College of Staten Island, CUNY

NURSING 110

KAPLAN NCLEX COMPREHENSIVE TEST 1

1)The nurse in the psychiatric emergency room assesses 4 clients. Which of the following clients should the nurse see FIRST?

1.A patient was raped 30 minutes ago and expresses feelings of self­blame, anxiety, and worthlessness.

2.A patient indicates an intent to kill himself and says he has access to a gun.

3. A patient had a miscarriage last evening and is experiencing anger and resentment.
4. A patient witnessed a child stabbed to death 2 weeks ago and is experiencing anxiety.

2. The nurse in a small town is called to a neighbor’s house in the middle of a blizzard. The neighbor woman states she is in the 39th week of gestation with her second baby and has been having contractions for several hours. The woman has been unable to obtain assistance because the roads are impassable. The nurse determines that the woman is in the second stage of labor. It is MOST important for the nurse to take which of the following actions?

1. Time the frequency of the contractions.
2. Assess the type of vaginal discharge.
3. Monitor the strength of the contractions.
4. Observe the perineum.

3. The nurse receives a call from the emergency management team that 50 victims will be transported to the hospital in 15 minutes by ambulance. Which of the following actions should the nurse take FIRST?

1. Contact the nursing supervisor.
2. Tell the emergency management team they will have to re­route 25 victims.
3. Activate the hospital’s disaster plan.
4. Inform the emergency department nurses they must work overtime.

4. As a part of discharge teaching, the nurse instructs a client receiving citalopram (Celexa) 20 mg OD. The nurse deter- mines that further teaching is necessary if the client states which of the following?"

1. "This medication helps me with my depression."
2. "I will notify my physician if I show signs of hyperactivity and mania."
3. "I will see improvement in my symptoms in 1 to 4 weeks."
4. "If I experience a fever I will take Tylenol."

5. The nurse has just received change-of-shift report. Which of the following clients should the nurse see FIRST?

1. A client diagnosed with COPD with an PaO 2 of 70%.
2. A client diagnosed with type 1 diabetes who was just informed her husband is seriously injured.
3. A client scheduled to leave for the operating room in 30 minutes for a heart valve replacement.
4. A client 10 hours postop after a right mastectomy complaining of wet sheets under her back.

6. The nurse instructs a mother of a child diagnosed with a myelomeningocele who developed an allergy to latex. The nurse determines that teaching is effective if the mother selects which menu for her child?

1. Guacamole with pita bread, lettuce, tomato juice.
2. Poached halibut, brown rice, carrots, peach cobbler.
3. Scrambled eggs, whole wheat toast, grapes, skim milk.
4. Baked chicken leg, mashed potatoes, spinach, milkshake.

7. The nurse cares for children in the outpatient pediatric clinic. It is MOST important for the nurse to perform tuberculo- sis screening on which of the following children?

1. A child just returned from a 2-week trip to Europe.
2. A child recently moved to an apartment because the family lost their home.
3. A child with a new nanny who just emigrated from Latin America.
4. A child who weighed 4 lb, 10 oz at birth.

8. The nurse plans care for a patient in hemorrhagic shock from injuries sustained in a fall. It is MOST important for the nurse to take which of the following actions?

1. Obtain vital signs.
2. Identify the source of the bleeding.
3. Elevate the head of the bed 30°.
4. Administer 0.9% NaCl IV.

9. During the change-of-shift report, the charge nurse overhears two nurses exchanging loud, rude remarks about one nurse's excessive use of overtime. Which of the following statements by the charge nurse is MOST appropriate?

1. "I want to see both of you in my office right away."
2. "Would you please lower your voices and finish the report."
3. "I want the two of you to stop yelling and work this problem out."
4. "Both of you are good nurses and are under a lot of stress right now."

10. A 25-year-old woman is receiving aminophylline 0.7 mg/kg/h by continuous IV infusion into her left arm. It is MOST important for the nurse to observe her for which of the following?

