2023 NCLEX Clinical Analysis Review Study Guide Comprehensive With Answers (260 Solved Questions)

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2023 NCLEX Clinical Analysis Review Study Guide Comprehensive With Answers (260 Solved Questions) - Page 1 preview image

NCLEX 2023 EXAM REVIEW STUDY GUIDECOMPREHENSIVE QUESTIONS AND ANSWERSNCLEX Review Study Guide Comprehensive 2023A client with diabetes mellitus calls the clinic nurse and reports that she has beenvomiting during the night and now has diarrhea. Which question does the nursemake a priority of asking the client? - ANSWER"Have you tested your bloodglucose?"A client's oral intake of liquids includes 120 mL on the night shift, 800 mL on theday shift, and 650 mL on the evening shift. The client is receiving an intravenous(IV) antibiotic every 12 hours, diluted in 50 mL of normal saline solution. Thenurse empties 700 mL of urine from the client's Foley catheter at the end of theday shift. Thereafter, 500 mL of urine is emptied at the end of the evening shift and325 mL at the end of the night shift. Nasogastric tube drainage totals 155 mL for the24-hour period, and the total drainage from the Jackson-Pratt device is 175 mL.What is the client's total intake during the 24-hour period? - ANSWER1670mLA client with heart failure suddenly experiences profound dyspnea, pallor, audiblewheezing, and cyanosis, and the nurse suspects pulmonary edema. The nursewould first: - ANSWERRaise the head of the client's bedA client with cervical cancer who is undergoing chemotherapy with cisplatin(Platinol). For which adverse effect of cisplatin will the nurse assess the client? -ANSWERHearing lossAlendronate (Fosamax) is prescribed for a client with postmenopausalosteoporosis. The nurse provides information on the medication to the client.When does the nurse tell the client to take the alendronate? - ANSWEREverymorning before breakfast, with a full glass of waterA client with emphysema is receiving theophylline (Theo-24). While providingdietary instructions, the nurse tells the client that it is acceptable to consume: -ANSWERApple juiceA nurse is reviewing the record of a client scheduled for electroconvulsive therapy(ECT). Which of the following diagnoses, if noted on the client's record, wouldindicate a need to contact the physician who is scheduled to perform the ECT? -ANSWERRecent strokeAn emergency department nurse is assessing a client with acute closed-angleglaucoma. Which of the following characteristics of the disorder does the nurse

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expect the client to exhibit? Select all that apply. - ANSWERNauseaEye painVomitingHeadacheThe nurse administers intravenous morphine sulfate to a client in pulmonaryedema. For which intended effect of the medication does the nurse monitor theclient? - ANSWERRelief of anxietyAn emergency department nurse is told that a client with carbon monoxidepoisoning resulting from a suicide attempt is being brought to the hospital byemergency medical services. Which intervention will the nurse carry out as apriority upon arrival of the client? - ANSWERAdministering 100% oxygenA client with agoraphobia will undergo systematic desensitization throughgraduated exposure. In explaining the treatment to the client, the nurse tells theclient that this technique involves: - ANSWERGradually introducing the client toa phobic object or situation in a predetermined sequence of least to mostfrighteningA client with a medical history of diabetes mellitus is found to have sarcoidosis,and oral prednisone is prescribed. The nurse provides instructions to the clientabout the medication and tells the client to: - ANSWERClosely monitor theblood glucose levelEnalapril maleate (Vasotec) is prescribed for a hospitalized client. Whichassessment does the nurse perform as a priority before administering themedication? - ANSWER Checking the client's blood pressureA client who has undergone abdominal hysterectomy asks the nurse when she willbe able to resume sexual intercourse. The nurse tells the client that sexualintercourse may be resumed: - ANSWERIn about 6 weeks, when the vaginal vaultis satisfactorily healedA nurse on the evening shift checks a physician's prescriptions and notes that thedose of a prescribed medication is higher than the normal dose. The nurse callsthe physician's answering service and is told that the physician is off for the nightand will be available in the morning. The nurse should: - ANSWERAsk theanswering service to contact the on-call physicianA hospitalized female client with mania enters the unit community room and says

