131 terms

Hogan Nclex Questions


Terms in this set (...)

Which action would the nurse institute that is specific to the care of an assigned client who has tuberculosis?
Wearing a particulate respirator mask when taking vital sign.
The nurse is providing home care instructions for a family with a toddler diagnosed with lice. The nurse includes which of the following instructions in the teaching plan?
a. vacuum floor and furniture to remove hair that might have live nits.
B. have the mother use a bright light and magnifying glass to check the hair for lice.
C. Launder the child's bedding and clothing in hot water with detergent and dry in a hot dryer for 20 minutes.
D. Teach children not to share combs, brushes, and hates.
Which of the following medication orders should the nurse question?
Ceftriaxone (Rocephin) IVBP every 8 hours
A client with narrow-angle glaucoma is scheduled for an outpatient colonoscopy later in the week. The nurse evaluates the client understands pre-procedure teaching when the client makes which statement?
I will inform my doctor and nurses of my glaucoma and the medication I am taking.
A client is found on the bathroom floor having a grand mal seizure. What is the nurse's priority intervention?
Sit on the floor and protect the client's head
The nurse is preparing to leave the room of a client on transmission-based precautions. Place in the correct order the steps the nurse would follow to remove personal protective equipment and perform hand hygiene.
1. Remove Gloves
2. Remove Mask
3. Remove Gown
4. Remove Eye Protection
5. Wash Hands
The nurse is preparing to enter the room of a client with pneumonia caused by penicillin-resistant Streptococcus pneumonia (PRSP), The Client has a tracheostomy and requires suction. Put the following personal protective equipment in order of donning. All options must be used.
1. Gown
2. Mask
3. Eye Protection
4. Gloves
An older adult client has fallen twice while getting up to go to the bathroom at night. The nurse implements which measure to decrease the risk of further client falls?
Leave the call bell within reach, and turn on the bathroom light.
A client asks the nurse to explain why she is receiving iodine (xylocaine) in there IV when her dentist injects it into her gums to numb the teeth before a filling. What is the best response by the nurse?
When given IV, this drug reduces irritability of heart cells and helps reduce dysrhythmias.
The nurse is giving a medication to a client at 8:00 am. What is the most important action the nurse should take before administering the medication?
Check the client's identification band.
A newborn is scheduled for discharge from the birthing center tomorrow. When teaching the new parents about car seats, which characteristics of infant restraint systems would the nurse include as essential for the newborn?
1. Rear Facing
2. In the back seat.
The nurse is working with a client who has chronic Diarrhea. In teaching ways to reduce diarrhea, the nurse would encourage the client to avoid which of the following?
Anxiety and anger.
A client has weakness of the lower extremities and uses crutches for mobility. The nurse concludes the client needs further information about using crutches when the client does which of the following?
Bears weight on the armpits.
The nurse is participating in a therapeutic touch session with a client. The nurse evaluates that it would be appropriate to stop the session when which of the following occurs?
The practitioner perceives that the imbalance has been resolved.
A client has a nasogastric (NG) Tude in place for gastic decompression and reports increaseing nausea. Which action should the nurse take first.
Instill 20ML of saline
Which assessment data gathered by the nurse would prohibit the use of imagery with a clinet?
Client has a history of psychosis
when using humor therapy with a client, the nurse should do which of the following?
Use humorous interventions after the nurse attended to the physcical or emational pain that the clinet might be experiencing.
The nurse is admitting a clinent with thermal burns to both arms and anterior trunk. The clinet asks for a dring of water. What is the most appropriate response for the nurse to make?
"Im Sorry, you cannot drink anything right now; let me moisten your mouth instead."
When instering an 18-gauge Fench unrinary catheter into a male clinet, the nurse met resistnace when it was instered less than one-half the distance required. what action would be most beneficial to complete catheter insertion?
Lifting the shaft of the penis to a 90-degree angle to the abdomnen.
A nurse is orineting a newly employed RN. Which statement by the new nurse indicates a lack of understanding about oxygen satruation?
Oxygen saturation is only assessed ny analyzing the PaO2.
A client has been referred for dietary teaching regarding the management of hepatitis. The nurse would base development of nutritional goals on which data?
The diet should be high in calories and high in protien.
