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NURS 421 NCLEX Kaplan Final Exam Predictor Test
NURS 421 NCLEX Kaplan Final Exam Predictor Test
The nurse cares for a client with a cuffed tracheostomy tube. Before performing oral
care, the nurse notes that the client's tracheostomy cuff is inflated. Which of the
following is the MOST appropriate action for the nurse to take?
2) Implementation: outcome not desired; accumulated oral secretions above the cuff will
drain into the bronchi; increased risk of infection
4) Implementation: outcome not desired; increases the risk of trauma to lower airways
A young adult brings a friend to the emergency department and states that the friend
has been using heroin. Which action by the nurse is the MOST appropriate?
3) Assessment: outcome not priority; most important to assess airway and breathing
4) Assessment: outcome not priority but may be appropriate; drowsiness and euphoria
may be seen; not priority
The client tells the clinic nurse that the client is thinking about using nicotine polacrilex
(Nicorette). Which question is MOST important for the nurse to ask?
2) Assessment: outcome not priority but may be appropriate; should be assessed for
further teaching
4) Assessment: outcome may be appropriate but not priority; gum is place between
cheek and gums; may stain dental work
The nurse cares for the client with a client controlled analgesia (PCA) pump. The nurse
determines that the client has pressed the button 11 times and received 6 doses of
morphine during the last hour. Which is the MOST appropriate action for the nurse to
take?
3) Implementation: outcome not desired; more important to assess severity of pain and
pain relief first
4) CORRECT - Assessment: outcome priority; must validate that client is in pain before
implementation
A pregnant woman receives an epidural anesthetic. After administration of the epidural
anesthetic, the client's blood pressure changes from 120/84 to 94/50. Which action by
the nurse is MOST appropriate?
4) Implementation: outcome not desired; elevation of legs will increase venous return,
but fetal pressure on vena cava will prevent blood return to heart
A nursing order, "Increase fluid intake" is written for a client diagnosed with dehydration.
Which finding BEST indicates improving fluid status?
1. "Your parents are going to leave a half hour before the surgery."
2. "You're going to talk with some other children who had this surgery."
3. "If you have this surgery, your parents will buy you a new toy."
4. "Take this doll and show me where the operation will be done."
1) Implementation: outcome not desired; parents are encouraged to remain with child
3) Implementation: outcome appropriate but not priority; does not keep client
independent and active
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The nurse cares for a client with a history of type 1 diabetes mellitus who has just
returned to the surgical acute-care unit after a right below-knee amputation. The client's
capillary blood glucose is 480 mg/dL. The postoperative orders indicate 6 units of
regular insulin subcutaneously should be administered. Which of the following is the
FIRST action the nurse should take?
1. Check the client records to see if insulin was given prior to surgery.
2. Administer the 6 units of regular insulin subcutaneously.
3. Administer the insulin when oral fluids are tolerated.
4. Contact the healthcare provider.
1) Assessment: outcome desired but not priority; client needs insulin coverage now
3) Implementation: outcome not desired; needs insulin regardless of oral intake due to
elevated blood glucose
2) Implementation: outcome not desired; NSAIDs should be used cautiously with aspirin
allergies
1. "The skin around the stoma should be cleaned with warm water and thoroughly
dried."
2. "The appliance should fit snugly around the ileostomy opening."
3. "I should take polyethylene glycol (MiraLax) with a large glass of water."
4. "I will continue to take a daily multi-vitamin."
1) Implementation: outcome desired; standard of care for ileostomy
2) Assessment: outcome not expected; crackles, heard with pneumonia and CHF,
caused by fluid in the alveoli
4) Assessment: outcome not priority; will be increased with any inflammatory process
The nurse cares for the client in the labor unit. During the transitional phase of labor, the
umbilical cord becomes prolapsed. It is MOST important for the nurse to take which
action?
1. Place the client on her back with thighs flexed on her abdomen.
2. Place the client on her left side with legs flexed.
3. Place the client supine with the head of the bed elevated 30°.
4. Place the client supine with the foot of the bed elevated.
1) Implementation: outcome not desired; lithotomy position; will not decrease pressure
on umbilical cord
2) Implementation: outcome not desired; position used to remove weight of fetus from
vena cava to prevent maternal hypotension; will not help with prolapsed cord
2) CORRECT - Assessment: outcome desired and priority; normal sodium range is 135-
145 mEq/L, dilutional hyponatremia due to SIADH; client is neurologically depressed
with increased risk of seizures
3) Asssessment: outcome desired but not priority; indicates fluid retention, not as
important as hyponatremia; important to watch trends in weight
4) Assessment: outcome not desired; 1.008 indicates that urine is very dilute; with
SIADH, urine will have high concentration and specific gravity due to excess ADH
secretion
The home care nurse cares for a client who is diagnosed with hypertension and mild
depression. The client's daughter states that her mother has been falling frequently.
WWhich response by the nurse is BEST?
2) Assessment: outcome not priority; "yes/no" question; doesn't help determine the
problem
3) Implementation: outcome not desired; NPO 8 hours prior to test; dye may cause
possible nausea; fluid intake should be increased after procedure to clear dye and
reduce risk of renal toxicity
4) Implementation: outcome desired but not highest priority; not at greatly increased risk
for atelectasis
A child sustains a crushing chest injury in a car accident. In the emergency room, an
endotracheal tube is inserted. Several hours later the nurse enters the client's room and
finds the child in respiratory distress. It is MOST important for the nurse to take which
action prior to the angiogram?
