NCLEX-RN EXAM – The ambulatory care nurse isdisa.Jssing preoperative procedures

1.            The ambulatory care nurse isdisa.Jssing preoperative procedures with a ..apanese American dient who issd”leduled for surgery the following week. D..lring the disa.Jssion, the dient rontinually smiles and nodsthe head. 1-bw should the nurse interpret thisnonverbal behavior?

1.            R:!flectinga rultural value

2.            An aa:Eptanre of the treatment

3.            Oient agreement to the required procedures

4.            Oient understanding of the preoperative procedures

2. When oommunicatingwith a dient who speaksa different language, whidl best practire should the nurse implement?

1.            k              loudly and slowly.

2.            Arrange for aninterpreter to translate.

3.            ktothedient andfamilytogether.

4.            Sanddose to the dient and speak loudly.

3. The nurse educator is providing in-servire education to the nursing staff regarding t ransa.Jlt ural nursing care; a staff member asks the nurse educator to describe the oonrept of acrulturation. The nurse educator should make whidl most appropriate response?

1. ft isa process of learning a different rulture to adapt toa new or dlanging environment. “

2.            ft isa subjective perspective of the peroon heritage and a sense of belonging to a group. “

3.            ft isa group of individuals in a society who are rulturallydistinct and have a unique identity.”

4.            ft isa group that sharesoomeof the dlaracteristicsof the larger population group of whidl it isa part. “

4. The nurse is providing disd”large instructions to a 01inese American dient regarding prescribed dietary modifications. D..lringthe teaming session, the dient oontinuouslyturns away from the nurse. The nurse should implement whidl best action?

1.            C.ontinue with the instructions, verifyingdient understanding.

2.            Walk around the dient oo that the nurse oonstantlyfaresthe dient.

3.            Gvethe dient a dietary booklet and return later to oontinue with the instructions.

4.            Tell the dient about the import anre of the instruct ions for the maintenanre of health care.

5.            The health care provider prescribes erythromydn suspension (erythromydn ethylsuoonate), 800 mgby mouth twire daily. After reoonstitution, how many millilitersshould the nurse pour into the medicine rup to deliver the prescribed dose? fefer to fig.ue. All in the blank.

 •……..,_,……,..,…….

-..!..I-l.l.•­-

…………

-,.-_

6.            The nurse should indude whidl interventions in the plan of care for a dient with hypothyroidism? led all that apply.

1.            A’ovide a oool environment for thedient.

2.            Instruct the dient to oonsume a high-fat diet.

3. Instruct the dient about thyroid replarement therapy.

4. Enrourage the dient to ronsume fluids and higi-fiber foods in the diet.

5. Inform the dient that iodine preparations will be prescribed to treat the dirorder.

6. Instruct the dient to rontact the health care provider (H::F? if epi&>des of mest pain cxx:ur.

7. When making as.5ig1ments to a team ronsisting of a regstered nurse (R-J), one lirensed practical nurse (l.RI), and two unlirensed as.5istive perronnel (UA . whim isthe best dient for the l.RI?

1.            A dient requiring frequent temperature mecks

2.            A dient requiring as.5istanre with ambulation every 4 hours

3.            A dient on a med’lanical ventilator requiring frequent asseS51Tlent and suctioning

4. A dient with a spinal rord injury requiring urinary catheterization every 6 hours asprescribed

8. To perform cardiopulmonary resurotation (o:R), the nurse should use this method to open the airway in whim situation? Refer to fi9.1re.(ffom 1-arkreader H, Hogan MA, lhobaben M: Fundamentals of nursing: Caring and clinicaljudgment, ed3, S. Louis, 2007, S3unders)

1.            If ned< trauma is suspected

2.            In all situations requiring GR

3.            If the dient hasa history of seizures

4.            If the dient hasa history of headames

9. The nurse teames skin care to a dient rereiving external radiation therapy. Whim dient statement indicates the need for further instrudion?

1.            f will handle the area gently. “

2.            f will wear loose-fitting dothing. “

3.            fwill avoid the use of deodorants.”

4. f will limit sun exposure to 1 hour daily. “

10.          The health care providers prescription readslevothyroxine ( throid), 150 mq;J orally daily. The medication label reads throid, 0.1 mg per tablet. The nurse should administer how manytablet(s) to the dient?