A client with a closed drainage system tries to get out of bed alone and disconnects the chest tube from the drainage system, which falls on the floor. Which action should the nurse take first upon entering the client's room?
Submerge the tube in sterile water or saline.
A client is reveiving radiation to the head and neck area for treatment of cancer. What intervention would the nurse use to help the client's complaint of a dry mouth?
Suggest the use of sugar-free candies.
A nurse is preparing for a busy morning. the first assigned clinet has hemodialysis in two hours. The second client has discharge orders. The third client has congestinve heart failure (CHR), and needs furosemide (Lasix) IV push. The fourth client is a 36- year old with type 2 diabletes melitus and a blood glucose of 156 mg/dl. What should the nurse do first?
Administer furosemide ( lasix) IVP to the clinet with CHF.
A new graduate nurse orientee plans to show an adolescent client a video about self-injection techniques. A staff nurse remarks, "I gave the client written literature yesterday, so the video probably isnt necessary." The nurse orientee proceeds with showing the video and discussing the skill with the adolescent after deciding to implement which ethical principle?
A charge nurse from the rehabiltation unit is floating on the medical unit to fill in as charge nurse. This is the nurse's first time on the medical unit. What should the charge nurse do first?
Get a quick orientation to the operation of the unit.
A nurse is caring for four clients who each have a priority nursing diagnosis. Based on each client's nursing diagnosis, which client should the nurse assess first?
Imapired gas exchange related to fluid in the bronchioles secondary to hypervolemia.
The nurse working on an adult medical-surgical unit would assign which clients to the licesnsed practial/vocational nurse (LPN/LVN) under supervision of the RN?
A 53 year old client with hypertension and chronic renal insufficiency.
The nurse has admitted to the intermediate care unit a client who sustained spinal cord injury at T1 in a motor vehicle accident. Which nursing care activity can the nurse delegate to the unlicensed assitive person (UAP) working with this client?
Measure oxygent saturation level every hour
Provide Mouth Care.
A nurse delegates to an unlicensed assistant (UA) the taks of blood glucose (BG) monitoring, which must be done every two hours. What critical component of delegation by the nurse is necessary to ensure the measurements are completed every two hours?
The nurse must provide feedback and evaluate performance.
A nurse is making rounds after receiving report. The nurse observes the client is receiving the wrong intervenous fluid. What is the nurse's next action?
Replace the bag of fluid with the fluid what was ordered.
The Registered nurse (RN) is assigned to the postpartum unit. Which task could the RN safely delegate to a beginning student nurse?
Ambulate a client who delivered by cesarean 2 days ago.
A client has sustained a factured femur. Which assessment should the nurse complete first?
Neurological assessment
An LPN/LVN is working with three clients. One client is receiving IV push morphine for left shoulder pain rated 7 on a scale of 0-10; a second has an oral order of digoxin (Lanoxin) and furosemide (Lasix) for heart failure (HF); the third is table and has vitamins ordred to improve wouldn healing. What task should the LPN/LVN request be completed by the registered nurse (RN) ?
The administration of IVP morphine for the client with pain.
A child is admitted with suspected abuse. Which action is most appropriate for the RN to request of the unlicensed assistant (UA)?
Sit with the child while the parents are interviewed.
The nurse explains that it is necessary to obtain a thorough history of Blood pressure problems before surgery to determine which of the following?
Possibility of malignant hypertension
A client is about to undergo skin biopsy to determine if a skin lesion is malignant. The clinet asks how much the biopsy will hurt. Which response by the nurse if best?
You may feel some discomfort while the local anesthetic is injected, but his will numb the area for the actual biopsy.
A client is admitted with complaints of severe nausea and vomiting for several days. The nurse expects the client is at rish for experiencing which acid-base imbalance?
Metabolic alkalosis
An elderly client with a history of not taking prescribed insulin is admitted to the hospital in an unresponsive state. Arterial blood gas (ABG) results are pH 7.30; PaCO2 40 mmHg; HCO3- 15 Meq/L. The nurse analyzes that this client has which imbalance?
Metabolic acidosis, uncompensated
Which PRN medication would the nurse anticipate using when a postoperative client is suspected to have taken an excessive dose of a narcotic, and has a respiratory rate of approximately 8 breaths per minute?
