College of Staten Island, CUNY

NURSING 110

KAPLAN NCLEX COMPREHENSIVE TEST 2

1)The nurse supervises the transfer of an elderly client with left-sided weakness from the bed to the chair. After assisting the client to a sitting position, which of the following actions should the nurse take NEXT?

1. Place nonskid shoes on the client's feet.
2. Instruct the client that she will be moving toward her left side.
3. Ask the client to pivot on her right foot.
4. Support the left leg with the nurse's knee.

2. A 16-year-old girl is brought to the emergency room by her parents for evaluation of an eating disorder. When the nurse approaches the client to draw a blood sample, the client cries out, "I hate having my blood drawn. Go away!" Which of the following responses by the nurse is BEST?

1. "What's the matter? Are you afraid of what we are going to find?"
2. "What is it about having your blood drawn that upsets you?"
3. "Take a deep breath. It will be over before you know it."
4. "I'll be back in 15 minutes so we can discuss your concern."

3. The nurse cares for clients in the prenatal clinic. A client comes to the clinic for a prenatal visit on June 6. Her last men- strual period was December 10. The nurse expects the client's fundal height to measure

1. 24 cm.

2. 26 cm.

3. 28 cm.

4. 30 cm.

4. Recently several staff members on the unit have complained of back strain. The nurse determines that the staff is not consistently using correct body mechanics when transferring patients. Which of the following suggestions should the nurse make FIRST?

1. "Encourage your patients to assist as much as possible."
2. "Use your arms and legs when moving a client."
3. "Determine if help is required to transfer a patient."
4. "Position yourself close to the patient."

5. A client is receiving packed red blood cells. Several minutes after the infusion is started, the client complains of nausea and low back pain. It is MOST important for the nurse to take which of the following actions?

1. Obtain a urine specimen.
2. Start an IV of D 5 W.
3. Discard the blood container in a biohazard container.
4. Decrease the rate of the transfusion.

6. A 75-year-old client is brought by his wife to the outpatient clinic. The nurse notes that the client has a 10-year history of chronic renal failure and has been taking cimetidine (Tagamet) for two weeks. It is MOST important for the nurse to in- vestigate which of the following statements made by the client's wife?

1. My husband has been complaining that his bowel movements are hard to pass.
2. My husband takes his Tagamet just before he eats his meals.
3. My husband seems to be having more trouble with his memory lately.
4. My husband sometimes has a headache after reading the newspaper.

7. The nurse cares for an older woman with frequent bladder incontinence following a cerebrovascular accident (CVA). Which of the following actions by the nurse is MOST appropriate?

1. Perform intermittent catheterizations using sterile technique
2. Teach the patient how to perform Valsalva maneuver.
3. Instruct the patient how to perform the Cred é maneuver.
4. Toilet the patient when she awakens in the morning and before and after meals.

8. An older man is returned to his hospital room three hours after a transurethral resection of the prostate (TURP). The pa- tient has a continuous bladder irrigation (CBI). Which of the following observations, if made by the nurse, requires an in- tervention?

1. The patient is in bed with his legs drawn up to his abdomen.
2. There is 500 cc fluid in the urinary drainage bag.
3. There is 350 cc of reddish urine in the drainage bag.
4. The head of the patient's bed is elevated 45 degrees.

9. The nurse on the medical/surgical floor receives four new admissions. Which of the following clients should be placed in a private room?

1. A client with a draining abdominal abscess covered with a dressing.
2. A client diagnosed with influenza.
3. A client diagnosed with cancer who appears septic.
4. A client with diverticulitis complaining of abdominal pain.

10. The nurse performs a prenatal assessment on a client at 20 weeks' gestation. Identify the location where the nurse ex- pects to palpate the client's fundus.

20 to 22 weeks — fundus at the level of the umbilicus

11. The home care nurse visits a client diagnosed with progressive systemic sclerosis. The client complains that she is having more trouble swallowing and moving her right hand. Which of the following responses by the nurse is MOST im- portant?

1. "This must be a difficult time for you."
2. "You should schedule an appointment with your health care provider."
3. "Can you tolerate pressure on your hand?"
4. "Tell me more about the problems you are having swallowing."

12. A terminally ill client with excruciating pain episodes complains the pain medication given at night does not relieve the pain as well as it does during the day. A chart review reveals that clients report pain medication being less effective, and the clients receive more medication when a particular nurse is working. Which of the following actions should the nurse take FIRST?

