NCLEX Reviewer fo

8/10/2019 NCLEX Reviewer fo

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NCLEX REVIEWERJASTINE JOY V. BELTRAN


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1. A 43 year old African American male isadmitted with sickle cell anemia. The nurse plansto assess circulation in the lower ext. q2h. Whichof the ff outcome criteria would the N test?a. Body temp of 99F or lessb. Toes moved in AROMc. Sensations reported when soles of feet are

touchedd. Capillary refill of 3sec


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2. A 30-year-old male from Haiti is brought to theER in sickle cell crisis. What is the best positionfor this patient?a. Side lying with knees flexedb. Knee chestc. High fowlers with knee flexed d. Semi-fowlers with legs extended on the bed


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3. A 25-year-old male is admitted with sicklecrisis. Which of the ff interventions would be ofthe highest priority for this client?a. Taking hourly BP with mechanical cuffb. Encouraging OFI of atleast 200ml/hrc. Position in high fowlers with knee gatched

raisedd. Adm Tylenol as ordered


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4. Which of the ff food would the Nencourage the client in sickle cell crisis toeat?a. Steakb. Cottage cheesec. Popsicled. Lima beans


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5. A newly admitted client has sickle cell crisis. Heis complaining of pain in his feet and hands. TheNs assessment findings include a pulse oximetryof 94. Assuming that all the interventions areordered, which should be done first?a. Adjust the room tempb. Give bolus of IV fluidc. Start O2d. Adm. Meperidine (Demerol) 75MG IV push


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6. The N is instructing the client with IDA. Whichof the ff meal plans would the N expect the clientto select?

a. Roast beef, gelatin salad, green beans, peachpieb. Chicken salad sandwich, coleslaw, French fries,

ice creamc. Egg salad on wheat bread, carrot sticks,

lettuce salad, raisin pied. Porked chop, cream potatoes, corn and cocnut

cake


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7. Clients with sickle cell anemia are taught toavoid activities that causes hypoxia andhypoxemia. Which of the ff activities would the Nrecommend?a. A family vacation in the Rocky Mt.b. Chaperoning the local boys club on a snow-

skiing trip

c. Traveling by airplanes for business tripd. A bus trip to the museum of Natural History


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8. The N is conducting an admission assessment ofa client with vit b12 def. which finding reinforcesthe dx of b12 def?a. Enlarged spleenb. Elevated BPc. Bradycardiad. Beefy tongue


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9. The body part that would most likely display jaundice in the dark skinned individual is the:a. Conjunctiva of the eyeb. Soles of the feetc. Roof of the mouthd. Shins


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10. The N is conducting a Physical Assessment ona client with anemia. Which of the ff clinicalmanifestations would be most indicative of theanemia?a. BP 146/88b. Respirations 28 shallowc. Wt gain of 10lbs in 6mosd. Pink complexion


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11. The N is teaching the client with polycythemiavera about prevention of complicxn of the dse.Which of the ff statements by the client

indicates a need for further teaching?a. I will drink 500ml of fluid or less each day. b. I will wear support hose. c. I will check my BP regularly. d. I will report ankle edema.


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12. A 33-year-old male is being evaluated forpossible acute leukemia. Which of the ff findingsis most likely r/t the dx of leukemia?a. The client collects stamps as a hobbyb. The client recently lost his job as a postal

workerc. The client had radiation as tx for Hodgkins

dsed. The clients brother had leukemia as a child


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13. Where is the best site for examining for thepresence of petechiae in an African Americanclient?a. Abdomenb. Thoraxc. Earlobed. Soles of the feet


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14. The client is being evaluated for possible acuteleukemia. Which inquiry by the N is most impt?a. Have you noticed a change in sleeping habit

recently? b. Have you had a respi infxn in the last 6mos? c. Have you los wt recently? d. Have you noticed changes in your alertness?