1. Slowed pulse and reduced blood pressure.
2. Constipation and decreased bowel sounds.
3. Palpitations and nervousness.
4. Difficulty voiding and oliguria.

11. The home care nurse visits a client diagnosed with type 1 diabetes being managed with insulin in the am and pm. The nurse identifies that which of the following BEST measures the overall therapeutic response to management of the dia- betes?

1. Glycosylated hemoglobin (HbA 1 c) 5% of total Hb.
2. Fasting blood sugar 128 mg/dL.
3. Blood pressure 130/82.
4. Serum amylase 100 Somogyi U/dL.

12. The nurse cares for a client in labor. The client's examination reveals that the cervix is 5 cm dilated and 100% effaced and the fetal head is at -1. The membranes rupture and the nurse notes clear fluid. Which of the following actions should the nurse take FIRST?

1. Ambulate the client for 15 minutes and evaluate the fetal heart rate every 30 minutes.
2. Prepare for delivery and notify the care provider.
3. Apply an electronic fetal monitor and start an IV.
4. Encourage the client to void every 1-2 hours and take her temperature every hour.

13. The nurse cares for a client receiving a heparin drip via an infusion pump. The physician orders warfarin (Coumadin) 5 mg PO. Which of the following actions should the nurse take NEXT?

1. Administer medication as ordered.
2. Notify the physician.
3. Check the most recent serum partial prothrombin levels.
4. Assess client for signs/symptoms of bleeding.

14. The nurse plans care for a 14-year-old hospitalized with a diagnosis of anorexia nervosa. The nurse identifies that which of the following activities is MOST appropriate for this client?

1. Making jewelry with the occupational therapist.
2. Exercising in the physical therapy department.
3. Assisting the dietician to plan the week's menus.
4. Reading teen magazines with other patients her age Strategy: Determine the outcome of each answer.

15. A mother reports to the clinic nurse that her daughter developed a large welt, red rash, and shortness of breath after be- ing stung by a bee. The mother asks the nurse, "What should I do if she gets stung again?" Which of the following re- sponses by the nurse is BEST?

1. "Make a paste of baking soda and water and apply it to the sting."
2. "Remove the stinger and immediately apply ice to the site."
3. "Give 12.5 mg of Benadryl by mouth."
4. "Administer 0.3 mg of epinephrine subcutaneously."

16. The nurse counsels the mother of a child diagnosed with impetigo. The nurse notes that the infection has not improved and learns the mother has not been caring for the child's skin because it "takes too much time." It is MOST important for the nurse to assess for which of the following?

1. White patches on buccal mucosa.
2. Hearing loss.
3. Respiratory wheezing.
4. Periorbital edema.

17. The nurse on a college campus is informed by the microbiology department that they accidentally received a shipment of highly toxic, contagious bacteria. Which of the following actions should the nurse take FIRST?

1. Determine if there are adequate supplies of antibiotics and antipyretics.
2. Order necessary equipment and supplies.
3. Contact the Red Cross.
4. Identify who was exposed to the shipment

18. The nurse administers promethazine (Phenergan) 25 mg IM to a client complaining of nausea and vomiting. After re- ceiving the medication, the client complains of dizziness when standing up. Which of the following actions should the nurse take FIRST?

1. Notify physician.
2. Monitor severity of symptoms.
3. Instruct client to ask for assistance before ambulating.
4. Assess client's hydration status.

19. The nurse in the outpatient clinic has four unscheduled clients waiting to see the physician. Which of the following clients should the nurse see FIRST?

1. A client complaining of a sore throat and nasal drainage.
2. A client with a history of kidney stones complaining of severe flank pain.
3. A client complaining of redness and pain in his left great toe.
4. A client receiving digoxin (Lanoxin) complaining of nausea and vomiting.

20. The nurse cares for a client diagnosed with a recurrence of colon cancer. The client tells the nurse that she is dreading taking chemotherapy again. Which of the following responses by the nurse is MOST appropriate?