1. Set up a hidden camera in the medication room.
2. Ask physician to consider increasing the dosage of medication at night.
3. Determine how long the client has been receiving the medication.
4. Temporarily assign another nurse to give all of the PRN medications.

13. The nurse cares for a patient hospitalized for a head injury. The client is receiving 0.9% sodium chloride at 100 cc/h and has an indwelling Foley catheter in place. The nurse notes the patient's urinary output is 1,000 cc in 3 hours. Which of the following actions by the nurse is MOST appropriate?

1. Contact the physician.
2. Decrease the amount of fluids the patient is receiving.
3. Assess the client's mucous membranes.
4. Measure the urine specific gravity.

14. The nurse cares for a patient with chest tubes. Two days after insertion, the chest tube is accidentally pulled out of the pleural space. Which of the following actions should the nurse take FIRST?

1. Don sterile gloves and replace the tube.
2. Apply pressure with a dressing that is tented on one side.
3. Instruct the client to cough and deep-breathe.
4. Auscultate the lung.

15. A tornado roared through a populated area, causing multiple casualties. Which of the following patients should the nurse see FIRST?

1. A patient with a small penetrating abdominal wound caused by flying debris.

2. A patient with blunt trauma to the abdomen that caused bruising.
3. A patient complaining of chest pain with asymmetrical chest movement noted.
4. A patient who is confused and restless with no visible injuries.

16. A man hospitalized for alcohol abuse comes to the nurses' station and asks the nurse if he can go to the cafeteria to get something to eat. When told that his privileges do not include visiting the cafeteria, the patient becomes verbally abusive. Which of the following actions by the nurse is MOST appropriate?

1. Tell the patient to lower his voice.
2. Ask the patient what he wants from the cafeteria.
3. Calmly but firmly escort the patient to his room.
4. Assign a nursing attendant to accompany the patient to the cafeteria.

17. The nurse prepares a client for a skin biopsy. Which of the following statements, if made by the client, should the nurse report to the physician?

1. "I have been taking aspirin for my aching joints."
2. "I applied lotion to my skin after my shower last night."
3. "I laid out in the sun yesterday."
4. "I had coffee and a sweet roll for breakfast this morning.”

18. The nurse counsels a client diagnosed with degenerative joint disease. It is MOST important for the nurse to include which of the following instructions?

1. "Place your joints in the position of comfort."
2. "Place your joints in a flexed position."
3. "Place your joints in full extension."
4. "Place your joints in their functional position."

19. The nurse is making staff assignments on the medical/surgical unit. The nurse should assign a nursing assistant to care for which of the following clients?

1. A client diagnosed with a CVA 2 weeks ago requiring assistance ambulating.
2. A client diagnosed with COPD who is in acute distress requiring assistance bathing.
3. A client receiving total parenteral nutrition through a PICC line requiring a dressing change.
4. A client diagnosed with type 1 diabetes on mechanical ventilation requiring a bath.

20. The home care nurse visits a client receiving warfarin (Coumadin) 5 mg PO daily for DVT. The nurse learns the client operates a horse ranch. It is MOST important for the nurse to include which of the following instructions?

1. Ride with a companion and wear an identification bracelet.
2. Carry a cell phone and dressings and tape.
3. Provide significant others with a written itinerary for the day.
4. Temporarily change to activities that are safer for client

21. The nurse cares for clients in the outpatient clinic. A client with a pacemaker calls to report that he just had an episode of dizziness and shortness of breath. Which of the following responses by the nurse is MOST important?

1. "What is your pulse?"
2. "What were you doing before the episode?"
3. "Have you experienced this before?"
4. "Is the area over the pacemaker painful or red?"

22. A client is admitted to the labor and unit in a sickle-cell crisis. Which of the following nursing actions should the nurse take FIRST?

1. Administer oxygen.
2. Turn client to right side.
3. Begin an IV with normal saline.
4. Administer antibiotics.

23. The nurse cares for a laboring patient. The patient requests something for pain and says to the nurse, "I'm really scared of shots." Which of the following responses by the nurse is BEST?

1. "A shot is your only option, because labor slows the GI tract."
2. "I can give you a pill now, but it will not last as long as an injection."
3. "What was your previous experience with shots?"
4. "What are you afraid of?"