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to a client who is wearing a blue shirt, "Boys in blue are fun to do! Boys in blue arefun to do!" What is the appropriate response by the nurse? - ANSWER "Don't saythat. If you can't control yourself, we'll help you."A client with HIV infection who has been found to have histoplasmosis is beingtreated with intravenous amphotericin B (Fungizone). Which parameter does thenurse check to detect the most common adverse effect of this medication? -ANSWERIntake and outputA nurse is gathering subjective and objective data from a client with suspectedrheumatoid arthritis (RA). Which early manifestations of RA would the nurseexpect to note? Select all that apply. - ANSWERFatigueLow-grade feverPhenelzine sulfate (Nardil) is prescribed for a client with depression. The nurseprovides information to the client about the adverse effects of the medication andtells the client to contact the physician immediately if she experiences: - ANSWERNeck stiffness or sorenessA client is receiving an intravenous infusion of oxytocin (Pitocin) to stimulatelabor. The nurse monitoring the client notes uterine hypertonicity andimmediately: - ANSWERStops the oxytocin infusionA nurse is assessing a pregnant woman for the presence of edema. The nurseplaces a thumb on the top of the client's foot, then exerts pressure and releases itand notes that the thumb has left a persistent depression. On the basis of thisfinding, the nurse concludes that: - ANSWERPitting edema is presentA nurse is caring for a client with community-acquired pneumonia who is beingtreated with levofloxacin (Levaquin). For which of the following findings,indicating an adverse reaction to the medication, does the nurse monitor theclient? - ANSWERFeverA client receiving parenteral nutrition (PN) suddenly experiences chest pain anddyspnea, and the nurse suspects an air embolism. The nurse immediately placesthe client in a lateral Trendelenburg position, on the left side. What action doesthe nurse take next? - ANSWERClamping the intravenous catheterA nurse is preparing a poster for a health fair booth promoting primary preventionof skin cancer. Which of the following recommendations does the nurse includeon the poster? Select all that apply. - ANSWERSeek medical advice if you find askin lesion.

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A nurse is providing instructions to a client with glaucoma who will be usingacetazolamide (Diamox) daily. Which of the following findings, an adverse effect,does the nurse instruct the client to report to the physician? - ANSWERDarkurineA nurse is providing morning care to a client who has undergone surgery to repaira fractured left hip. Which item is most important for the nurse to use in turningthe client from side to side to change the bed linens? - ANSWERAbductiondeviceA nurse is performing an assessment of a client being admitted to the hospitalwith a diagnosis of multiple sclerosis. The client tells the nurse that she tookbaclofen (Lioresal) for the past 9 months but completely stopped the medication 2days ago because it was making her feel weak. On the basis of this information, thenurse notes in the plan of care that the client should be monitored most closelyfor: - ANSWERSeizure activityA nurse administers nitroglycerin sublingually to a client with angina pectoris whocomplains of chest pain. The medication is ineffective, so the nurse prepares toadminister a second dose. Before administering the nitroglycerin, which actiondoes the nurse make a priority? - ANSWERChecking the client's blood pressureA nurse provides information to a client with coronary artery disease (CAD) aboutsmoking-cessation measures. Which statement by the client indicates a need forfurther information? - ANSWER"I should drink a cup of coffee if I feel the urgeto smoke."A client with myasthenia gravis who has been taking pyridostigmine bromide(Mestinon) for the treatment of the disorder comes to the emergency departmentcomplaining of severe muscle weakness, and cholinergic crisis is diagnosed.Which medication does the nurse prepare for immediate use in treating the crisis?- ANSWERAtropine sulfateA rape victim being treated in the emergency department says to the nurse, "I'mreally worried that I've got HIV now." What is the appropriate response by thenurse? - ANSWER"Let's talk about the information that you need to determineyour risk of contracting HIV."A nurse is providing instruction to a client with osteoporosis regardingappropriate foods to include in the diet. The nurse tells the client that one fooditem high in calcium is: - ANSWERSardines