3) CORRECT - Assessment: outcome priority; will give early and clearest indication of
respiratory status, will hear changes with narrowed airways, fluid in alveoli or
pneumothorax
4) Assessment: outcome desired but not priority; late indication of respiratory distress;
intercostal muscles are accessory muscles
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The nurse cares for an elderly man diagnosed with Alzheimer's disease. It is MOST
important for the nurse to take which action?
3) Implementation: outcome not priority; does not address safety needs or orientation
4) Implementation: outcome desired not priority; addresses safety but not orientation or
stimulation needs
The nurse is responsible for triage of injured residents of an apartment building that
collapsed during a tornado. Which client should the emergency personnel see FIRST?
1. A 38-year-old client with potential fracture left femur. Blood pressure 110/78, pulse
92/minute, shallow respirations at 16/minute.
2. A 42-year-old client with ecchymotic areas on the left anterior and posterior chest.
Blood pressure 142/90, pulse 88/minute, shallow respirations at 20/minute.
3. A 48-year-old client with severe head trauma. Blood pressure 168/52, pulse 58 per
minute, irregular respirations at 12/minute.
4. A 64-year-old client complaining of left hand and wrist pain asking, "Where am I?"
Blood pressure 128/72, pulse 88/minute, respirations unlabored at 16/minute.
1) Potential for hemorrhage or fatty embolism; eliminate second
2) Outcome not desired; elderly clients are at risk for clostridium difficile infection due to
antibiotic therapy; client would need frequent assessment and evaluation
3) CORRECT - Outcome desired; LPN/LVN can care for stable clients with expected
outcomes; nothing in question indicates instability; as cerebral edema resolves, the
condition will improve
4) Outcome: not desired; client requires frequent assessment and evaluation; WBC
indicates possible infection
The nurse cares for a client during a 24-hour urine specimen collection. Several hours
later, the client tells the nurse that she has started to menstruate. Which action by the
nurse is MOST appropriate?
2) Implementation: outcome not desired; all urine must be collected for accuracy
4) Implementation: outcome not desired; would change the results of the 24-hour urine
sample; all urine must be collected for accuracy
The nurse cares for the client in the recovery room after a knee surgery procedure. The
client has an oral airway in place. Which is the BEST indicator that the oral airway can
be removed?
3) Outcome not priority; colostrum may leak from breast during pregnancy; normal
finding
4) Outcome not priority; normal finding; quickening doesn't occur before 18 weeks in
primagravidas; 20 weeks in multigravidas
The nurse instructs a client about include digoxin (Lanoxin), furosemide (Lasix),
spironolactone (Aldactone), and a low-sodium diet. Which statement by the client
indicates the need for further instruction?
1. "I should weigh myself every morning and call the health care provider if I gain more
than a couple of pounds in a few days."
2. "I should call the health care provider immediately if I start to feel nauseated or have
difficulty breathing with normal activities."
3. "I plan to use salt substitutes now that I have to limit my sodium intake."
4. "I should read food and nonprescription medication labels to check the ingredients."
1) Implementation: outcome desired; would indicate fluid retention
1. "After I explain the operation to you, both of us will sign the form for legal purposes
and it will be placed in your chart."
2. "Tell me what the healthcare provider told you about the risks and benefits of this
operation."
3. "Can I answer any questions that you have about the procedure?"
4. "You should read all these materials to be sure that you understand everything about
this procedure."
1) Implementation: outcome not desired; nurse should not explain the procedure; the
health care provider doing the procedure should explain the risks and benefits
4) Implementation: outcome desired but not priority; reading materials do not ensure
that client understands risks and benefits of the procedure
A man scheduled for a vasectomy tells the nurse that he and his wife are involved in a
monogamous relationship. Which statement by the nurse is BEST?
1. "You will need to wear a condom when having sexual intercourse for 6 weeks
following the vasectomy."
2. "No other form of birth control is necessary for you or your wife at this time."
3. "You do not need to wear a condom when having sexual intercourse for the next few
weeks, but your wife should use spermicidal jelly."
4. "Always wear a condom when having sexual intercourse because not all vasectomies
are successful."
1) CORRECT - Implementation: outcome desired; sperm count decreased after the
vasectomy; some sperm may remain in the vas deferens
3) Assessment: outcome not priority; nurse should be able to delegate procedure if UAP
is competent
4) Assessment: outcome not priority; obtaining a capillary glucose sample is within UAP
scope of practice
A 12-year-old diagnosed boy with a fractured right femur is placed in balanced
suspension traction with a Thomas splint and Pearson attachment. The nurse is MOST
concerned by which client statement?
1. "I will experience more muscle spasms and pain while my leg is in traction."
2. "I can lift my body up while I grab the overhead trapeze and bend my left leg."
3. "The health care provider told me it is okay to move the head of my bed up and down
by myself."
4. "I need to put the phone where I can reach for it without moving onto my side."