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17. A client has autoimmune thrombocytopeniapurpura. To det the clients response to tx, the Nwould monitor:a. Platelet countb. WBC countc. K levelsd. PTT


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18. The home health nurse is visiting a client withATP. The clients platelet is 80,000. it will be mostimpt to teach the client and fx about:a. Bleeding prcxnb. Prevention of fallsc. O2 therapyd. Conservation of energy


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19. The client has surgery for removal ofProlactinoma. Which of the ff interventions wouldbe appropriate for this client?

a. Place in trendelenburg for postural drainageb. Encourage deep breathing and coughing q2hc. Elevate HOB 30d. Encourage Valsalva maneuver for bowel

movements


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20. The client with a hx of DI is admitted withpolyuria, polydipsia, and mental confusion. Thepriority intervention for this client is:

a. Measure the UOb. Check the V/Sc. Encourage IOFId. Weigh the client


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21. A client with hemophilia has a nosebleed. Whichnsg action is moast appropriate to control beeding?a. Place in sitting position

b. Adm. Acetaminophen (Tylenol)c. Pinch the soft lower part of the nosed. Apply ice packs to the forehead


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22. A client has had a unilateral adrenalectomy toremove a tumor. The most impt measurement in theimmediate post-op period for the nurse to take is:

a. BPb. Tempc. UOd. Spec gravity of urine


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23. A client with Addisons Dse has been admittedwithna hx of nausea and vomiting for the past3days. The client is rcving IV glucocorticoids (Solu-Medrol). Which of the ff interventions would thenurse implement?a. Glucometer readings as orderedb. Intake/output measurementc. Evaluating the Na/K levelsd. Daily wt


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24. A client had atotal thyroidectomy yesterday.The client is complaining of tingling around themouth and in the fingers and toes. What would bethe nurses next action be? a. Obtain a crash cartb. Check the Ca levelc. Assess the dressing for drainage

d. Assess BP for HPN


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25. A 32-year-old mother of three is brought to theclinic. Her pulse is 52, there is a wt gain of 30lbs in4mos, and the client is wearing two sweaters. Theclient is dx with hypothyroidism. Which of the ffnursing dx is of highest priority?a. Impaired physical mobility r/t decreased

toleranceb. Hypothermia r/t decreased metabolic ratec. Disturbed thought processes r/t interstitial

edemad. Decreased CO r/t bradycardia


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26. The client presents to the clinic with a serumcholesterol of 257mg/dl and is placed onrosuvastatin(Crestor). Which instruction should begiven to the client taking Crestor?a. Report mm weakness to the MDb. Allow 6mos for the drug to take effectc. Take the med with fruit juiced.

Report diff sleeping


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27. The client is admitted to the H with HPN crisis.Diazoxide(Hyperstat) is ordered. During adm the Nshould:

a. Utilize an infusion pumpb. Check bld glucose levelc. Place in trendelenburg positiond. Cover soln with foil


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28. The six-month-old client with a ventral septaldefect is receiving digitalis of regulation of hisheart rate. Which finding should be reported tothe doctor?

a. Blood pressure of 126/80

b. Blood glucose of 110mg/dl

c. Heart rate of 60 bpm

d. Respiratory rate of 30 per minute


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29. The client admitted with angina is given aprescription for nitroglycerine . The client should beinstructed to:

a. Replenish his supply every three monthsb. Take one every 15 minutes if pain occurs

c. Leave the medication in the brown bottle

d. Crush the medication and take with water


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30. The client is instructed regarding foods that arelow in fat and cholesterol. Which diet selection islowest in saturated fats?

a. Macaroni and cheeseb. Shrimp with ricec. Turkey breastd. Spaghetti with meat sauce


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31. The client is admitted with Left CHF. Inassessing the client for edema, the N should checkthe:a. Feetb. Neckc. Handsd. sacrum


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32. The N is checking the clients CVP. The nurseshould check the zero of manometer at the:a. Phlebostatic axis

b. PMIc. Erbs pointd. Tail of Spence


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33. The MD orders lisonipril(Zestril) andfurosemide(Lasix) to be administered concomitantlyto the client with HPN. The N should:a. Question the orderb. Adm the medc. Adm separatelyd. Contact the pharmacy