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A nurse prepares to administer digoxin (Lanoxin) to a client with congestive heartfailure. Which vital sign must be checked before the medication is administered? -ANSWER Apical pulseA nurse provides home care instructions to a client with coronary artery disease(CAD) who is being discharged from the hospital. Which statement by the clientindicates a need for further instruction? - ANSWER"I need to participate inaerobic and weightlifting exercise three times a week."A nurse is caring for a client with a cuffed endotracheal tube who is undergoingmechanical ventilation. Which intervention to prevent a tracheoesophagealfistula, a complication of this type of tube, does the nurse implement? - ANSWERMaintaining cuff pressureErgotamine (Cafergot) is prescribed to a client with cluster headaches. Which ofthe following occurrences does the nurse tell the client to report to the physicianif she experiences them while taking the medication? - ANSWERNumbness andtingling of the fingers or toesA nurse who will be staffing a booth at a health fair is preparing pamphletscontaining information regarding the risk factors for osteoporosis. Which of thefollowing risk factors does the nurse include in the pamphlet? Select all that apply.- ANSWERSmokingHigh alcohol intakeWhite or Asian ethnicityA nurse is caring for a client who has just undergoneesophagogastroduodenoscopy (EGD). The client says to the nurse, "I'm reallythirsty—may I have something to drink?" Before giving the client a drink, thenurse should: - ANSWERCheck for the presence of a gag reflexA nurse provides information to a client who will be undergoing endoscopicretrograde cholangiopancreatography (ERCP). The nurse tells the client that: -ANSWERDye may be injected during the procedure to permit visualization ofthe pancreatic and biliary ductsCascara sagrada has been prescribed for a client with diminished colonic motorresponse as a means of promoting defecation. The nurse provides information to

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the client about the medication and tells the client to: - ANSWERIncrease fluidintakeA nurse provides instruction to a pregnant woman about foods containing folicacid. Which of these foods does the nurse tell the client to consume as sources offolic acid? Select all that apply. - ANSWERSpinachLegumesWhole grainsA client with a history of angina pectoris tells the nurse that the chest pain usuallyoccurs with moderate to prolonged exertion and is generally relieved bynitroglycerin or rest. Which type of angina does the nurse recognize in the client'sdescription? - ANSWERStableA client with myasthenia gravis is taking neostigmine bromide (Prostigmin). Thenurse determines that the client is gaining a therapeutic effect from themedication after noting: - ANSWERImproved swallowing functionA child is brought to the emergency department by ambulance after swallowingseveral capsules of acetaminophen (Tylenol). Which medication does the nurseprepare, anticipating that it will be prescribed to treat the child? - ANSWERAcetylcysteine (Mucomyst)A nurse is caring for a client with sarcoidosis. The client is upset because he hasmissed work and worried about how he will care financially for his wife and threesmall children. On the basis of the client's concern, which problem does the nurseidentify? - ANSWERAnxietyA male client arrives at the emergency department and reports to the nurse, "Iwoke up this morning and couldn't move my arms." He also tells the nurse that heworks in a factory and witnessed an accident 3 weeks ago in which a fellow

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employee's hands were severed by a machine. What is the priority response by thenurse? - ANSWERAssessing the client for organic causes of loss of armmovementAfter delivering a normal, healthy newborn, a client complains of severe pelvicpain and a feeling of extreme fullness in the vagina, and uterine inversion issuspected. For which immediate intervention does the nurse prepare the client? -ANSWERReplacement of the uterus through the vagina into a normal positionA client arrives in the emergency department and tells the nurse that she isexperiencing tingling in both hands and is unable to move her fingers. The clientstates that she has been unable to work because of the problem. During thepsychosocial assessment, the client reports that 2 days earlier her husband toldher that he wanted a separation and that she would have to support herselffinancially. The nurse concludes that this client is exhibiting signs compatiblewith: - ANSWERConversion disorderA client scheduled for suprapubic prostatectomy has listened to the surgeon'sexplanation of the surgery. The client later asks the nurse to explain again how theprostate is going to be removed. The nurse tells the client that the prostate will beremoved through: - ANSWERA lower abdominal incisionA nurse caring for a woman in labor is reading the fetal monitor tracing (seefigure). How does the nurse interpret this finding? - ANSWERUteroplacentalinsufficiency during a contractionA clinic nurse is assessing a client who has had a cast applied to the lower left arm1 week ago. The client tells the nurse that the skin is being irritated by the edges ofthe cast. What is the appropriate action on the part of the nurse - ANSWERPlacesmall pieces of tape over the rough edges of the castA nurse developing a plan of care for a client with HIV infection identifies several

