NCLEX Practice Set 2

A nurse is teaching a class about information security and client confidentiality. Using a PowerPoint presentation, the nurse reviews a number of scenarios that address client privacy.

>Which of the following scenarios would be considered a violation of client privacy?

A nurse is educating a pregnant client about vaccines recommended in pregnancy, including the influenza and Tdap vaccines.

>Which type of immunity does the fetus receive from maternal administration of these vaccines?

A nurse is caring for a woman in labor. She reviews the fetal strip and notes moderate variability with occasional decelerations. The decelerations occur with a contraction, show a gradual decrease in fetal heart rate to its lowest point over 30 seconds, and the shape of the deceleration mirrors the contraction.

>Which of the following is the correct course of action for the nurse to take?

A client is ordered 2 units of packed red blood cells.

>Which of the following steps should the nurse take before and during the transfusion? Select all that apply.

A nursing instructor is watching a student perform a sterile procedure.

>Which of the following would require action by the nursing instructor?

A 5-year-old boy is admitted to the pediatric floor and is scheduled for a tonsillectomy. His 7-year-old sister is very anxious and keeps telling her mother that she is afraid something bad will happen to her brother.

>Which of the following actions by the nurse is most appropriate in easing the older sister’s fears?

A 15-year-old female is brought to the emergency room after being rescued from a house fire. She is having some shortness of breath from smoke inhalation and the nurse notes that her hands are burned. Further assessment reveals that the burn has destroyed the epidermis and dermis. The skin is bright red and leathery in appearance and does not blanche under pressure.

The client asks, “Why doesn’t it hurt very much?”

>Which of the following descriptions is the appropriate response?

A concerned new mother is watching the nurse take vital signs on an active newborn. She asks, “What are the normal ranges for vital signs in a baby?”

>Which of the following parameters is incorrect and would be considered out of range for the newborn?

A physician adds spironolactone to a client’s medication regimen. The client is also taking lisinopril to treat hypertension.

>With the client taking both spironolactone and lisinopril, which of the following labs is most important for the nurse to monitor?

An 18-year-old female has recently been admitted for management of an eating disorder. She reports binging episodes followed by intense guilt and purging. She is diagnosed with bulimia.

>Which of the following would the nurse expect to find with this client?