11.          RII in the blank.

12.          The nurse iscaringfor a dient who was involuntarily hospitalized and is scheduled for electroronvulsivetherapy. The nurse notes that an informed ronsent hasnot been obtained for the procedure. Based on thisinformation, what is the nurses best determination?

1.            The informed ronsent does not need to be obtained.

2.            The informed ronsent should be obtained from the family.

3. The informed ronsent needs to be obtained from the dient.

4. The health care provider will provide the informed ronsent.

12. A dient newly diag1osed with diabetesmellitusis instructed by the health care provider to obtain gucagm for emergency home use. The dient asksa home care nurse about the purpose of the medication. What is the nurses best response to the dient s question?

1.            ‘ft will boost the rellsin your pancreas if you have insufficient insulin.”

2.            ‘ft will help promote insulin abrorption when your gurose levels are higi. “

3. ‘ft is for the timeswhen your blood gurose istoo low from too mum insulin.”

4. ‘ft will help prevent lipoatrophy from the multiple insulin injections over the years.”

13. The nurse is providing care to a R.Jerto i;,can -American dient who is terminally i11. Numerous family members are present most of the time,and many of the family members are very emotional. What is the most appropriate nursing action for thisdient?

1.            R3strict the number of family members visiting at one time.

2.            Inform the family that emotional outbursts are to be avoided.

3. Make the neres5ary arrangementsoo family members can visit.

4. Contact the health care provider to speak to the family regarding their behaviors.

14. A dient presents to the emergency department with upper gastrointestinal bleeding and isin moderate distress. In planning care, what isthe priority nursing action for thisdient?

1.Asseffiment of vital signs

2.            Completion of abdominal examination

3.            Insertion of the prescribed naoogastrictube

4.            Thorough investigation of precipitating events

15. The nurse is performing anasse$Tlent on a dient with dementia. Which data gathered during thea5Se$Tlent indicates a manifestation ass::>dated with dementia?

1. Usesoonfabulation

2.            Improvement in sleeping

3.            Absenre of sundown syndrome

4.            4.A-esenre of peroonal hygenic care

16. The nurse is caring for a dient with anorexianervosa. Which behavior is characteristic of thisdioorder and refledsanxiety management?

1.            81gagng in immoral acts

2.            AIWcffS reinforcing self-approval

3. O:>serving rigdrulesand regulations

4.Having the need alwcffsto make the right decision

17. The nurse provides instructions to a malnourished pregnant dient regarding iron supplementation. Which dient statement indicates an understanding of the instructions?

1.            fron supplements will gve me diarrhea.”

2.            Meat does not provide iron and should be avoided. “

3. ‘The iron is best aboorbed if taken on an empty stomach. “

4. 01 thedays that I eat green leafy vegetables or calf liver I can omit taking the iron supplement.”

18. L.evothyroxine( nthroid) isprescribedfor a dient diagnosed with hypothyroidism. Upon review of the dient sreoord, the nurse notes that the dient

is taking warfarin (C.oumadin). Which modification to the plan of care should the nurse review with the dient health care provider?

1.            A decreased dosage of levothyroxine

2.            An increased dosage of levothyroxine

3. A decreased dosage of warfarin oodium

4. An increased dosage of warfarin oodium

19. The nurse prepares to gvea bath and change the bed linens of a dient with cutaneous posi s sarooma lesions. The lesions are open and draininga scant

amount of serous fluid. Which would the nurse inoorporate into the plan during the bathing of thisdient?

1. Wearing goves

2. Wearing a gown and goves

3.            Wearing a gown, goves, and a mask

4.            Wear a gown and goves to change the bed Iinens and goves only for the bath

20. The nurse provides home care instructions to a dient with systemic lupus erythematosusand tells the dient about methods to mana fatig.Je. Which statement by the dient indicates a need for further instrudions?

1.            fshouldtakehot bathsbecausetheyarerelaxing.”

2.            f should sit whenever pos5ible to ronserve my energy. “

3.            f should avoid long periods of rest because it causes joint stiffnes&”

4.            f should do some exercises, such as walking, when I am not fatig.Jed. “

21. A dient develops an anaphylacticreaction after rereiving morphine sulfate. The nurse should plan to institute which actions?S!lect all that apply.

1. Administeroxy n.

2. Q.Jickly asses;the dient s respiratory status.

3. D::>cument the event, interventions, and dient s response.

4.            Leave the dient briefly to rontact a health care provider.

5.            p             thedient supine regardles;of the blood pres;ure readings.

