prenatal client with a history of rheumatic heart disease is experiencing unusual episodes of a nonproductive couth on minimal exertion. The nurse interprets that this assessment finding may be an early manifestation of which potential complication? a) Chronic hypertension b) Eisenmengers syndrome c) Right-sided heart failure d) Cardiac decompensation 20. A nurse is performing an assessment on a client with a diagnosis of chronic angina pectoris who is receiving sotalol (Betapace) 80 mg orally daily. Which assessment finding indicates that the client is experiencing a side effect of a medication?

a) Dry mouth b) Palpitations c) Diaphoresis d) Difficulty swallowing Ans: 1. D 2. B 3. A 4. C 5. B 6. D 7. B 8. B 9. D 10. D 11. D 12. B 13. D 14. A 15. D 16. B 17. B 18. C 19. D 20. B