1. "There are web sites that provide information about chemotherapy."
2. "Have you discussed this with your physician?"
3. "I can give you a handout about how to treat the side effects of chemotherapy."
4. "What are your concerns about taking chemotherapy?"

21. The nurse in the outpatient clinic receives a call from a client who has been receiving continuous ambulatory peri- toneal dialysis (CAPD) for 1 year. The client states that he infused 2 L of dialysate and 1200 cc returned. Which of the fol- lowing statements by the nurse is BEST?

1. "Record the difference as intake."
2. "When was your last bowel movement?"
3. "Are you having shoulder pain?"
4. "Increase your fluid intake."

22. The nurse evaluates assignments on the unit. The nurse determines that assignments are appropriate if the LPN/LVN is assigned to which client?

1. A client with type 1 diabetes scheduled for discharge.
2. A client newly admitted to the unit with chest pain.
3. A client receiving chemotherapy.
4. A client diagnosed with myasthenia gravis.

23. An elderly client is brought to the emergency department complaining of acute back pain. The client denies any chronic illness, allergies, or previous hospitalizations. Which of the following is the BEST initial response for the nurse to make to this client?

1. "We'll get this pain under control in no time."
2. "Are you sure you've never been in the hospital?"
3. "Did you fall, lift something heavy, or turn the wrong way?"
4. "On a scale of 1 to 10, with 10 being the worst, rate the pain you are experiencing."

24. A nurse observes a student nurse administer carvedilol (Coreg) to an elderly patient. The patient refuses medication, saying, "Go away. It makes me dizzy." The nurse should intervene if the student nurse states which of the following?

1. "If you don't take this medication, you will be restrained."
2. "This medication will help control your blood pressure."
3. "Side effects of this medication make some patients feel uncomfortable."
4. "When do you notice the dizziness?"

25. The nurse cares for clients in the emergency department (ED). An 82-year-old client comes to the ED complaining of muscle weakness and drowsiness. The nurse notes decreased deep tendon reflexes and hypotension. Which of the follow- ing actions should the nurse take FIRST?

1. Escort the client to an emergency room unit.
2. Ask the client if he has been taking antacids.
3. Assess for Chvostek's sign.
4. Measure client's intake and output

26. A tornado has just leveled a large housing division near the hospital, and a disaster alarm has been declared at the hos- pital. The nurse caring for clients on the maternal-child unit considers which of the following clients appropriate for dis- charge within the next hour? SELECT ALL THAT APPLY

1. A multipara client who delivered over an intact perineum 12 hours ago.
2. A postpartum client with an infection who has been on antibiotics for the past 24 hours.
3. A 3-year-old with newly diagnosed type 1 diabetes, diarrhea, and vomiting.
4. A 3-day-old breast-feeding infant with a total serum bilirubin of 14 mg/dL.
5. A client at 34 weeks' gestation diagnosed with generalized edema and complaints of epigastric pain.
6. A 2-day-old infant delivered of a mother receiving intrapartum antibiotic therapy for vaginal group B-strepto- coccus (GBS).

27. The nurse cares for a client following a scleral buckling. Which of the following nursing actions is MOST important?

1. Remove all reading material.
2. Assess for nausea.
3. Assess drainage from affected eye.
4. Irrigate affected eye every 3 hours.

28. The nurse supervises care for a patient admitted to the psychiatric unit with a diagnosis of bipolar disorder: manic phase. A student nurse plans activities for the patient. The nurse should intervene if the student nurse chooses which of the following activities?

1. Volleyball.
2. Painting.
3. Walking.
4. Dancing.

29. The nurse on the medical/surgical unit is approached by an LPN/LVN from a different team. The LPN/LVN expresses concern because one of her patients is diagnosed with COPD and the RN (a new graduate) is giving the patient oxygen at 2 L/min. Which of the following statements by the nurse is MOST appropriate?

1. "I will assess the patient for oxygen toxicity."
2. "Are you concerned about the oxygen or the new graduate's competency?"
3. "Please tell me more about your concerns."
4. "Leave the oxygen in place."

