1. A client with HIV and AIDS confides that he is homosexual and his employer does not know his HIV status. The nurse’s best response to him is:
A. “Would you like me to help you tell them?”
B. “The information you confide in me is confidential.”
C. “I must share this information with your family.”
D. “I must share this information with your employer.”
2. The mother of a child with bronchial asthma tells the nurse that the child wants a pet. Which of the following pets should the nurse tell the mother is most appropriate?
3. An elderly client is being admitted to same-day surgery for cataract extraction. The client has several diamond rings. The nurse should explain to the client that
A. her rings will be taped before the surgery.
B. she will sign a valuables envelope that will be placed in a safe.
C. the rings will be locked in the narcotics box.
D. the nursing supervisor will hold onto the rings during the surgery.
4. When an infant resumes taking oral feedings after surgery to correct intussusception, the parents comment that the child seems to suck on the pacifier more since the surgery. The nurse explains that sucking on a pacifier
A. provides an outlet for emotional tension.
B. indicates readiness to take solid foods.
C. indicates intestinal motility.
D. is an attempt to get attention from the parents.
5. A 22-year-old client is brought to the emergency department with his fiancée after being involved in a serious motor vehicle accident. His Glasgow Coma Scale score is 7 and he demonstrates evidence of decorticate posturing. Which of the following would be appropriate for obtaining permission to place a catheter for intracranial pressure (ICP) monitoring?
A. The nurse will obtain a signed consent from the client’s fiancée because he is of legal age and they are engaged to be married.
B. The physician will get a consultation from one other physician and proceed with placement of the ICP catheter until the family arrives to sign the consent.
C. Two nurses will receive a verbal consent by telephone from the client’s next of kin before inserting the catheter.
D. The physician will document the emergency nature of the client’s condition and that an ICP catheter for monitoring was placed without a consent.
6. A 68-year-old client’s daughter is asking about the follow-up evaluation for her father after his pneumonectomy for primary lung cancer. The nurse’s best response is which of the following?
A. “The usual follow-up is chest x-ray and liver function tests every 3 months.”
B. “The follow-up for your father will be a chest x-ray and a computed tomography (CT) scan of the abdomen every year.”
C. “No follow-up is needed at this time.”
D. “The follow-up for your father will be a chest x-ray every 6 months.”
7. The nurse is preparing to administer blood to an otherwise healthy client who requires postoperative blood replacement. The nurse is aware that the blood administration set must include
A. a micron mesh filter.
B. a nonfiltered administration blood set.
C. a special leukocyte-poor filter.
D. a microdrip administration set.
8. Under which circumstance may a nurse communicate medical information without the client’s consent?
A. When certifying the client’s absence from work.
B. When requested by the client’s family.
C. When treating clients who have a sexually transmitted disease (STD).
D. When ordered by another physician.
9. During the health history interview, which of the following strategies is the most effective for the nurse to use to help clients feel that they have an active role in their health care?
A. Ask clients to complete a questionnaire.
B. Provide clients with written instructions.
C. Ask clients for their description of events and for their views concerning past medical care.
D. Ask clients if they have any questions.
10. A client with severe major depression states, “My heart has stopped and my blood is black ash.” The nurse interprets this statement to be evidence of which of the following?
11. When a client wants to read his chart, the nurse should
A. call the doctor to obtain permission.
B. give the client the chart and answer questions for him.
C. tell the client that he can read the chart when the doctor makes rounds.
D. ask the client what he wants to know and answer those questions without giving him the chart.
12. A client who has a fractured leg has been instructed to ambulate without weight bearing on the affected leg. The nurse evaluates that the client is ambulating correctly if she uses which of the following crutch-walking gaits?
A. Two-point gait.
B. Four-point gait.
C. Three-point gait.
D. Swing-to gait.
13. A client with major depression states, “Life isn’t worth living anymore. Nothing matters.” Which of the following responses by the nurse would be best?
A. “Are you thinking about killing yourself?”
B. “Things will get better, you know.”
C. “Why do you think that way?”
D. “You shouldn’t feel that way.”
14. A client with bipolar 1 disorder has been prescribed olanzapine (Zyprexa) 5 mg two times a day and lamotrigine (Lamictal) 25 mg two times a day. Which of the following adverse effects would the nurse report to the physician immediately? Select all that apply.
D. Muscle rigidity.
15. A client is prescribed atropine, 0.4 mg IM. The atropine vial is labeled 0.5 mg/mL. How many milliliters should the nurse plan to administer?
16. A multiparous client tells the nurse that she is using medroxyprogesterone (Depo-Provera) for contraception. The nurse instructs the client to increase her intake of which of the following?
A. Folic acid.
B. Vitamin C.
17. Which of the following statements made by a woman in the first trimester are consistent with this stage of pregnancy? Select all that apply.
A. “My husband told his friends we will have to give up the mustang for a minivan.”
B. “Oh my, how did this happen? I don’t need this now.”
C. “I can’t wait to see my baby. Do you think it will have my blond hair and blue eyes?”
D. “I wonder how it will feel to buy maternity clothes and be fat.”
18. The nurse is teaching a client about topical gentamicin sulfate (Garamycin). Which of the following comments by the client indicates the need for additional teaching?
A. “I will avoid being out in the sun for long periods.”
B. “I should stop applying it once the infected area heals.”
C. “I’ll call the physician if the condition worsens.”
D. “I should apply it to large open areas.”
19. A client has been taking imipramine (Tofranil) for his depression for 2 days. His sister asks the nurse, “Why is he still so depressed?” Which of the following responses by the nurse would be most appropriate?
A. “Your brother is experiencing a very serious depression.”
B. “I’ll be sure to convey your concern to his physician.”
C.”It takes 2 to 4 weeks for the drug to reach its full effect.”
D. “Perhaps we’ll need to change his medication.”
20. Which interventions would the nurse use to assist the client with grandiose delusions? Select all that apply.
A. Accepting the client while not arguing with the delusion.
B. Focusing on the feelings or meaning of the delusion.
C. Focusing on events and topics based in reality.
D. Confronting the client’s beliefs.
ANSWERS AND RATIONALE: NCLEX COMPREHENSIVE EXAM PART 1