6.            Sart an intravenous(!/) infusion of r:JSW and administer a 500-mlbolus.

22. A dient with pemphig.Js is being seen in the dinic reg.1larly. The nurse plans care based on which des:;ription of thisrondition?

1. The presence of tiny red vesides

2. An autoimmune disease that causes blistering in the epidermis

3.            The presence of skin vesidesfound along the nerve caused by a virus

4.            The presence of red, raired papules and larplaques rovered by silvery scales

23. The nurse is assisting in planning care for a dient with a diagnosis of immunodeficiency and should inrorporate which action asa priority in the plan?

1. A”otectingthe dient from infection

2.            A”oviding emotional support to decrease fear

3.            Enrouragng disrussion about lifes:yle changes

4.            ldentifyingfactorsthat decreased the immunefunction

24. A dient callsthe nurse in the emer ncy department and statesthat he was just stungby a bumble bee while gardening. The dient is afraid of a severe reaction because the dient neighbor experienood such a reaction just 1 weekag:i. Which nursing action should the nurse take?

1. Advise the dient to soak the sitein hydro n peroxide.

2. Ask the dient if he ever sustained a bee sting in the past.

3.            Tell the dient to call an ambulanre for transport tot he emer ncydepartment.

4.            Tell the dient not to worry about the stingunless difficulty with breathing oocurs.

25. lherommunity health nurse isronductinga research study and is identifying dientsin the rommunity at risk for latex allergy. Which dient population isat most risk for developing thistype of allergy?

1.Hairdressers

2.            The homeless

3.            Olildren in daycare renters

4.            Individuals living in a group home

26. A dient with acute kidney injury has a serum potassium level of 6.0 mB:VL The nurse should plan which action asa priority?

1. Oleck the sodium Ievel.

2. Rare the dient on a cardiac monitor.

3.            Enroura increased v tablesinthe diet.

4.            Allow an extra500 mlof fluid intake to dilute the electrolyteronrentration.

27. A dient being hemodialyied suddenly beromesshort of breath and romplainsof chest pain. The dient istachycardic, pale, and anxious and the nurse suspects air embolism. What isthe priority nursing action?

1. Monitor vital signs every 15 minutes for the next hour.

2. ?srontinuedialysisand notify the health care provider (HJ=?.

3.            Continue dialysis at a slower rateafter checking the lines for air.

4.            Bolusthe dient with 500 mlof normal saline to break up the air embolus.

28. A dient arrivesat the emergency department with romplaintsof low abdominal pain and hematuria. The dient isafebrile. lhe nurse next asseg;esthe dient to determine a history of whidl rondition?

1.            Pyelonephritis

2.            Glomerulonephritis

3. Trauma to the bladder or abdomen

4. Renal canrer int he dient s family

28. A dient is admitted to the emergency department following a motor vehide acrident. The dient was wearing a lap seat belt when theacrident oocurred and now thedient hashematuriaand lower abdominal pain. Toasses:;further

whether the pain is caused by bladder trauma, the nurse should ask the dient if the painis referred to whidl area?

1. Hp

2. Sloulder

3.            Umbilirus

4.            Costovertebralange

30. A dient is admitted to the emergency department following a fall from a horse and the health care provider (..-0:, prero-ibes insertion of a Foley catheter.

While preparing for the procedure, the nurse notesblood at the urinary meatus.

The nurse should take whidl action?

1.            Notify the1-(F_

2.            Use a small-sized catheter.

3.            Administer pain medication before insertingthe catheter.

4.            Use extrapovidone-iodine solution in deansingthe meatus.

31. The nurse is assessing the patency of a dient s left arm arteriovenous fistula prior to initiating hemodialysis. Whidl finding indicatesthat the fistula is patent?

1.            Palpation of a thrill over the fistula

2.            A’esenre of a radial pulse in the left wrist

3.            Absenre of a bruit on ausrultation of the fistula

4.            Capillary refill lessthan 3 seronds in the nail beds of the fingers on the left hand

32. A maledient hasa tentative diagnosis of urethritis. The nurse should asseS5the dient for whidl manifestation of the disorder?

