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2024-2025 NCLEX Comprehensive Review Study Guide with Answers (261 Solved Questions) - Document preview page 1

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2024-2025 NCLEX Comprehensive Review Study Guide with Answers (261 Solved Questions)

Prepare like a pro with 2024-2025 NCLEX Comprehensive Review Study Guide with Answers, featuring authentic past exams.

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2024-2025 NCLEX Comprehensive Review Study Guide with Answers (261 Solved Questions) - Page 1 preview imageNCLEXReviewStudyGuideComprehensive2024/2025100% VERIFIED ANSWERSA 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?"Have you tested your blood glucose?"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 ofurine is emptied at the end of the evening shiftand 325 mL at the end of the night shift. Nasogastric tube drainage totals 155 mLfor the 24-hour period, and the total drainage from the Jackson-Pratt device is 175mL. What is the client's total intake during the 24-hour period?1670mLA client with heart failure suddenly experiences profound dyspnea, pallor, audiblewheezing, and cyanosis, and the nurse suspects pulmonary edema. The nursewould first:Raise 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?Hearing loss
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2024-2025 NCLEX Comprehensive Review Study Guide with Answers (261 Solved Questions) - Page 2 preview image
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2024-2025 NCLEX Comprehensive Review Study Guide with Answers (261 Solved Questions) - Page 3 preview imageAlendronate (Fosamax) is prescribed for a client with postmenopausalosteoporosis. The nurse providesinformation on the medication to the client.When does the nurse tell the client to take the alendronate?Every morning 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:Apple juiceA nurse is reviewing the record of a client scheduled for electroconvulsivetherapy (ECT). Which of the following diagnoses, if noted on the client's record,would indicate aneed to contact the physician who is scheduled to perform theECT?Recent strokeAn emergency department nurse is assessing a client with acute closed-angleglaucoma. Which of the following characteristics of the disorder does the nurseexpect the client to exhibit? Select all that apply.NauseaEye painVomitingHeadacheThe nurse administers intravenous morphine sulfate to a client in pulmonaryedema. For which intended effect of the medication does the nurse monitor theclient?Relief of anxietyAn emergency department nurse is told that a client with carbon monoxidepoisoning resulting from a suicide attempt is being brought to the hospital by
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2024-2025 NCLEX Comprehensive Review Study Guide with Answers (261 Solved Questions) - Page 4 preview imageemergency medical services. Which intervention will the nurse carry out as apriority upon arrival of the client?Administering 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:Gradually introducing the client to a phobic object or situation in a predeterminedsequence of least to most frighteningA 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:Closely monitor the blood glucose levelEnalapril maleate (Vasotec) is prescribed for a hospitalized client. Whichassessment does the nurse perform as a priority before administering themedication?Checking the client's blood pressureA client who has undergone abdominal hysterectomy asks the nurse when shewill be able to resume sexual intercourse. The nurse tells the client that sexualintercourse may be resumed:In about 6 weeks, when the vaginal vault is satisfactorily healedA nurse on the evening shift checks a physician's prescriptions and notes thatthe dose of a prescribed medication is higher than the normal dose. The nursecalls the physician's answering service and is told that the physician is off forthenight and will be available in the morning. The nurse should:Ask the answering service to contact the on-call physician
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2024-2025 NCLEX Comprehensive Review Study Guide with Answers (261 Solved Questions) - Page 5 preview imageA hospitalized female client with mania enters the unit community room and saysto a client who is wearing a blue shirt, "Boys in blue are fun to do! Boys in blueare fun to do!" What is the appropriate response by the nurse?"Don't say that. 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?Intake 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.FatigueLow-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:Neck stiffness or sorenessA client is receiving an intravenous infusion of oxytocin (Pitocin) to stimulatelabor. The nurse monitoring the client notes uterine hypertonicity andimmediately:Stops 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 lefta persistent depression. On the basis of thisfinding, the nurse concludes that:
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2024-2025 NCLEX Comprehensive Review Study Guide with Answers (261 Solved Questions) - Page 6 preview imagePitting 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?FeverA client receiving parenteral nutrition (PN) suddenly experiences chest pain anddyspnea, and the nurse suspects an air embolism. The nurse immediately placestheclient in a lateral Trendelenburg position, on the left side. What action doesthe nurse take next?Clamping the intravenous catheterA nurse is preparing a poster for a health fair booth promoting primaryprevention of skin cancer. Which of the followingrecommendations does thenurse include on the poster? Select all that apply.Seek medical advice if you find a skin lesion.A nurse is providing instructions to a client with glaucoma who will be usingacetazolamide (Diamox) daily. Which of the followingfindings, an adverse effect,does the nurse instruct the client to report to the physician?Dark urineA nurse is providing morning care to a client who has undergone surgery torepair a fractured left hip. Which item is most important for the nurse to useinturning the client from side to side to change the bed linens?Abduction deviceA 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 took
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2024-2025 NCLEX Comprehensive Review Study Guide with Answers (261 Solved Questions) - Page 7 preview imagebaclofen (Lioresal) for the past 9 months but completely stopped the medication2 days ago because it was making her feel weak. On the basis of this information,the nurse notes in the plan of care that the client should be monitored mostclosely for:Seizure activityA nurse administers nitroglycerin sublingually to a client with angina pectoriswho complains of chest pain. The medication is ineffective, so the nurse preparesto administer a second dose. Before administering the nitroglycerin, which actiondoes the nurse make a priority?Checking 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?"I should drinka cup of coffee if I feel the urge to 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 thecrisis?Atropine 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?"Let's talk about the information that you need to determine your risk of contractingHIV."
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2024-2025 NCLEX Comprehensive Review Study Guide with Answers (261 Solved Questions) - Page 8 preview imageA nurse is providing instruction to a client with osteoporosis regardingappropriate foods to include in the diet. The nurse tells theclient that one fooditem high in calcium is:SardinesA nurse prepares to administer digoxin (Lanoxin) to a client with congestive heartfailure. Which vital sign must be checked before the medication is administered?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?"I need to participate in aerobic 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?Maintaining 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?Numbness and tingling of the fingersor 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 thatapply.
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2024-2025 NCLEX Comprehensive Review Study Guide with Answers (261 Solved Questions) - Page 9 preview imageSmokingHigh alcohol intakeWhite or Asian ethnicityA nurse is caring for a client who has just undergoneesophagogastroduodenoscopy (EGD). The client says to the nurse, "I'm reallythirstymay I have something to drink?" Before giving the client a drink, thenurse should:Check 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:Dye may be injected during the procedure to permit visualization of the pancreatic andbiliary ductsCascara sagrada has been prescribed for a client with diminished colonic motorresponse as a means of promoting defecation. The nurse provides information tothe client about the medication and tells theclient to:Increase fluid intakeA nurse provides instruction to a pregnant woman about foods containing folicacid. Which of these foods does the nurse tell the client to consume as sourcesof folic acid? Select all that apply.SpinachLegumesWhole grainsA client with a history of angina pectoris tells the nurse that the chest painusually occurs with moderate to prolonged exertion and is generally relieved bynitroglycerin or rest. Which type of angina does the nurse recognize in theclient's description?