1) CORRECT - Implementation: outcome not desired; muscle spasm should decrease
with traction; if muscle spasm pain increases, the amount of traction weight should be
assessed
4) Implementation: outcome desired; can move up and down only, moving side-to-side
changes line of pull of traction
The nurse prioritizes the needs of a client who has been raped. Which nursing action is
MOST important?
3) Assessment: outcome desired but not highest priority; address physical needs first
4) Implementation: outcome not highest priority; legal documentation is not the highest
priority
A child in a new plaster walking cast has dusky, swollen toes. Which action by the nurse
is MOST appropriate?
3) Assessment: outcome desired but not priority; should report changes in circulation
1. "If you take 5 mg folic acid daily while trying to conceive, you should be able to get
pregnant."
2. "It is recommended that you take carbamazepine suspension instead of the tablets
when trying to get pregnant."
3. "You should contact your health care provider and discuss your concerns about
pregnancy."
4. "If you avoid drinking grapefruit juice, there should be no problem with conception."
1) Implementation: outcome not desired; carbamazepine and valproic acid increase risk
of birth defects; daily folic acid decreases risk of neural tube defects if taken during
pregnancy; folic acid will not increase fertility
2) Implementation: outcome not desired; possible birth defects due to action of the
medication; route of administration does not matter
4) Implementation: outcome not desired; grapefruit juice can increase serum levels of
carbamazepine as much as 40%
The nurse cares for the client 3 days after a stroke. It is MOST important for the nurse
to take which action?
1. Instruct the client to push with the feet while moving client up in bed.
2. Offer the client soft foods on request.
3. Auscultate the client's lungs every 4 hours.
4. Observe the client's legs for warm, reddened, and tender areas every 4 hours.
1) Implementation: outcome not desired; if client holds breath, may increase intracranial
pressure
2) Implementation: outcome not desired; need to assess risk for aspiration first before
any oral fluids or foods given
3) CORRECT - Assessment: outcome desired and priority; decreased oxygen levels will
increase intracranial pressure, client at high risk for aspiration
4) Assessment: outcome desired but not priority; at risk for thrombophlebitis due to
immobility
The nurse cares for the client diagnosed with schizophrenia. Which question is MOST
important for the nurse to ask the client's spouse?
3) Implementation: outcome not desired; "passing the buck"; must check identification
2) Assessment: outcome not a problem; 120-160/minute; varies while asleep and awake
3) Assessment: outcome not desired but not priority; possible orthostatic hypotension;
further assessment needed
4) Correct - Implementation: outcome not desired and priority; metformin should be held
for 48 hours prior to tomography with contrast media; risk lactic acidosis with potential
renal damage
The nurse cares for clients in a mental health center. The nurse observes the client,
formerly homeless and malnourished, diagnosed with chronic schizophrenia putting
food from lunch into a plastic bag. Which statement by the nurse is MOST appropriate?
1. "We don't allow people to take food from the dining room."
2. "What are you going to do with the food?"
3. "We will be serving snacks and juice at 3 P.M."
4. "Let's go watch a movie with the others."
1) Implementation: outcome not desired; judgmental; non-therapeutic communication
1. "I take a multivitamin tablet daily for cold and flu prevention."
2. "I had major abdominal surgery a year ago."
3. "I get some stomach pain when I eat spicy foods."
4. "I hit my head and lost consciousness during a car accident 2 months ago."
1) Implementation: outcome not a problem; no interaction
3) Assessment: outcome not priority; immunization deferred only if client has active
infection
2) Implementation: outcome not desired; legally competent senior can choose where to
live and with whom
units
50 units heparin/1 mL
1. "I shall apply cream to the residual limb to soften the skin."
2. "I should rewrap my residual limb with elastic bandages 3 times a day."
3. "I will not be able to sleep on my stomach from now on."
4. "I will no longer be able to sit in straight back chairs at home."
1) Implementation: outcome not desired; skin needs to be toughened if prosthesis is
going to be used; no lotions, creams, or powders should be used unless prescribed
3) Implementation: outcome not desired; the prone position will decrease the risk of
flexion contractures
4) Implementation: outcome not desired; client can sit in straight back chair; time should
be restricted to 1 hour or less
The husband of an elderly client who is incontinent asks the nurse whether his wife will
have to wear diapers. Which response, if made by the nurse, is MOST appropriate?
3) Outcome not desired; need to deal with the "here and now"
1. A 5-month-old infant after a cast application on the left extremity due to club foot.
2. A 4-year-old boy with right abdominal swelling and a decreased appetite.
3. A 6-year-old boy admitted with cystic fibrosis and a temperature of 101.5 F (38.68 C).
4. A 10-year-old girl with newly diagnosed type 1 diabetes.
1) CORRECT-Implementation: outcome desired; stable client with predictable outcome;
serial casting used to correct congenital club foot
2) Implementation: outcome unstable client; needs assessment and evaluation; possible
teaching interventions needed
1. "Giving your mother salty food will only make her condition worse."
2. "Didn't your mother tell you she's on a low-sodium diet?"
3. "Tell me what you know about your mother's diet."
4. "Let's make an appointment for you to meet with a dietician."
1) Implementation: outcome desired but not priority; non-therapeutic; closed statement
3) Implementation: outcome not desired; nurse can never change prescribed dose
1. The LPN/LVN reports that a client who had a thoracotomy 2 days ago has clots in the
chest drainage system.