1.            l-lematuriaand pyuria

2.            Dysuria and proteinuria

3.            l-lematuriaand urgency

4. Dysuriaand peniledis:narge

33. The nurse is assessing a dient with epididymitis. The nurse antid pates whidl findings on physical examination?

1.            Fever, diarrhea, groin pain, and ecx:nymosis

2.            Nausea, vomiting, ro-otal edema, and ecx:nymosis

3. Fever, nausea, vomiting, and painful ro-otal edema

4. Darrhea, groin pain, testirular torsion, and &rotal edema

34. A dient romplainsof fever, perinea! pain, and urinary urgency, frequency, and dysuria. To asseS5whether the dient s problem is related to bacterial prostatitis, the nurse reviews the results of the prostate examination for whidl dlaracteristic of this disorder?

1.            S::>ft and swollen prostate gand

2.            Reddened, swollen, and boggy prostate gand

3.            Tender and edematous prostate gand with ecx:nymosis

4. Tender, indurated prostategand that is warm to thetoudl

35. The nurse isrolledingdatafrom a dient who hasa history of benign prostatic hyperplasia. To determine whether the dient rurrently isexperiendngthis rondition, the nurse should ask thedient about the presence of whidl early $)1111ptom?

1. Ao.rte rejection

1.            Kidney infection

2.            01ronic rejection

3.            Kidney obstruction

36. The nurse monitoring a dient reooiving peritoneal dialysis notesthat the dient s outflow is lessthan the inflow. Whidl actions should the nurse take? Select all that apply.

1.            Oleck the level of the drainage bag.

 2. Reposition the dient to hisor her side.

3. Contact the health rareprovider (rKJ=?.

4. Aaoothe dient in good body alignment.

5. Oleck the peritoneal dialysis system for kinks.

6. Increase the flow rateof the peritoneal dialysis solution.

37. A hemodialyssdient with a left armfistulaisat riskfor arterial steal syndrome. The nurse should asseg;the dient for whidl manifestations of thisrompliration?

1.            Warmth, redness, and pain in the left hand

2.            Adling pain, pallor, and edema of the left arm

3.            Edema and reddish disroloration of the left arm

4. Pallor, diminished pulse, and pain in the left hand

38. The nurse is reviewing a dient srerord and notes that the health rareprovider hasdocumented that the dient has a renal function disorder. Qi review of the laboratory results, the nurse most likely would expect to note whidl finding?

1.Bevated creatinine level

2.            D3aeased hemoglobin level

3.            D3aeased redblood ooll rount

4.            D3aeased white blood ooll rount

39. A dient with dlronic kidney disease returns to the nursing unit following a hemodialysstreatment. Qi asses911ent, the nurse notes that the dient s temperature is 100.2° F. Whidl nursing action ismost appropriate?

1.            Enrourage fluids.

2.            Notify the healthrare provider.

3. Continue to monitor vital signs.

4. Monitor the site of the shunt for infection.

40. The nurse is performing anasse$1Tlent on a di ent who has returned from the dialysis unit following hemodialyss. lhe dient isromplainingof headadle and nausea and is extremely restless. Whidl is the most appropriate nursing action?

1.            Monitor thedient.

2.            Bevatethe head of the bed.

3.            Mediratethedient for nausea.

4. Notify the health rare provider (rKJ=?.

41. A dient newly diagnosed with dlronic kidney disease has just been started on peritoneal dialysis. D.Jring the infusion of the dialysate, the dient romplainsof abdominal pain. Whidl action by the nurse ismost appropriate?

1.            Sop the dialysis.

2.            Sow the infusion.

3.            D3aeasetheamount tobe infused.

4. Explain that the pain will subside after the first few exdlanges.

42. The nurse is instructing a dient with diabetesmellitusabout peritoneal dialysis.

The nurse tellsthe dient that it is important to maintain theprescribed dwell time for thedialysisberause of the risk of whidl rompliration?

1. Infection

2.  rglyoomia

3.            phosphatemia

4.            Dsequilibrium syndrome

43. A weekafter kidney transplantation, a dient develops a temperature of 101° F, the blood pressure iselevated, andthe kidney istender. lhex-rayindiratesthat the transplanted kidney isenlarged. Based on these asses911ent findings, the nurse

44. A dient is admitted to the hospital with a diagiosisof benigi prostatic hyperplasia, and a transurethral resection of the prostate is performed. Four hours after surgery, the nurse takesthe dient s vital sigisand emptiest he urinary drainage bag. Which asseS:rnent finding indiratesthe need to notify the health rare provider (f-U??