30. The nurse cares for an infant diagnosed with congenital heart disease. The nurse notes that the infant becomes easily fatigued during feedings and the infant's pulse and respirations increase. The nurse should take which action?

1. Feed the infant soon after awakening.
2. Change the infant's diaper before feeding.
3. Increase the caloric content of the feeding to 30 kcal/oz.
4. Mix rice cereal in the formula.

31. The nurse instructs a client who is scheduled for a 24-hour creatinine clearance test. Which statement, if made by the client to the nurse, indicates further teaching is required?

1. "I will eat a high-protein meal before the test begins."
2. "I will use the specimen collection time to catch up on my reading."
3. "I will drink as much fluid as I want before and during the test."
4. "I will save all of my urine during the 24 hours and keep it in the refrigerator."

32. The nurse prepares to admit a 6-month-old diagnosed with rotavirus, severe diarrhea, and dehydration. The nurse should place the infant in which of the following rooms?

1. In a semiprivate room with a 2-year-old in traction due to a fracture.
2. In a semiprivate room with a 9-month-old admitted for a shunt revision.
3. In a private room that is close to the nurse's station.
4. In any private room that is available.

33. A patient returns from surgery for a total replacement of the right hip with a large surgical dressing and a Jackson-Pratt drain. Which of the following, if observed by the nurse 2 hours after surgery, necessitates calling the physician?

1. There is a small amount of bloody drainage on the surgical dressing.
2. The patient complains of increased hip pain.
3. A harsh, hollow sound is auscultated over the trachea.
4. The patient's blood pressure is 136/86.

34. An older client is placed in balanced suspension traction for a compound fracture of the femur. The client reports, "My hands, feet, and nose feel cold. Which action should the nurse take FIRST?

1. Provide the client with more blankets.
2. Assess for dependent edema.
3. Assess that client is exhaling when moving in bed.
4. Increase the temperature of the room.

35. The nurse cares for a client at term in labor. The client's blood pressure is 182/88 and fetal heart rate (FHR) is 132-134 with minimal beat-to-beat variability. Her bloody show is dark red and there is more bleeding than anticipated. Her ab- domen is firm between contractions and she complains of back pain. The nurse understands that the client is at risk for which of the following?

1. Placenta previa.
2. Abruptio placenta.
3. Miscarriage.
4. Imminent delivery.

36. The nurse cares for an older client diagnosed with terminal lung cancer. When told about the diagnosis, the client be- comes very angry. He curses, throws objects, and hits the nurse tech and LPN/LVN when they attempted provide care for him. It is MOST important for the nurse to take which of the following actions?

1. Inform client that injury or risk of injury to staff is not acceptable.
2. Send the staff out of the room.
3. Administer prescribed antianxiety with full glass of water.
4. Report signs/symptoms to physician immediately.

37. The nurse, caring for clients in the outpatient clinic, performs a chart review for clients who are receiving medication. The nurse determines that which of the following clients is at risk to develop problems with hearing?

1. A client receiving spironolactone (Aldactone) and cefaclor (Ceclor).
2. A client receiving metformin (Glucophage) and alendronate (Fosamax).
3. A client receiving paroxetine (Paxil) and cholestyramine (Questran).
4. A client receiving furosemide (Lasix) and indomethacin (Indocin).

38. The nurse in the pediatric clinic receives a phone call from the mother of a 3-year-old child. The mother reports that her child has been complaining of a sore throat, has a temperature of 102°F (39°C), and he has suddenly begun drooling. Which of the following suggestions should the nurse make FIRST?

1. "Place a cold water vaporizer in your child's room."
2. "Take your child to the emergency department immediately."
3. "Look into your child's throat and tell me what you see."
4. "Frequently offer your child oral fluids."

39. The nurse cares for a 27-year-old female diagnosed with type 1 diabetes. Two days after admission, the client begins complaining of severe nausea. Which of the following actions should the nurse take FIRST?

1. Determine the client's most recent fasting serum glucose level.
2. Perform a comprehensive client assessment.
3. Ask the client if she is pregnant.
4. Administer an antiemetic.