2. The nursing assistive personnel reports that a client who had a thyroidectomy 24
hours ago refuses to ambulate 30 minutes after receiving hydrocodone (Vicoden).
3. The family of a client who had a small bowel resection 48 hours ago reports the client
is more confused than yesterday.
4. A client who had an ileostomy 3 days ago complains of "aching legs."
1) Not priority; further assessment required; see second
2) Not priority; may be safety issue; further assessment needed; see last
3) CORRECT-Priority; may have decreased cerebral blood flow or oxygenation; see first
4) Not priority; client is at risk for thrombophlebitis; further assessment and evaluation
needed; see third
The nurse makes a follow-up phone call to the family of an infant receiving treatment for
watery diarrhea after 7 days of amoxicillin (Amoxil) therapy. The nurse knows teaching
is successful if the family makes which statement?
1. "We wear a fresh pair of clean gloves with each diaper change."
2. "We are not allowing our other children to be in the same room with the baby."
3. The grandmother wears a mask when changing the baby's diaper.
4. The mother wears an apron when changing the baby's diaper.
1) CORRECT-Implementation: outcome desired; contact precautions; Clostridium
difficile infection may develop after antibiotic treatment
2) Implementation: outcome not desired; unnecessary; should use stool and enteric
precautions
3) Implementation: outcome not desired; mask unnecessary; used for airborne infection
4) Implementation: outcome not desired; need to use contact precautions, gown only if
soiling likely
A 25-year-old woman is admitted to the labor unit for delivery of her first child. Her
husband is coaching her during labor. During the transitional phase of labor, the client
begins to scream and grab the side rails with each contraction. Which action, if taken by
the nurse, is MOST effective?
2) Implementation: outcome desired but not priority; priority action is to assist client to
get control
4) Implementation: outcome desired but not priority; meet physical needs first
The client with with a 5-year history of alcohol abuse is treated in the emergency room
for acute alcohol intoxication. The client is agitated and verbally abusive. Admission
orders include chlordiazepoxide (Librium) 50 mg IM or PO every 4-6 hours for agitation.
Which action by the nurse is MOST appropriate?
4) Implementation: outcome not desired; administered to assist the client to refrain from
drinking first dose administered at least 12 hours after the last alcohol consumed
The nurse reviews health assessments completed by student nurses. Which
assessment warrants further investigation?
1. An 11-year-old female who states that she has had 3 periods in the past 6 months.
2. A 13-year-old male with intermittent voice changes.
3. A 14-year-old male with bilateral breast enlargement.
4. A 15-year-old female with bilateral breast buds.
1) Assessment: outcome expected; irregular menstrual periods common during the first
year or two after menarche
1. "The healthcare provider told me to come in once a month for vitamin B12 injections."
2. "I eat frequently throughout the day."
3. "I do not eat concentrated sweets."
4. "I drink several glasses of iced tea with my meals."
1) Implementation: outcome desired; required monthly to prevent pernicious anemia
3) Assessment: outcome not expected; oliguria is seen with rejection due to failing
kidney
4) Assessment: outcome not expected; edema and weight gain are seen with rejection
A client is brought to the clinic by the spouse. The client's lab results are Na+ 156
mEq/L, Cl- 100 mEq/L, K+ 4.0 mEq/L, BUN 86 mg/dL, glucose 100 mg/dL. Which is the
MOST appropriate action for the nurse to take?
1. (1.) Osteoporosis.
2. (2.) Decreased white count.
3. (3.) Low blood sugar.
4. (4.) Low serum potassium.
5. (5.) Retinal detachment.
6. (6.) Fluid retention
(1.) CORRECT-Glucocorticoids decrease bone density; calcium and vitamin D
supplements or biphosphonates will decrease risk
(2.) Glucocorticoids depress the immune response, but not the white cell count
2) Implementation: outcome not desired; meets safety needs but lacks environmental
stimulation
1. "You need to see the health care provider today, but come in after hours."
2. "Come in this afternoon for your regularly scheduled appointment."
3. "You will receive the rubella vaccine during your regularly scheduled appointment."
4. "Please cancel today's appointment and reschedule for next month."
1) Implementation: outcome not desired; incubation period is 14-21 days, not
communicable at this time; if woman develops rubella infection during the first trimester,
abortion may be considered
1. "When I document information about these injuries, it will be on your son's hospital
record forever."
2. "How would you describe your son's relationship with his brothers and sisters?"
3. "What I see suggests that someone has been abusing your son."
4. "I will need to talk to the nurse manager about this situation before you leave."
1) Implementation: outcome not desired and not priority; documentation of suspected
abuse should contain facts and be nonjudgmental
2) Assessment: outcome not priority; priority action is to report potential abuse to nurse
manager
1. "The benefits of the procedure usually outweigh the risks of bleeding and infection."
2. "You should ask your obstetrician or pediatrician to advise you."
3. "It is not mandatory that your son have a circumcision. What are your concerns?"
4. "Some parents worry about the pain associated with circumcision, but there is
actually very little discomfort."
1) Implementation: outcome not desired; program of good hygiene provides advantages
without risks of circumcision
1. A 70-year-old diabetic with fasting blood glucose readings of 240-260 mg/dL for 1
week.