Naloxone (Narcan)
A client needs to have a type and crossmatch complete prior to administering a transfusion. The nurse is aware that the blood type of the client represents which of the following?
An antigen found on the red blood cell membrane
Prior to the administration of filgrastim (Neupogen), the client reports a history of hypersensitivity to E. Coli products. The nurse should take which action?
Withhold the administration of filgrastim, and notify the physician.
Which intervention should the nurse complete when caring for a client admitted with a sodium level of 152 mEq/L?
Observe and prepare for possible seizures.
A female client has been successfully resuscitated after cardiac arrest. Her aterial gas reveals a pH of 7.6. The nurse attributes this result to which of the following?
Excess sodium bicarbonate, which was administered during the resuscitation.
This is the first postoperative day for a client who unerwent cesarean delivery. The client asks the nurse why sh has to get up and walk when it hurts her incision so much. What should the nurse include in a response?
Walking decreases the risk of blood clots after surgery
When caring for a client who has partial thickness and full thickness burns, the nurse should expect laboratory results to reveal which electrolyte imbalance because of the burn injury?
The nurse who reads the results of a client's tuberculin (TB) test notes that an induration is apparent. The client asks what this means. What is the nurse's best response?
A postitive test meants that you have been exposed to the TB organism. It does not mean that you currently have active bacteria. Further testing will be needed.
A client beginning medication therapy with furosemide (Lasix) once daily. The nurse should instruct the client to take the medication at which optimal time?
8:00 Am
The client asks the nurse about self-care related to newly ordered zafirlukast (accolate). What is the appropriate resonse by the nurse?
Liver function tests should be monitored
The nurse caring for a client receiving chemotherapy incorporates which practices into the routine for the day's work shift?
1.Anticipate dosage changes by the physician based on the client's lab values.
2.Maintain dose intensity through management of treatment of side effects.
3. Administer oral drugs that are part of the treatment regiment for the client.
The client is being prepared to have labor induced with oxytocin (pitocin). The nurse concludes that medication teaching has been effective when the client makes which statement?
Pitocin is a synthetic version of a hormone my body produces naturally.
A nurse giving an intramuscular injection places the heel of the hand on the client's greater trochanter, with the fingers pointing toward the client's head. The nurse places the index finger on the client's anterior superior iliac spine, while the middle finger is stretched dorsally, palpaing the iliac crest. After giving the injection in the triangle formed, the nurse documents the injection as being given in which inttramuscular injection site?
When caring for the client with signs of severe hypocalcemia, the nurse anticipates administration of which item?
Ten percent calcium gluconate by slow IV push
A 3-year-old client has been diagnosed with attention-deficit/hyperactivity disorder (ADHD). The child's parents report that a friend told them that the child will likely receive "Lots of Drugs". Which drug should the nurse reply that the child is most likely to be given?
Ampetamine and dextroamphetamine (Adderall)
Mycoplasmal infections are usually resistant to antibiotics such as penicillin because of the following
Mycoplasma have no cell wall membrane
A diabetic client newly diagnosed with hypertension also smokes. The nurse would question an order for which antihypertensive medication?
Propranolol (Inderal)
A client has a new order for a medication that should be taken at the same time every day. Because the meaning of time varies from one culture to another, which of the following strategies would best promote the effectiveness of the medication regimen?
Be flexible in establishing time parameters, allowing client to provide input in the establishment of the medication schedule.
A family member reports a client history of chemical abuse when the client is admitted to a medical unit for treatment of chest pain. The client is ambivalent abou the recommendation for treatment made by an addiction counsulting team. What would be an appropriate nursing diagnosis at this time?
Decisional conflict
The elderly client expresses difficulty sleeping because her spirit is distrubed of sin in her life. The nurse should select which of the following as the priority intervention?
Ascertain what religious practice is appropriate to the client.
A client has recently been admitted for depression and suicidal idealations with a plan to hang himself. The nurse assesses the client most carfully for risk for attempting suicide at which time?
when the client begins to demonstrate clinical improvement.
what is the most important intervention by the nurse when a client does not respond to less restrictive interventions and is rapidly escalating toward violence?
Cease negotiation with client and implement plan of intervention to control client and provide safety
A client is diagnosed with paranoid personality disorder. Which assessment data does the nurse conclude are consistent with this diagnosis?
