1. The nurse is preparing a teaching plan for a 45-year-old client recently diagnosed with type 2 diabetes mellitus. What is the first step in this process?
a. Establish goals.
b. Choose video materials and brochures.
c. Assess the client’s learning needs.
d. Set priorities of learning needs.
2. A loading dose of digoxin (Lanoxin) is given to a client newly diagnosed with atrial fibrillation. The nurse begins instructing the client about the medication and the importance of monitoring the heart rate. An expected outcome of the education program will be:
a. a return demonstration of palpating the radial pulse.
b. a return demonstration of how to take the medication.
c. verbalization of why the client has atrial fibrillation.
d. verbalization of the need for the medication.
3. A multigravida client is scheduled for a percutaneous umbilical blood sampling (PUBS) procedure. The nurse instructs the client that this procedure is useful for diagnosing which of the following?
a. Twin pregnancies.
b. Fetal lung maturation.
c. Rh disease.
d. Alpha-Fetoprotein level.
4. Which of the following is a side effect of vancomycin (Vancocin) and needs to be reported promptly?
c. Muscle stiffness.
5. Which of the following statements indicates that the client with a peptic ulcer understands the dietary modifications he will need to follow at home?
a. “I should eat a bland, soft diet.”
b. “It is important to eat six small meals a day.”
c. “I should drink several glasses of milk a day.”
d. “I should avoid alcohol and caffeine.”
6. The client with a nasogastric tube begins to complain of abdominal distention. Which of the following measures should the nurse implement first?
a. Call the physician.
b. Irrigate the nasogastric tube.
c. Check the function of the suction equipment.
d. Reposition the nasogastric tube.
7. A male client has been diagnosed as having a low sperm count during infertility studies. After instructions by the nurse about some causes of low sperm counts, the nurse determines that the client needs further instructions when he says low sperm counts may be caused by which of the following?
b. Frequent use of saunas.
c. Endocrine imbalances.
d. Decreased body temperature.
8. The nurse assesses a client and notes puffy eyelids, swollen ankles, and crackles at both lung bases. The nurse understands that these clinical findings are most specifically associated with fluid excess in which of the following compartments?
a. Interstitial compartment.
b. Intravascular compartment.
c. Extracellular compartment.
d. Intracellular compartment.
9. An expected physiologic response to a low potassium level is
a. cardiac dysrhythmias.
d. increased energy.
10. When teaching unlicensed assistive personnel (UAP) about the importance of handwashing in preventing disease, the nurse makes which of the following statements?
a. “It is not necessary to wash your hands as long as you use gloves.”
b. “Handwashing is the best method for preventing cross-contamination.”
c. “Waterless commercial products are not effective for killing organisms.”
d. “The hands do not serve as a source of infection.”
11. The nurse is performing Leopold maneuvers on a woman who is in her eighth month of pregnancy. The nurse is palpating the uterus at the symphysis pubis area. Which of the following maneuvers is the nurse performing?
a. First maneuver.
b. Second maneuver.
c. Third maneuver.
d. Fourth maneuver.
12. A client in a cardiac rehabilitation program states that he would like to make sure he is eating the right foods to ensure adequate endurance on the treadmill. Which of the following nutrients is most helpful for promoting endurance during sustained activity?
13. A client’s chest tube is connected to a chest tube drainage system with a water seal. The nurse notes that the fluid in the water-seal column is fluctuating with each breath that the client takes. The fluctuation means that
a. there is an obstruction in the chest tube.
b. the client is developing subcutaneous emphysema.
c. the chest tube system is functioning properly.
d. there is a leak in the chest tube system.
14. A client with diabetes is explaining to the nurse how she will care for her feet at home. Which statement indicates that the client understands proper foot care?
a. “When I injure my toe, I will plan to put iodine on it.”
b. “I should inspect my feet at least once a week.”
c. “I do not plan to wear shoes while I am in the house.”
d. “It is important to dry my feet carefully after my bath.”
15. The nurse assesses a client with diverticulitis and suspects peritonitis when which of the following symptoms is noted?
a. Hyperactive bowel sounds.
b. Rigid abdominal wall.
c. Explosive diarrhea.
d. Excessive flatulence.
16. When assessing a client, which risk factors would lead the nurse to suspect that the client has pancreatitis? Select all that apply.
a. Excessive alcohol use.
c. Abdominal trauma.
d. Hyperlipidemia with excessive triglycerides.
17. When performing chest percussion on a child, which of the following techniques would the nurse use?
a. Firmly but gently striking the chest wall to make a popping sound.
b. Gently striking the chest wall to make a slapping sound
c. Percussing over an area from the umbilicus to the clavicle.
d. Placing a blanket between the nurse’s hand and the child’s chest.
18. The nurse walks into the room of a client who has a “Do Not Resuscitate” order and finds the client without a pulse, respirations, or blood pressure. What is the most appropriate action?
a. Stay in the room and notify the nursing team for assistance.
b. Push the emergency alarm to call a code.
c. Dial the hospital phone number for a code.
d. Pull the curtain and leave the room.
19. A client is trying to lose weight at a moderate pace. If the client eliminates 1000 calories per day from his normal intake, how many pounds would he lose in 1 week?
a. 1 pound.
b. 2 pounds.
c. 3 pounds.
d. 4 pounds.
20. A nulliparous client calls the clinic and tells the nurse that she forgot to take her oral contraceptive this morning. Which of the following would the nurse instruct the client to do?
a. Take the medication immediately.
b. Restart the medication in the morning.
c. Use another form of contraception for 2 weeks.
d. Take two pills tonight before bedtime.
ANSWER and RATIONALE for NCLEX Comprehensive Exam Part 3