2. A 65-year-old discharged from the hospital 2 days ago following coronary artery
bypass graft surgery (CABG).
3. A 55-year-old with congestive heart failure who gained 3 lbs in the last 24 hours.
4. A 40-year-old with metastatic breast cancer complaining of pain unrelieved by pain
medication.
1) Follow-up required, but not priority; see second
2) Will require assessment and teaching, but no immediate care indicated; see third
3) CORRECT-Rapid weight gain indicates fluid retention, which could exacerbate CHF;
see first
4) Stable client; pain control will be addressed but not first; see last
The home care nurse instructs the daughter of a client diagnosed with congestive heart
failure. The daughter states her father is taking digoxin (Lanoxin) 0.25 mg and the
healthcare provider just prescribed furosemide (Lasix) 40 mg. Which statement, if made
by the daughter to the nurse, indicates teaching is successful?
2) Implementation: outcome not desired; high in sodium, would increase fluid retention
3) Assessment: outcome not priority; more important to look for obstruction in tubing
1. Instruct the staff transporting the client to wear a gown and mask.
2. Place a face mask on the client.
3. Request that the x-ray be postponed.
4. Give the client an emesis basin and tissues.
1) Implementation: outcome not desired; mask is placed on client to prevent
transmission of airborne pathogen
4) Implementation: outcome desired but not priority; mask worn to prevent transmission
of airborne pathogen
The nurse cares for an 80-year-old client taking medication for the treatment of
hypertension and heart failure. Which action is MOST important for the nurse to take?
1. Check the client's blood pressure and heart rate immediately after ambulation.
2. Instruct the client to use a walker at all times during ambulation.
3. Encourage the client to walk with the feet as close together as possible.
4. Instruct the client to sit on the edge of the bed for 3 to 5 minutes before arising.
1) Assessment: outcome not desired; blood pressure and heart rate should be assessed
prior to ambulation; more important to assess for shortness of breath and activity
tolerance
4) Assessment: outcome a concern but not priority; intolerance to light not seen; blurred
vision not commonly seen
The nurse teaches the client how to perform a colostomy irrigation. During the teaching,
the client states, "I can't do this." Which response, if made by the nurse, is BEST?
1. "Sure you can do this. You just need to have more practice."
2. "I'll do it for you this time, but you must perform the irrigation the next time."
3. "You seem to be frustrated. What are your specific concerns?"
4. "Most of the other clients learn this without any difficulty. Let's try it again."
1) Implementation: outcome not desired; false reassurance; need to assess first
2) Implementation: outcome not desired; activity does not precipitate a gout attack
1. A client with an open fracture of the left femur. BP 110/60, P 86, R 20, T 99.2° F
(37.3° C).
2. A client complaining of a "crushing" headache. BP 160/ 100, P 76, R 18, T 98.4° F
(36.9° C).
3. A client with burns on the face, chest, and hands. BP 120/80, P 100, R 24, T 98.8° F
(37° C).
4. A client with type 1 diabetes. Blood sugar 480 mg/dL. BP 100/60, P 100, R 26, T
99.4° F (37.4° C).
1) See last; most stable client
3) CORRECT-See first; unstable client; upper airway injury possibly due to inhalation
injury
4) See third; vital signs consistent with dehydration, rapid respiration is Kussmaul's and
expected
The home care nurse makes an initial visit to an 80-year-old client. The client's daughter
states that her mother has a history of colon cancer and has been restless and
confused for about a week. It is MOST important for the nurse to obtain an answer to
which question?
4) Assessment: outcome desired but not priority; not most important; urinary tract
infections cause acute confusion in elderly
The nurse cares for a client in active labor. The client's membranes rupture
spontaneously at 6 centimeters of dilation. Which action actions should the nurse take
FIRST?
2) Assessment: outcome not priority; dysrhythmias occur due to right heart failure;
priority is oxygenation
4) Assessment: outcome not priority; common reason for worsening status is respiratory
infection; more important to establish respiratory status first
The home care nurse visits a client diagnosed with Parkinson's disease. The nurse is
MOST concerned if which of the following is observed?
3) CORRECT-Assessment: outcome priority; anterior wall MI high risk for heart failure;
assess client first and then equipment
4) Assessment: outcome desired but not priority; should be assessed, but ABCs apply
here
A woman delivers a 6-lb and 2-oz infant. The Apgar scores at 1 and 5 minutes are 8 and
9, respectively. Which action is MOST appropriate for the nurse to take?
(2.) herbal preparations are classified as dietary supplements; adverse reactions may
be reported after use
(3.) CORRECT - the FDA does not research or regulate herbal preparations because
they are classified as dietary supplements
(4.) CORRECT - read labels carefully to determine what the herbal preparation contains
(5.) label should state that the herbal preparation will "decrease inflammation or support
the immune system"; label cannot say that the preparation "protects against cancer"
The nurse feeds the client in a chair when the client suddenly begins to choke on food.
The client is conscious but unable to speak. Which action is MOST appropriate for the
nurse to take?
4) Implementation: outcome not desired; could cause increased problems; food could
migrate further into respiratory tract
While playing on the floor in the hospital room, a 2-year-old has a tonic-clonic seizure.
Which action should the nurse take FIRST?