Jealousy and secretiveness
The 34-year old woman client presents with regular, heavy menses with clots up to golf-ball size. she has had three first-trimester spontaneous abortions this year. The nurse would expect the physician to order which of the following?
Which client assigned to the nurse is most at risk for developing a deep vien thrombosis (DVT)?
a 40-year old woman who smokes and uses oral contraceptives
The nurse has been caring for a client who has become extremely anxious and agitated. When assessing the client, the nurse would expect to note which of the following that could unlimately lead to an acid-base imbalance?
Rapid, Shallow respiratoy pattern
A 6-year old child with asthma is being treated with metaproterenol (Alpupent). The mother informs the nurse that she has been using the medication more fequently lately bacuase the child's symptoms have worsened. For what potential side effects should the nurse monitor the client?
Nervousness and tachycardia
An elderly client is admitted with pneumonia and respiratoy acidosis. The nurse is aware that respiratoy compensatory mechanisms are not likely to correct the acid-base balance due to:
Decreased respiratoy function and decreased alveolar exchange areas in the lungs.
The nurse assesses that the first indication of bone loss in clients with osteoporosis is which of the following
loss of height
The parent of a newborn with epispadias is asking how this happend. What is the best answer by the nurse
the defect happens early in fetal development
A 70-year old hospitalized client with a past medical history of hypertension and mycoardial infraction is postoperative followinng stomach surgery. vital signs have beeen stable and an IV of D5 1/2 NS is unfusing at 100 mL/hr. The Client reports trouble breathing, and has a moist cough, and the pulse oximetry reading has fallen to 92%. What action should the nurse take first?
Slow the intervenous rate to 10-12 mL/Hr
The wife of a client diagnosed as HIV-postitive states she will never be able to have sexual intercourse again. How should the nurse respond?
Sexual activity can be resumed, but you must always have protected sex.
The client is admitted in active labor with a breech presentation. Which sign would indicate to the nurse that there is fetal distress?
Fetal heart rate (FHR) of 180 beats/minute
Which of the following would be a priority nursing intervention for a newborn experiencing hypothermia?
monitoring for hypoglycemia
An older adult client with osteoarthritis is scheduled for discharge. The client says, "I don't know if I will be able to remember all that you have told me. I live alone, and am not sure what pills to take or when to do the treatments." What is the next action the nurse would take?
ask the physician to refer the client to a home health agency for nursing care
The schoool nurse is speaking to parents at a parent teacher orginization (PTO) meeting on car safety. What care restreaint system would the nurse recommend for use with a child in third grade?
Must sit in the rear with a lap/shoulder belt. Use a booster seat if lap/Shoulder belt does not fit properly.
For the client diagnosed with iron-deficiency anemia, the nurse should recommend an increased intake of which food?
organ meats
An older adult client with sensory deficits is scheduled for surgery. What action by the nurse is appropriate?
plan for extra time for preoperative teaching content
the pregnant client, who is 34 weeks' gestation, calls the prenatal clinic reporting cramping pain in her abdomen. After the diagnosis of Braxton-Hicks contractions is made, the nurse should give the client which recommendation?
Empty your bladder fequently and change postitions if these contractions are bothering you
Which of the following should the nurse review in discharge teaching for a client with Type 1 diabetes mellitus who was admitted with a blood glucose level of 562 mg/dl?
1. Nutrient intake and diet planning
2. exercise requirements
3. Importance of keeping medical appointments
A mother asks, "Is it true that breast milk will prevent my baby from catching colds and other infections?" The nurse should make which reply?
your baby will have increased resistance to illness caused by bacteria and viruses, but she may still contract infections.
A 9-year old child is at the 98th percentile for weight and at the 40th percentile for height. What interpretation should the school nurse draw from this data?
The Child is overweight or large in stature
The school health nurse is interested in promoting safety in the school population. In planning safety education for this age group and parents, the nurse would recognize that which of the following as a development risk factor for adolescents?
feelings of immortality related to the perception of being inculnerable to risks that affect others.
The nurse is preparing a teaching plan for a client with sickle cell disease about ways to prevent crisis episodes. Which of the following should be emphasized to prevent sickle cell crisis?
seek treatment for infections as soon as possible
A nurse is working with a group of postpartum women. using Culturally based practices as a guide, which of the following clients is greatest risk for postpartum depression?