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34. The best method of evaluating the amt ofperipheral edema is:a. Weighing the client dailyb. Measuring the extremityc. Measuring the intake and outputd. Checking for pitting edema


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36. The n is caring for the client hospitalized with afacial stroke. Which diet selection would be suitedto the client?a. Roast beef sandwich, potato chips, pickle spear,

iced teab. Split pea soup, mashed potatoes, pudding, milkc. Tomato soup, cheese toast, jello, coffeed. Hamburger, baked beans, fruit cup, iced tea


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37. The physician has prescribed Novalog insulin fora client with DM. Which statement indicates thatthe client knows when the peak action of the insulin

occurs?a. I will make sure I eat breakfast within 10mins

of taking my insulin. b. I will need to carry candy or some form of sugar

with me all the time. c. I will eat snack around 3oclock each afternoon d. I can save my dessert from supper for a

bedtime snack.


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38. The N is taking basic infant care to a group of1st time parents. The N should explain that a spongebath is recommended for the 1 st two wks of lifebecause:a. New parents need time to learn how to hold the

babyb. The umbilical cord needs time to separate

c. Newborn skin is easily traumatized by washingd. The chance if chilling the baby outweighs the

benefits of bathing


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39. A client with leukemia is rcving trimetrexate.After reviewing the clients chart, the MD ordersWellcovorin (Leucovorin Ca). The rationale foradministering leucovorin Ca to a client rcvingTrimetrexate is to:a. Treat IDA caused by chemotherapeutic agentb. Create a synergistic effect that shortens tx

timec. Increase the # of circulating neutrophilsd. Reverse drug toxicity and prevent tissue damage


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40. A 4-month-old is brought to the well-baby clinicfor immunization. In addition to the DPT and poliovaccines, the baby should rcv:a. Hib titerb. Mumps vaccinec. Hep B Vacd. MMR


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41. The MD has prescribed Nexium (esomeprazole)for a client with erosive gastritis. The N should admthe med:a. 30mins ACb. With q mealc. In a single dose at bedtimed. 30mins p meal


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44. A client is admitted to the H with temp of98.9F, complaints of blood-tinged hemoptysis.,fatigue, and night sweats. The clients symptoms areconsistent with a dx of:a. Pneumoniab. Rxn to antiviral medc. TBd. Superifxn d/t low CD4 count


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45. The client is seen in the clinic for tx of migraineh/a. the drug imitrex (sumatripan succinate) is Rxfor the client. Which of the ff clients hx should bereported to the MD?a. Diabetesb. Prinzmetal anginac. CAd. Cluster H/A


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46. The client with suspected meningitis is admittedto the unit. The MD is performing an assessment todetermine meningeal irritation and spinal nerve rootinflamm. A positiveKernigs sign is charted if the Nnotes:a. Pain on the flexion of the hip and kneeb. Nuchal rigidity on flexion of the neck

c. Pain when the head is turned on the left sided. Dizziness when changing position


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47. The client with Alzheimers Dse is being assistedwith ADLs when the N notes that the client usesher toothbrush to brush her hair. The N is awarethat the client is exhibiting:a. Agnosiab. Apraxiac. Anomiad. Aphasia


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48. The client with dementia is experiencingconfusion late in the afternoon and before bedtime.The N is aware that the client is experiencing whatis known as:a. Chronic fatigue syndromeb. Normal agingc. Sundowningd. Delusions


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49. The client with confusion says to the N, I haventhad anything to eat all day long. When are they going tobring breakfast? the N saw the client in the day roomeating breakfast with other client 30mins before thisconversation. Which response would be best for the Nto make?a. You know you had breakfast 30mins ago. b. I am so sorry that they didnt get you breakfast. Ill

report it to the charge nurse. c. Ill get you some juice and toast. Would you like

something else? d. You will have to wait a while; lunch will be here in a

little while.

50.


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