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concerns. List them in order of priority, from highest to lowest. - ANSWER1Possible infection2Decreased nutrition3Fatigue4DespairAn emergency department nurse has a physician's prescription to irrigate a client'sears. List in order of priority the steps that the nurse should take in performingthis procedure. - ANSWER1 Use an otoscope to ensure that the tympanicmembrane is intact.2Warm tap water to body temperature.3Fill an irrigating syringe with warm water.4Insert the irrigating solution by directing the solution toward the wall of the earcanal.5Document the completion of the procedure and how the client tolerated it.The nurse is preparing to administer a tube feeding by way of a nasogastric tube.Which action does the nurse carry out as a priority before starting the flow of thesolution? - ANSWERChecking for gastric residual volume and assessing tubeplacementA client with schizophrenia says to the nurse, "I decided not to take my medicationbecause it can't help. I am the only one who can help me." Which nursing responseis therapeutic in this situation? - ANSWER"Your doctor wants you to continuethis medication because it's helping you. Do you recall needing to be hospitalizedbecause you stopped your medication?"A client is brought to the emergency department by ambulance, and diabeticketoacidosis is suspected. Blood samples are taken, and the nurse obtains suppliesthat will be needed to treat the client. Which type of insulin does the nurse take

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from the medication supply room for intravenous (IV) administration? - ANSWERRegular (Humulin R)A nurse is assessing a client who is experiencing chest pain. Which of the followingobservations indicates to the nurse that the pain is most likely a result of angina? -ANSWER The pain is relieved by rest and nitroglycerin.While being seen by a physician, a client complains of persistent fever, malaise,and night sweats. On physical examination, the physician palpates enlarged lymphnodes, and the client states that the nodes are painless. Hodgkin's lymphoma issuspected, and several diagnostic studies are performed. Which characteristic ofthis type of lymphoma does the nurse expect to note while reviewing the results ofthe diagnostic studies? - ANSWERReed-Sternberg cells on biopsy of a lymphnodeA client with chronic renal failure who will require dialysis three times a week forthe rest of his life says to the nurse, "Why should I even bother to watch what I eatand drink? It doesn't really matter what I do if I'm never going to get better!" Onthe basis of the client's statement, the nurse determines that the client isexperiencing which problem? - ANSWERPowerlessnessTolbutamide (Orinase) is prescribed to a client whose type 2 diabetes mellitus hasnot been controlled with diet and exercise alone. The nurse provides instructionsto the client about the medication. Which statement by the client indicates a needfor further instruction? - ANSWER"I can have a beer or glass of wine as long as Istay within my daily dietary restrictions."A client with adenocarcinoma of the ovary is scheduled to undergo chemotherapywith cyclophosphamide after total abdominal hysterectomy with bilateralsalpingo-oophorectomy. What does the nurse instruct the client to do duringchemotherapy? Select all that apply. - ANSWER-Drink copious amounts of fluidand void frequently-Avoid contact with any individual who has signs or symptoms of a cold