American client
The nurse working in a pernatal clinic concludes that genetic counseling would be most important for the client who has family history of which disorder?
Sickle Cell Anemia
Which of the following clinets is at risk of experiencing a spontaneous pneumothorax
a tall thin young man who smokes
When counseling clients regarding prevention of common burns, the nurse should streess which of the following
temperature setting of the water heater
The nurse determines that instructions about mypyramid has been effective when the client states that frankfurters belong to which food group
When caring for a client with sickle cell crisis, which dietary measures should hte nurse emphasize
high fluid intake
During the fist prenatal assessment, the nurse discovers that the client has not had a second vaccination for measles, mumps, and rubella. What is the best plan for this client?
administer the vaccine following delivery
The public health nurse administering inactivated hepatitis a (Hep A) vaccine to clients at risk. The nurse determines that, acording to statistics regarding incidence, a clinet from which cultural group should have highest priority to recieve the vaccine
a native american client
The nurse is caring for the client who is recovering from partial thinkness burs, Which of the follwoing breakfast choices indicates the client's understanding of the recommended diet?
Two poached eggs, hash brown potatoes, and whole milk
Which information should the nurse provide a client who is planning to begin a low-carbohydrate (CHO) diet to lose weight?
a minimum level (50-100 grams/day) of CHOs is needed in the body in order to prevent protein breakdown
a 55-year old African-American female client presents with a heart rate of 124 bmp and blood pressure of 130/80 mm Hg. The client reports palpitations and shortness of breath. During health history, the nurse notes that the client takes multivitamins and fish oil. What should the nurse expolore during the assessment?
use of other herbs and over-the-counter medicines
For the client diagnosed with iron-deficiency anemia, the nurse should recommend an increased intake of which food?
organ meats
A client is found on the bathroom floor having a grand mal seizure. What is the nurse's priority intervention
sit on the floor and protect the client's head
The nurse provides care for a 13-year-old in a halo brace because of spinal cord injury. Which of the following is the first priority
assess the pin sites
The nurse would perform which actions when washing hands as part of medical asepsis before caring for a client in an outpatient clinic
use a clean paper towel to trun water off
rub vigorously using firm, circular motions
The nurse concludes that client teaching about infection control measures has been effective when a client with tuberculosis makes which statement
i need to wear a mask when i go to x-ray
The nurse is preparing to irrigate a wound infected with vancomycin-resistant enterococci. What person protective equipment (PPE) would the nurse wear
gloves, gown, eye protection and surgical mask
A 7-year old client is diagnosed with rheumatic fever. The physican orders throat cultures of all family members. When questioned by the parents about the rationale for this order, how should the nurse respond
family members can carry streptococcus and be asymptomatic
When the clinet is at high risk for suicide, which action is of the highest priority to the nurse
monitor the clien'ts location and behavior constantly
A client with acquired immunodeficiency syndrome (AIDS) who has Pneumocystis carinil is being admitted to the nursing unit. the nurse should institute which of the followin
standard precautions
While making rounds, the nurse observes a client receiving oxygen through a venturi mask. The nurse expects that the client will receive which primary benefit of this method of oxygen supplementation
oxygen concentration can be regulated
A client with congestive heart failure has digoxin (Lanoxin) ordred every day. Prior to giving the medicine, the nurse checks the digoxin level that is therapeutic and auscultates an apical pulse. The apical pulse is 62 bpm for 1 minute. What action should the nurse take
give the lanoxin as ordred
The nurse is admitting a clinet to the nursing unit who will be placed on contact precautions. What action should the nurse take regarding the client's mean trays
inform the dietary department that a disposable meal tray is needed
A nurse asks a client, "Have you ever felt a sudden, intense fear with no apparent reason?" When the client Responds "yes" , the nurse would assess the client for other symptoms compatable with which problem
panic disorder
A client who had an aortic valve replacement has been started on sodium warfarin ( coumadin) and is soon to be discharged. What would the nurse instruct the float RN to address as a priority in client teaching at this time?
avoid foods high in vitamin K
A woman calls the Emergency Department (ED) stating that she has been raped. What is the priority action of the nurse?