1.            R:Kl bloody urine

2.            Pain related to bladder spasms

3.            Urinary output of 200 mLhigher than intake

4. Blood pressure, 100/50 mm HJ; pulse, 130 beats/minute

45. The dient newly diagiosed with chronic kidney disease rerently has begun hemodialysis. lvlowing that the dient isat risk for disequilibrium Syndrome, the nurse should asses;thedient during dialysisfor which asrodated manifestations?

1.            rtension, tachyrardia, and fever

2.            Hypotension, bradyrardia, and hypothermia

3.            Rastlessnes.5, irritability, and generalized weakness

4. l-leadache, deteriorating level of ronooousness, and twitching

46. Adient isadmittedtoanemergencydepartment withchest painthat isronsistent with myorardial infarction based on elevated troponin levels. l-leart rounds are normal and vital sigis are noted on the dient chart. The nurse should alert the health rare provider berause these changes are most ronsistent with which rompliration? Fefer to dlart.

1.Cardiogenic shock

2.            Cardiactamponade

3.            R.Jlmonaryembolism

4.            ?ssed ingthoradc aortic aneurysm

47. A dient admitted to the hospital with chest pain and a history of type 2 diabetes mellitusisscheduled for rardiacratheterization. Which medirationwouldneed to be withheld for 24 hoursbefore the procedure and for 48 hours after the procedure?

1.            lar insulin

2.            Glipizide (Glurotrol)

3.            Repaginide (A”andin)

4. Metformin (Glurophage)

48. A dient in sinus bradyrardia, with a heart rate of 45 beats/minute, romplainsof dizziness and hasa blood pressure of 82/60 mm HJ. Which prescription should the nurse antidpatewill be prescribed?

1.            D:lfibrillatethe dient.

2.            Administer dig::>xin (Lanoxin).

3.            Continue to monitor the dient.

4. A”epare for transa.rtaneous pacing.

49. The nurse in a medical unit israringfor a dient with heart failure. The dient suddenly develops extremedyspnea, tamyrardia, and lung crad<lesand the nurse suspects pulmonary edema. The nurse immediately asks another nurse tooontact the health rare provider and prepares to implement whim priority interventions? &led all that apply.

1.Administeringoxygen

2. Inserting a Foley catheter

3. Administeringfurosemide (Lasix)

4. Administering morphine sulfate intravenously

5.            Transporting the dient to the ooronary rare unit

6.            Radngthe dient in a low Fowler s side-lying position

50. A dient with myocardial infarction suddenly beoomestamyrardic, shows signs

of air hunger, and begnsooughingfrothy, pink-tinged sputum. Whim finding would thenurse antid pate when auSOJltating the dient s breath oounds?

1. lridor

2. 0-ad<les

3.            S:attered rhonmi

4.            ?minished breath oounds

51. A dient with myocardial infarction isdeveloping rardiogenicshock. Because of the riskof myocardial iro-iemia, what oondition should the nurse carefully a5se$ the dient for?

1. Bradyrardia

2. Ventricular dysrhythmias

3.            Rising diastolic blood pressure

4.            Palling amtral venous pressure

52. A dient who had cardiac surgery 24 hours ag:> has had a urine output averagng 20 ml/hour for 2 hours. The dient rereived a singe bolus of 500 mlof intravenous fluid. Urine output for the subsequent hour was25 ml D:lily laboratory results indicate that theblood urea nitrogen level is45 mg’dland the serum creatinine level is2.2 mg’dL 01 the basisof these findings, the nurse would anticipate that thedient isat risk for whim problem?

1.  volemia

2. Acute kidney injury

3.            Glomerulonephritis

4.            Urinary tract infection

53. The nurse is reviewing an electrocardiogram rhythm strip. The P waves and ORS oomplexesare regular. The FR.interval is0.16 second, and QRSoomplexes measure0.06 second. lheoverall heart rateis64 beatS”minute. Whim would be a oorrect interpretationbased on these maracteristics?

1.            Snus bradyrardia

2.            Sek sinus syndrome

3. Normal sinus rhythm

4. Rrst-degree heart block

54. A dient is wearing a oontinuousrardiacmonitor, whim begnsto oound its alarm. A nurse sees no electrocardiographicoomplexeson the ro-een. Whim is the priority action of the nurse?

1.            can a oode.

2.  &nbsp

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