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2024-2025 NCLEX Comprehensive Review Study Guide with Answers (261 Solved Questions) - Page 10 preview imageStableA client with myasthenia gravis is taking neostigmine bromide (Prostigmin). Thenurse determines that the client is gaining a therapeutic effect from themedication after noting:Improved 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?Acetylcysteine (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 thenurse identify?AnxietyA 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 fellowemployee's hands were severed by a machine. What is the priority response bythe nurse?Assessing the client for organic causes of loss of arm movementAfter 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?Replacement of the uterus through the vagina into a normal position
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2024-2025 NCLEX Comprehensive Review Study Guide with Answers (261 Solved Questions) - Page 11 preview imageA 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:Conversion disorderA client scheduled for suprapubic prostatectomy has listened to the surgeon'sexplanation of the surgery. The client laterasks the nurse to explain again howthe prostate is going to be removed. The nurse tells the client that the prostatewill be removed through:A lower abdominal incisionA nurse caring for a woman in labor is reading the fetal monitor tracing (seefigure).How does the nurse interpret this finding?Uteroplacental insufficiency during a contractionA clinic nurse is assessing a client who has had a cast applied to the lower leftarm 1 week ago. The client tells the nurse that the skin is being irritated by theedges of the cast. What is the appropriate action on the part of the nursePlace small pieces of tape over the rough edges of the castA nurse developing a plan of care for a client with HIV infection identifies severalconcerns. List them in order of priority, from highest to lowest.1 Possible infection2 Decreased nutrition3 Fatigue4 Despair
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2024-2025 NCLEX Comprehensive Review Study Guide with Answers (261 Solved Questions) - Page 12 preview imageAn emergency department nurse has a physician's prescription to irrigate aclient's ears. List in order of priority the steps that the nurse should take inperforming this procedure.1 Use an otoscope to ensure that the tympanic membrane is intact.2 Warm tap water to body temperature.3 Fill an irrigating syringe with warm water.4 Insert the irrigating solution by directing the solution toward the wall of the ear canal.5 Document 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?Checking for gastric residual volume and assessing tube placementA client with schizophrenia says to the nurse, "I decided not to take mymedication because it can't help. I am the only one who can help me." Whichnursing response is therapeutic inthis situation?"Your doctor wants you to continue this medication because it's helping you. Do yourecall needing to be hospitalized because 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 obtainssupplies that will be needed to treat the client. Which type of insulin does thenurse take from the medication supply room for intravenous (IV) administration?Regular (Humulin R)A nurse isassessing a client who is experiencing chest pain. Which of thefollowing observations indicates to the nurse that the pain is most likely a resultof angina?The pain is relieved by rest and nitroglycerin.
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2024-2025 NCLEX Comprehensive Review Study Guide with Answers (261 Solved Questions) - Page 13 preview imageWhile being seen by a physician, a client complains of persistent fever, malaise,and night sweats. On physical examination, the physician palpates enlargedlymph nodes, and the client states that the nodes are painless. Hodgkin'slymphoma is suspected, and several diagnostic studies are performed. Whichcharacteristic of this type of lymphoma does the nurse expect to note whilereviewing the results of the diagnostic studies?Reed-Sternberg cells on biopsy of a lymph nodeA 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 Ieat and drink? It doesn't really matter what I do if I'm never going to get better!"On the basis of the client's statement, the nurse determines that the client isexperiencing which problem?PowerlessnessTolbutamide (Orinase) is prescribed to a client whose type 2 diabetes mellitushas not been controlled with diet and exercise alone. The nurse providesinstructions to the client about the medication. Which statement bythe clientindicates a need for further instruction?"I can have a beer or glass of wine as long as I stay within my daily dietary restrictions."A client with adenocarcinoma of the ovary is scheduled to undergochemotherapy with cyclophosphamide after total abdominal hysterectomy withbilateral salpingo-oophorectomy. What does the nurse instruct the client to doduring chemotherapy? Select all that apply.-Drink copious amounts of fluid and void frequently-Avoid contact with any individual who has signs or symptoms of a coldA 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:
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2024-2025 NCLEX Comprehensive Review Study Guide with Answers (261 Solved Questions) - Page 14 preview imageRespiratory alkalosisA school nurse observing a child with Down syndrome is participating inaphysical 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. Whatis the appropriate action by the nurse in this situation?Contacting the child'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?"I need 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:Contact 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?Decreased fluid 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:DecreaseA maternity nurse providing an education session to a group of expectantmothers describes the purpose of the placenta. Which statement by one of the
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2024-2025 NCLEX Comprehensive Review Study Guide with Answers (261 Solved Questions) - Page 15 preview imagewomen attending the session indicates a need for further discussion of thepurpose of the placenta?"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?28 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:To 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:Identify the client's treatment goalsA child with growth hormone deficiency will be receiving somatropin(Humatrope). The nurse provides information to the mother about the medication.Which of the following laboratory values does the nurse tell the mother willrequire monitoring?Thyroid-stimulating hormone (TSH)A client who has sustained an acute myocardial infarction (AMI) is receivingintravenous reteplase (Retavase). For which adverse effect of the medicationdoes the nurse monitor the client?Epistaxis
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