4) Implementation: outcome not desired; turn client to side after the seizure to reduce
risk of aspiration; should protect extremities during seizure
The nurse describes to a male client how to collect a clean-catch urine for culture and
sensitivity. Which explanation, if made by the nurse, is MOST accurate?
1. "The urinary meatus is cleansed with an antiseptic solution, and then a urinary
drainage catheter is inserted to obtain urine."
2. "You will be asked to empty your bladder one half-hour before the test; you will then
be asked to void into a container."
3. "Before voiding, the urinary meatus is cleansed with an antiseptic solution; urine is
then voided into a sterile container; the container must not touch the penis."
4. "You must void a few drops of urine, and then stop; then void the remaining urine into
a clean container which should be immediately covered."
1) Implementation: outcome not desired; unnecessary to use catheter
2) This is the procedure for a double void specimen and the question is for a clean
catch specimen.
4) Implementation: outcome not desired; always complete form for any medication error
The nurse counsels a woman at 36 weeks gestation who has attended childbirth class
in preparation for labor and delivery. Which statement by the client requires an
intervention by the nurse?
1. "I now know when to expect discomfort during labor and delivery and the things I can
do to decrease the discomfort."
2. "My husband is still concerned that he is not sure what to do during the labor
process."
3. "Even though I learned pain control techniques, I still may need some pain
medication during labor and delivery."
4. "The breathing patterns I learned in class will decrease the amount of time I spend in
labor."
1) Implementation: outcome desired; purpose of childbirth class is to eliminate fear of
the unknown
2) Implementation: outcome not desired but not priority; focus of class is on fetus and
mother; further assessment needed
4) Assessment: outcome not desired but not priority; urine is concentrated; fluids
encouraged to flush dye through kidneys
A client calls the healthcare provider's office reporting a rash, intermittent fever,
headache, fatigue, muscle pain, and stiff neck. It is MOST important for the nurse to ask
which question?
3) Assessment: outcome not priority; causes papular urticaria, not systemic symptoms
1. The student nurse sets the wall suction to 160 mm Hg pressure prior to suctioning.
2. The student nurse increases the oxygen level to 100% prior to suctioning.
3. The student nurse uses a catheter half the size of the tracheostomy opening.
4. The student nurse tells the client to breathe normally as the catheter is inserted.
1) CORRECT-Implementation: outcome not desired; will cause trauma to
tracheobronchial mucosa; suction should be set at 80-120 mm Hg
2) Implementation: outcome desired; will decrease the risk of tissue hypoxia; is standard
of care; must remember to decrease oxygen level to ordered concentration after
suctioning
3) Implementation: outcome desired; a larger catheter will obstruct the lumen and
increase the risk of trauma
4) Implementation: outcome desired; should breathe normally during suctioning
A man diagnosed with a stroke develops dysphagia. Before allowing the client to eat,
which action should the nurse take FIRST?
2) Assessment: outcome desired but not priority; should be assessed, but is not first
action
3) Assessment: outcome not desired; will be done by other health professionals; more
important to determine level of decontamination in field
2) Assessment: outcome desired but not priority; protein deficiency may cause
peripheral edema
3) Assessment: outcome desired but not priority; more important to provide nutrition
3) Assessment: outcome desired but not priority; more important to increase blood
glucose level
4) Implementation: outcome desired but not priority; should take action to correct
hypoglycemia first
The nurse assesses the IV site before administering vancomycin. The nurse notes that
the area around the IV infusion site is pale and feels cool. Which INITIAL action will the
nurse perform?
1. "I'm sorry about your wife. I'm sure you will miss her."
2. "This must be a difficult time for you; I will stay with you."
3. "I know you're going to miss your wife; would you like to talk about some memories
you both shared?"
4. "Is there anything I can get for you?"
1) Implementation: outcome not desired; should focus on husband, not nursing staff;
assumes husband's feelings
3) Implementation: outcome not desired; should focus on here and now; assumes
husband's feelings
4) Assessment: outcome desired but not priority; "yes/no" question; does not respond to
feeling tone
The nurse teaches a wellness class to a group of women. The nurse knows that which
of the following clients is MOST at risk for developing cervical cancer?
1. A woman who began menstruating at age 9.
2. A woman who used oral contraceptives for 8 years.
3. A woman diagnosed with endometriosis at age 20.
4. A woman who has had approximately 10 sexual partners.
1) Assessment: outcome not priority; increases risk of breast cancer
4) Assessment: outcome desired but not priority; usually won't change unless infection
is causing septic shock
On the third day after a thyroidectomy, the nurse notes that the client has developed
tremors. Which of the following is the MOST appropriate action for the nurse to take?
2) Assessment: outcome desired but not priority; blood glucose below 50 mg/dL;
symptoms include sweating, trembling, anxiety, hunger, weakness
3) Assessment: outcome desired but not priority; K+ below 3.5 mEq/L; symptoms
include fatigue, vomiting, muscle weakness, dysrhythmias
4) Assessment: outcome desired but not priority; if Na+ below 135 mEq/L; symptoms
include muscle cramps, lethargy, hemiparesis (paralysis of one side of body)
The nurse cares for a client with Addison's disease who is taking 20 mg hydrocortisone
(Cortef) daily. Which statement by the client requires an intervention by the nurse?