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A nurse reviews arterial blood gas values and notes a pH of 7.50 and a Pco2 of 30mm Hg. The nurse interprets these values as indicative of: - ANSWERRespiratory alkalosisA school nurse observing a child with Down syndrome is participating in aphysical education class and notes that the child is experiencing a diminution inmotor abilities. The nurse asks to see the child and conducts an assessment,during which the child complains of neck pain and loss of bladder control. What isthe appropriate action by the nurse in this situation? - ANSWERContacting thechild's physician to report the findingsA nurse is providing instruction about insulin therapy and its administration to anadolescent client who has just been found to have diabetes mellitus. Whichstatement by the client indicates a need for further instruction? - ANSWER"Ineed to keep any unopened bottles of insulin in the freezer."A nurse preparing to administer digoxin (Lanoxin) to a client calls the laboratoryfor the result of the digoxin assay performed on a specimen that was drawn at 6a.m. The laboratory reports that the result was 2.4 ng/mL. On the basis of thisresult, the nurse would: - ANSWERContact the physicianA nurse is developing a plan of care for a pregnant client with sickle-cell disease.Which concern does the nurse recognize as the priority? - ANSWER Decreasedfluid volumeA client with type 1 diabetes mellitus has just been told that she is 6 weekspregnant. The nurse provides information to the client about dietary and insulinneeds and tells the client that during the first trimester, insulin needs generally: -ANSWERDecrease

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A maternity nurse providing an education session to a group of expectant mothersdescribes the purpose of the placenta. Which statement by one of the womenattending the session indicates a need for further discussion of the purpose of theplacenta? - ANSWER"The placenta maintains the body temperature of my baby."A nurse is measuring intraocular pressure by means of tonometry in a client whohas just been found to have open-angle glaucoma. Which tonometry readingwould the nurse expect to note in this client? - ANSWER28 mm HgIodine solution (Lugol solution) is prescribed to a client who is scheduled forsubtotal thyroidectomy. The client calls the nurse at the clinic and complains of aburning sensation in the mouth and soreness of the gums and teeth. The nursemost appropriately tells the client: - ANSWERTo contact the physicianA client with chronic back pain asks a nurse about the use of complementary andalternative therapies to treat the pain. The nurse would initially: - ANSWERIdentify the client's treatment goalsA child with growth hormone deficiency will be receiving somatropin(Humatrope). The nurse provides information to the mother about themedication. Which of the following laboratory values does the nurse tell themother will require monitoring? - ANSWERThyroid-stimulating hormone (TSH)A client who has sustained an acute myocardial infarction (AMI) is receivingintravenous reteplase (Retavase). For which adverse effect of the medication doesthe nurse monitor the client? - ANSWEREpistaxisA client arrives at the clinic for her first prenatal assessment. The client tells thenurse that the first day of her last menstrual period (LMP) was September 25, 2012.Using Nagele's rule, the nurse determines that the estimated date of delivery(EDD) is: - ANSWERJuly 2, 2013

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A nurse provides instructions to a client who has been prescribed lithiumcarbonate (Lithobid) for the treatment of bipolar disorder. Which of thesestatements by the client indicate a need for further instruction? Select all thatapply. - ANSWER"I need to avoid salt in my diet.""It's fine to take any over-the-counter medication with the lithium.""Diarrhea and muscle weakness are to be expected, and if these occur I don'tneed to be concerned."An adult client with an ileostomy is admitted to the hospital with a diagnosis ofisotonic dehydration. What findings does the nurse expect to note during theadmission assessment? Select all that apply. - ANSWERSkin tentingFlat neck veinsWeak peripheral pulsesWarfarin sodium (Coumadin) is prescribed for a hospitalized client. Whiletranscribing the physician's prescription, the nurse notes that the client is takinglevothyroxine (Synthroid) to treat hypothyroidism. The nurse calls the physicianto confirm the prescription for warfarin sodium because: - ANSWERLevothyroxine amplifies the effect of warfarin sodiumA nurse caring for a client with preeclampsia prepares for the administration of anintravenous infusion of magnesium sulfate. Which of the following substancesdoes the nurse ensure is available at the client's bedside? - ANSWERCalciumgluconateA client with hypoparathyroidism is taking calcium gluconate to treathypocalcemia. The client calls the clinic nurse and complains of becomingconstipated since starting the medication. The nurse tells the client to: - ANSWERIncrease intake of high-fiber foods

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