40. A new registered nurse asks the assigned nurse mentor to check on 4 clients who are receiving oxygen therapy. It is MOST important for the nurse mentor to ask the nurse which of the following questions?

1. "Which client should I see first?"
2. "Have you completed your assessment?"
3. "What are your specific concerns?"
4. "Don't you think you should be able to care for the clients?"

41. The nurse cares for a client receiving chlordiazepoxide (Librium). It is MOST important for the nurse to observe for which of the following?

1. Skeletal muscle spasms and insomnia.
2. Anorexia and dry mouth.
3. Diarrhea and euphoria.
4. Drowsiness and confusion

42. Following the administration of morphine sulfate for an adult client, the nurse expects to observe which finding?

1. The client states they feel better.
2. The client is talking with visitors.
3. The client appears to be physically relaxed.
4. The client is no longer crying or moaning.

43. After being admitted for management of a cervical spine injury, a client in a rehabilitation center reports a severe headache. Which of the following actions should the nurse take FIRST?

1. Administer an analgesic medication
2. Ask the client to rank the pain from 1 to 10.

3. Ask the client if he is worried about something.
4. Place the client in a sitting position.

44. The nurse receives report on the medical/surgical unit. Which of the following clients should the nurse see FIRST?

1. A client newly diagnosed with type 1 diabetes who had a myocardial infarction 2 days ago.
2. A client diagnosed with right-sided heart failure and glaucoma.
3. A client diagnosed with chronic obstructive pulmonary disease and psoriasis.
4. A client diagnosed with rheumatoid arthritis and malnutrition.

45. The nurse cares for a 4-year-old on the pediatric unit. The child is unable to go to sleep while in the hospital. It is MOST important for the nurse to take which of the following actions?

1. Turn out the light and close the door.
2. Encourage the child to exercise during the evening.
3. Identify the child's home bedtime ritual.
4. Ask the child's siblings to visit during the evening.

46. The nurse prepares an elderly client newly diagnosed with type 1 diabetes for discharge. The client is alert and ori- ented and lives alone in her home. It is MOST important for the nurse to assess for which of the following?

1. Client's vision and manual dexterity.
2. Client's understanding of diabetes.
3. Client's need for visits from the home care nurse.
4. Client's ability to perform blood glucose monitoring.

47. The nursing assistive personnel inform the nurse that the elderly client admitted following a hemorrhagic stroke ate half of the food on the tray. The food left on the tray looked as if someone had drawn a straight line down the center of the plate and eaten the food only to one side of the line. Which instruction by the nurse is MOST important?

1. "Rotate the plate so that the food is on the other side."
2. "Offer him a snack later in the day."
3. "Ask the client's family to assist him with the next meal."
4. "Which foods did he omit?"

48. The nurse evaluates care for a client who demonstrates manipulative behavior. The nurse should intervene if which of the following is observed?

1. The staff discusses with the client the consequences of his manipulative behavior.
2. The staff establishes limits on the client's manipulative behavior.
3. The staff clarifies the consequences of the client's manipulative behavior.
4. The staff decreases the demands on the client.

49. The nurse in the pediatric clinic performs a well-child assessment on a 20-month-old. The child's mother tells the nurse that she is earning extra money by growing houseplants in her home. Which of the following responses by the nurse is MOST appropriate?

1. "How did you get into that business?"
2. "What a great opportunity."
3. "You should not have plants in your home."
4. "Where do you keep the plants?"

50. The nurse performs discharge teaching for a client diagnosed with gastroesophageal reflux disease (GERD). The nurse determines that teaching is successful if the client selects which of the following menus?

1. Pork loin, lettuce and tomato salad with vinegar and oil dressing, jello, and cola.
2. Cheddar cheese omelet, spinach salad, chocolate brownie, and milk.
3. Broiled chicken, cream of broccoli soup, rice pudding, and apple juice.
4. Baked salmon with lemon butter, baked potato, mint chocolate chip ice cream, and lemonade.