1. "I will need to have my blood sugar levels checked while on this medication."
2. "I may have episodes of low blood pressure while taking this medication."
3. "I need to weigh myself twice a week and keep a record of my weight."
4. "I should notify my health care provider if I am running a fever."
1) Assessment: outcome expected; glucocorticoids can increase serum glucose levels
3) Assessment: outcome expected; weight gain due to sodium and water retention
expected
(2.) CORRECT - Bruit should be heard over the area of the fistula due to increased
blood flow; if no bruit heard, notify healthcare provider
(3.) CORRECT - Increased risk of infection in the fistula area; possible infection should
be reported to healthcare provider
1. Lemonade.
2. Skim milk.
3. Ginger ale.
4. Tomato juice.
1) CORRECT- Implementation: outcome desired; 1 cup = 2 mg Na+
2) Implementation: outcome not desired; 1 cup = 125 mg; high Na+ in milk products
4) Implementation: outcome not desired; 1 cup = 500 mg; extremely high Na+
The nurse cares for a 24-year-old female client admitted to an inclient treatment unit
with a diagnosis of purging-type bulimia. It is MOST important for the nurse to take
which action?
4) Assessment: outcome desired but not priority; may be done after trust relationship
established
A 22-year-old woman at term comes to the hospital in labor. Two hours after admission,
the client remains 4 centimeters dilated, and her contractions are weak. The healthcare
provider orders oxytocin (Pitocin). Which finding would require an intervention by the
nurse?
1. Elevate the head of the bed 30° and then turn the client.
2. Place a pillow between the client's legs and then turn the client.
3. Have the client grasp the side rail on the opposite side of the bed and then assist the
client to turn.
4. Instruct the client to bend the knees and then assist the client to turn.
1) Implementation: outcome not desired; must stay flat to maintain alignment
1. The LPN/LVN enters the client's room and leaves the door open.
2. The nursing assistive personnel leaves the client's room with the face mask hanging
from the neck.
3. The student nurse washes hands and puts on gloves.
4. The client's mother stands away from the client while talking to the client.
1) Implementation: outcome desired; droplet precautions necessary, door may be left
open
3) Assessment: outcome not priority; changes in vital signs are late sign of increased
intracranial pressure
4) Assessment: outcome desired but not priority; increased carbon dioxide level will
increase intracranial pressure
The husband of a woman at 39 weeks gestation calls the clinic nurse and states, "My
wife's water just broke, and I think she's going to have the baby!" Which statement, if
made by the nurse, is BEST?
1. "Look at your wife's vaginal area and tell me what you see."
2. "Time the contractions for 5 minutes."
3. "Tell your wife to pant between contractions."
4. "I will instruct you about how to deliver the baby."
1) CORRECT- Assessment: outcome desired and priority; determine if presenting part is
crowning
2) Assessment: outcome desired but not priority; need to determine stage of labor first
4) CORRECT- Assessment: outcome desired and priority; will guide further assessment
and interventions; will gather needed information to tell health care provider
The nurse plans care for a 4-year-old girl who has been sexually abused by her
grandfather. Play therapy is scheduled as part of the treatment plan. Which statement, if
made by the child's parents, indicates understanding of the primary purpose of play
therapy?
1. "The main goal of play therapy is for our child to deal with any anger that she has."
2. "During these play sessions, our child will be encouraged to communicate at her own
level."
3. "Our child's developmental level will be evaluated by a child development specialist
during these sessions."
4. "The main purpose of play therapy is to determine exactly what type of abuse
occurred."
1) Implementation: outcome not desired; expression of anger may occur; main goal is
communication
2) CORRECT- Implementation: outcome desired; child may not be able to express her
perception of the events verbally; play with dolls will facilitate communication
3) Implementation: outcome not desired; not primary goal of play session; assessment
of developmental level may occur
4) Implementation: outcome not desired; may occur, but not the primary purpose
The nurse cares for a client with suspected Neisseria meningitidis infection. Which
action is MOST important for the nurse to take?
2) Assessment: outcome expected but not priority; could be due to other causes such
as change in position
4) Assessment: outcome expected but not priority; will increase due to diuretic but may
not change heart failure
The home care nurse performs a health screening at the local mall. The nurse knows
that which of the following clients is at HIGHEST risk for developing a stroke?
1. A 32-year-old Caucasian female who has a history of type 1 diabetes mellitus and
has used oral contraceptive for 8 years.
2. A 49-year-old Caucasian male who works as an account executive at an ad agency
and has a cholesterol level of 250 mg/dL.
3. A 56-year-old African-American female who consumes 1 to 2 alcoholic beverages
weekly and has smoked cigarettes for 30 years.
4. A 69-year-old African-American male who has a history of hypertension and is 30
pounds overweight.
1) Assessment: outcome not priority; risk factors include diabetes and oral contraceptive
use
3) Assessment: not priority; risk factors include race and smoking; daily consumption of
2 or more alcoholic beverages a day increases risk of hypertension and stroke
4) CORRECT- Assessment: priority; risk factors include age, race, hypertension, and
obesity
The nurse supervises the distribution of meal trays on a medical unit. Which tray will
should be given to a client who has requested a kosher diet?