Instruct the client not to show, and instruct her to come to the hospital
The registered nurse is assigned to the postpartum unit. Which task could the RN safely delegate to an unlicensed assistive person (UAP)?
ambulate a client who had a vaginal delivery yesterday
While making rounds with the nurse, the physican asks the nurse to write an order for tylenol 500 mg q 4 prn for temperature evelation > 100. What should be the nurse's reponse?
record the order with "verbal order" written with the nurse's signature and remind the physician to cosign it within the next 24 hours.
During a coffee break, the nurse notices two coworkers arguing about how to handle a difficult client. Their voices are raised and body postures are tense and defensive. Which would be the most appropriate apporach for the nurse to use to address this conflict between staff members?
speak privately to the coworkers, telling them about personal reactions to this public encounter
The nurse has received peropertaive medications from the pharmacy for an adult male is scheduled for a coronary artery bypass graft. which nursing action is a priority in administering thses drugs?
checking the allergy history
A nurse assess a client who has an elevated blood pressure, crackles in the lower bases, respiratory rate of 26, and an oxygen saturation of 89%. What is the nurse's next action
administer a scheduled daily dose of furosemide (lasix) 40 mg IV push
the nurse working on a neuroscience unit has just recieved an intershift report. Which of the following assigned clients should the nurse assess first
a client who had a hemorrhagic stroke and reports a severe headache
A nurse is caring for a client with an unsteady gait. The client was found by the unlicensed assistnat (UA) on the floor. The client is reporting hip pain. how should the nurse document this incident
complete an incident report , and document the fall in the client's chart
Which of the following is an appropriate assignment for the registered nurse (RN) to delegate to the licensed practival nurse (LPN)
33-year old man with back pain scheduled for a CT scan
The nurse is preparing for a busy day on the unit. Which task should the nurse compelte first
assess a client in physical restraints
A nurse is delegating care of clients to the certified nursing assistant (CNA) and licesed practical/vocational nurse (LPN/LVN) which tasks should the nurse give the CNA and LPN/LVN
CNA: measure vital signs LPN/LVN Give oral medications on assigned clients
The nurse would intervene after noting another nursing staff member perform which action in the care of a child who has had surgery for clubfoot
administering pain medication immediately when it is due and covering the cast with blankets
A community health nurse is conducting a seminar for clients ingesting warfarin (coumadin) the nurse instructs the clients to make which dietary adjustment
reduce intake of foods like broccoli and cabbage
Metformin (Glucophage) has been prescribed for a client newly diagnosed with type 2 diabetes mellitus. The nurse evaluates that the client understood medication teaching when the client states that this medication does which of the following
decreases production of glucose by the liver
The client has bipolar I disorder. Lithium Carbonate (lithium) 300 mg 4 times daily has been prescribed. After 3 days of lithium therapy, the client says, "What's wrong? My hands are shaking a little." What is the best reponse by the nurse
Minor hand trembling often happens for a few days after lithium is started. It usually stops 1-2 weeks
A client who presents to the emergency department with wheezes and intercostal retractions is diagnosed with acute bronchospasm secondary to acute bronchitis. Epinephrine (Bronkaid) is ordred to be given subcutaneously. The nurse would anticipate seeing the intended effect of the medication in how many minutes
5 minutes
The nurse explains to a client recently diagnosed with parkinson's disease that most of the medications used to treat the disorder improve the availability of what susbstance to the brain
which statement made by the client who is taking saw palmetto indicates a need for further teaching
i will take saw palmetto in the morning as a tea
A client is to start on sulfamethoxazole (Grantanol) for a urinary tract infection (UTI) what priority nursing intervention precedes administration of the first dose
ensure that a urine specimen for culture and sensitivity (C&S) has been ordred
A client in active labor is to have an epidural block. While this is being administed, which of the following nursing actions takes priority
monitoring the maternal blood pressure for possible hypotension
A client is receiving bleomycin (Blenoxane) as treatment for cancer. For which of the following cardinal symptoms of pulmonary toxicity should the nurse assess
Dyspnea on exertion and at rest
A client who requires diuretic therapy has a creatinine clearance less than 30 ml/min. The nurse checks the physican order sheet, expecting to find an order for which type of medication
furosemide (Lasix)
A client has received 10 units of stored blood following massive blood loss. The nurse plans to check for which electrolyte imbalance in this client