24. The nurse on the medical/surgical unit admits an elderly client after the patient has undergone a below-the-knee ampu- tation. The nurse obtains vitals signs and assesses that the client is able to be aroused but is sleepy. When the client awak- ens and realizes that the amputation was performed, the client begins to scream. Which of the following statements by the nurse is MOST appropriate?

1. "The physician informed you that the amputation was required."
2. "I'll get you some medication so that you can rest."
3. "Your family is waiting in the lobby to come see you."
4. "Since you seem upset, I'll stay with you.”

25. The nurse determines that which of the following clients is MOST at risk to develop gastroesophageal reflux disease (GERD)?

1. A 16-year-old African American male who had an NG tube for 3 days after surgery for a ruptured appendix.
2. A 30-year-old Hispanic female with a diagnosis of cholelithiasis and a t-tube in place.
3. A 52-year-old Caucasian female who is 5'5" tall and weighs 185 pounds.
4. A 65-year-old Caucasian male with a laryngectomy for laryngeal cancer.

26. The nurse cares for clients in the emergency department after an earthquake. Which of the following clients should the nurse see FIRST?

1. A client at 7 months' gestation complaining of cramping and blood-streaked discharge.
2. A client with a displaced fracture of the right radius with blood seeping from the wound.
3. A client complaining of lightheadedness; nurse notes client is clammy, pulse 112, respirations 28.
4. A client with type 1 diabetes who took insulin immediately before the earthquake and is complaining of lightheaded- ness.

27. The nurse on the medical unit is called to the room of an elderly client. The nurse finds the client sitting up in bed re- porting pressure in the chest and jaw. Vital signs are: BP 160/94, P 112, R 20, T 99.5°F (38°C). The client has a history of hypertension and is receiving IV antibiotics for a diagnosis of pneumonia. Which action should the nurse take first?

1. Administer oxygen at 4 L/min via nasal canula.
2. Place the client on a cardiac monitor and obtain a 12-lead ECG.
3. Obtain blood for CK-MB, troponin, and myoglobin levels.
4. Assess patency of the client's IV line.

28. The nurse administers meperidine (Demerol) 75 mg IM to a postoperative patient. Thirty minutes later, it is MOST im- portant for the nurse to take which of the following actions?

1. Reposition the patient.
2. Elevate the patient's head and place a pillow under the shoulders.
3. Observe the patient for restlessness and distress.
4. Ambulate the patient.

29. The nurse admits a patient to the cardiac unit with a diagnosis of heart failure. It is MOST important for the nurse to clarify which of the following orders by the physician?

1. Furosemide (Lasix) 20 mg IV every 12 hours.
2. 2 g/day sodium diet
3. Normal saline at 125 ml/hour IV.
4. Oxygen at 2 L per nasal cannula.

30. The nurse performs an assessment for a client diagnosed with bilateral cataracts. To determine the amount of visual impairment experienced by the client, which of the following questions by the nurse is BEST?

1. "Would you please identify what you can see clearly?"
2. "How have your visual abilities changed?"
3. "When did you first notice that your vision had changed?"
4. "Would you please tell me what you have difficulty seeing?"

31. The nurse performs dietary teaching with a client who has hepatitis B. Which of the following menus, if selected by the client, is BEST?

1. Hamburger, french fries, a dill pickle, and malted milk.
2. Lean roast beef, baked potato, green beans, and coffee.
3. Bacon, eggs, toast with butter, and milk.
4. Biscuits with sausage, gravy, and buttered grits, and orange juice.

32. The nurse assesses a client diagnosed with paranoid schizophrenia. Which of the following assessments indicates to the nurse that the client may need assistance with self-care activities?

1. The client speaks in a low monotone voice.
2. The client had suicidal ideation on two previous admissions.
3. The client is fearful that poison is being placed in his food.
4. The client is unable to maintain eye contact with the nurse.

33. The charge nurse on the night shift receives a call from one of the nurses who is to report the next morning. The day- shift nurse reports that she has been diagnosed with strep throat and placed on antibiotics. Which of the following re- sponses by the charge nurse is MOST appropriate?

1. "How long have you had the sore throat?"
2. "How long have you been on antibiotics?"
3. "Do you have an elevated temperature?"
4. "Do you have a doctor's release to work?"