1. Cheeseburger, sliced tomato, french fries, and a milkshake.
2. Pork chops, applesauce, baked potato, and ginger ale.
3. Shrimp salad, sliced avocado, bread, and coffee.
4. Fruit salad, cottage cheese, crackers, and tea.
1) Implementation: outcome not desired; cannot eat dairy and meat at the same meal;
eat dairy 6 hours after meat meal
2) Implementation: outcome not desired; cannot eat pork products (bacon, ham, animal
shortening, gelatin or foods containing gelatin, e.g., marshmallows)
3) Implementation: outcome not desired; cannot eat shellfish or scavenger fish; fish
must have scales
4) Assessment: outcome not priority; defoliant used in war, not significant for MRI
The home care nurse is visiting a client terminally ill with pancreatic cancer who wishes
to die at home. Which question, if asked by the nurse, is MOST appropriate?
2) Assessment: outcome desired but not priority; important to obtain the needed
equipment, but is very specific
3) Assessment: outcome not priority; passing the buck, yes-no question, non-
therapeutic
4) CORRECT- Assessment: outcome desired and priority; physical need, meet basic
needs first before psychosocial
A client returns to the unit following a thyroidectomy. Which assessment finding requires
an intervention by the nurse?
1. Remind the client that too much caffeine is bad for her health.
2. Tell the client that she may have coffee and a snack when her bath is complete.
3. Remove the client from the bath and return her to bed.
4. Get help from other staff members to complete the bath.
1) Implementation: outcome not desired; not effective with this client
3) Implementation: outcome not desired; needs physical needs met; need to develop
trusting relationship; action may increase distress
4) Implementation: outcome not desired; shouldn't use force; client should feel
environment is safe; action may increase distress
A 39-year-old man is admitted with a diagnosis of Acquired Immune Deficiency
Syndrome (AIDS). His lab results are hemoglobin 9.3 g/dL, hematocrit 25%, platelets
50,000/mm3, white cell count 1,500/mm3. Which order will should the nurse implement
FIRST?
4) CORRECT- Implementation: outcome desired and high priority; at risk for acquiring
life-threatening infection due to leukopenia
To locate the point of maximum impulse (PMI) of a client's heart, the nurse's hand
(fingertips) should be placed over which location?
1. A
2. B
3. C
4. D
QUESTION - Where do you find the PMI?
STRATEGY - Picture the anatomy of the heart and its position in the body.
NEEDED INFO - PMI: forward thrust of left ventricle during systole produces normal
pulsation on chest wall. Indicates size and position of heart. Should be felt in 5th
intercostal space. If apical impulse appears in more than one intercostal space, may
indicate ventricular enlargement.
CORRECT ANSWER - (3) The fifth intercostal space at the midclavicular line. (1) Wrong
position. (2) Wrong position. (4) Incorrect.
The nurse is caring for an elderly client admitted for type 1 diabetes mellitus. The nurse
notes that the client appears to have difficulty understanding what is said. Which of the
following actions, if taken by the nurse, is MOST appropriate?
1. Ask the client if cotton-tipped applicators are used for ear cleaning.
2. Perform the Weber hearing test.
3. Check the client's ear canals for cerumen.
4. Use facial expressions and speak in a high frequency tone of voice.
1) Assessment: outcome not priority; most common cause is cerumen in elderly
1. The client's diastolic blood pressure decreases 20 mm when the client rises to a
standing position.
2. The client's urinary specific gravity is 1.020.
3. The client has lost 3 pounds since her last admission.
4. The client appears pale and thin.
1) CORRECT- Assessment: outcome priority; indicates fluid volume deficit, check blood
pressure supine, sitting and standing; other symptoms include concentrated urine and
weak, rapid pulse
3) Assessment: outcome not priority; don't know when client was last hospitalized
4) Assessment: outcome not priority; more concerned about fluid volume deficit
The nurse performs dietary teaching for a client taking lithium carbonate (Lithonate).
Which snack, if selected by the client, indicates that teaching is effective?
1. SaO2 91%.
2. Expiratory wheezing.
3. Intercostal retractions.
4. Arterial pH 7.25.
1) Assessment: outcome expected; minimal acceptable level
1. Hepatitis B (HB).
2. Measles/mumps/rubella (MMR).
3. Inactivated polio (IPV).
4. Diphtheria, tetanus toxoid, and acellular pertussis (DTaP).
1) Implementation: outcome desired; no contraindication
1. A child with chickenpox placed in a private room at the end of the hall.
2. A child with meningitis placed in a private room across from the nurses' station.
3. A client with cellulitis of the right leg placed in a semi-private room with a client
diagnosed with type 1 diabetes.
4. A client with essential hypertension placed in a semi-private room with a client who
has pancreatitis.
1) Implementation: outcome desired; communicable disease, appropriate room
placemen
3) CORRECT- Implementation: outcome not desired; don't put a client with infection
(cellulitis) with a client who is at risk for infection
3) Implementation: outcome not desired: high risk of infection and sepsis, RN can do
thorough assessment during bath
Kaplan Predictor
150 terms
AdanayP
Kaplan Predictor B
117 terms
bohemianowl
Kaplan Predictor
150 terms
cheree_demarce_goch
predictor c
156 terms
lhmschool
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