34. The nurse cares for a client receiving cholestyramine (Questran) 4 g BID. The nurse would be MOST concerned if the client makes which of the following statements?

1. "I have a hard bowel movement every 2 or 3 days."
2. "I sprinkle the powder on my orange juice at breakfast."
3. "I have increased my intake of milk and green leafy vegetables."
4. "I take digoxin (Lanoxin) at lunch every day."

35. The nurse performs teaching for a client receiving alendronate (Fosamax) 10 mg PO OD. The nurse determines that teaching is effective if the client states which of the following?

1. "I will take the medication at lunch."
2. "I'm glad that I don't have to participate in a regular exercise program."
3. "If I forget a dose, I should take it when I remember it."
4. "I should wear sunscreen when I go outside.

36. The nurse admits a client to the medical unit with a diagnosis of heart failure and pneumonia. The client's wife states that the client has recently experienced a significant decline in his hearing and is extremely depressed. Which of the fol- lowing actions by the nurse is MOST appropriate?

1. Provide the client an opportunity to express his feelings about the hearing loss.
2. Assign the client to a nurse who has a hearing impairment.
3. Encourage the client to use the incentive spirometer every hour while awake.
4. Contact a support group for the hearing impaired.

37. The home care nurse visits an elderly client 1 day following a colonoscopy. The daughter states that her mother has been confused since coming home from the procedure. Which of the following actions should the nurse take FIRST?

1. Instruct the client to increase her intake of fluids.

2. Obtain the client's vital signs.
3. Determine how many times the client has voided.
4. Ask the client if she has experienced abdominal cramping. Strategy: Assess before implementing.

38. The nurse in the outpatient clinic performs an assessment of an elderly woman. The client states that her husband had a CVA 7 months ago, and she cared for him for 3 months. Four months ago she had to place her husband in a long-term care facility because she was no longer able to care for him. Since that time the client reports she has lost 40 pounds, she is afraid to live alone, and she sorely misses her husband. The nurse notices that the client is extremely hard of hearing. Which of the following suggestions should the nurse make FIRST?

1. "I think you should move to the nursing home with your husband."
2. "Have you considered installing a security system in your home?"
3. "I'm going to refer you to Meals on Wheels."
4. "Perhaps you should find a hobby or join a club for seniors.”

39. The nurse cares for a client diagnosed with chronic obstructive pulmonary disease (COPD) receiving oxygen per nasal canula at 2 L/min. The nurse observes that the client has shortness of breath and chest pain. The nurse notifies the as- signed physician, and the physician makes no changes in the amount of oxygen the client is receiving. Which of the fol- lowing responses by the nurse is MOST appropriate?

1. Report concerns to the supervisor.
2. Contact the physician a second time.
3. Inform the family members that the physician has not changed the client's orders.
4. Continue to monitor the respiratory status of the client.

40. The community health nurse visits the home of a client with four school-aged children. The client is diagnosed with severely disabling migraine headaches. Which of the following instructions by the nurse is MOST appropriate?

1. "Hire someone to help with your children."
2. "Report excessive menstrual flow."
3. "Avoid stressful situations."
4. "Go to bed at the same time every night."

41. In early October, a home health nurse makes a home visit to an older client diagnosed with cataracts who is scheduled to have cataract removal with a lens implant in mid-November. Which of the following recommendations by the nurse is MOST important?

1. "Notify a trusted neighbor that you will be gone overnight."
2. "Get a flu shot as soon as possible"
3. "Read this information about surgical removal of cataracts."
4. "Check with your insurance company regarding co-payment and services."

42. A patient is to be discharged after a right total hip replacement. Which of the following statements, if made by the pa- tient to the nurse, indicates that teaching has been effective?

1. "I can't sit in my favorite recliner with my legs up."
2. "I should ask my wife to put on my socks and shoes."
3. "I should clean the incision with a mixture of hydrogen peroxide and water before applying a sterile dressing."
4. "I don't need to continue to do the leg exercises I learned in the hospital."

43. The mother of an 8-month-old boy is concerned because her son has started to scream and refuses to eat when left with the child-care provider. Which of the following statements by the nurse is BEST?

1. "Start looking for a different child-care provider."
2. "Check your son for bruises and other injuries."
3. "Remember that this is just a phase your son is going through."
4. "Hand your child his blanket as you say goodbye."