NCLEX Practice Set 3

A nurse is filling out an incident report after a client experienced a fall while in the bathroom. The client states that he became very dizzy and felt as though he would faint.

>Which of the following would be inappropriate to include in the incident report?

A 62-year-old woman, who was independent prior to surgery, is recovering from a total knee replacement. While the nurse is performing discharge teaching, the client reports that her husband has Parkinson’s and may have trouble helping her at home, including changing her dressings. The closest family member lives 60 minutes away.

>Which of the following actions by the nurse is most appropriate?

A client was recently diagnosed with a spinal cord injury at the level of T3 after a motor vehicle accident. The nurse is educating the patient on his condition, potential complications, and preventive actions.

>Which of the following are signs and symptoms of autonomic dysreflexia that the nurse should educate the patient about? Select all that apply.

A client is admitted with complaints of sudden onset of significant epigastric pain, nausea and vomiting, and fever. He is diagnosed with acute pancreatitis.

>The nurse anticipates which of the following labs will be elevated with acute pancreatitis? Select all that apply.

A 2-year-old male is brought to the emergency room after accidentally ingesting antifreeze.

>Which of the following is an antidote to ethylene glycol poisoning?

A client with history of heavy alcohol abuse is admitted to the hospital. The physician orders several days of thiamine supplementation.

>The nurse understands thiamine supplementation is needed to lower the risk of which of the following?

A home health nurse is performing a home safety check for a 75-year-old male.

>Which of the following statements by the client is most concerning?

A nurse is admitting a Muslim client and when asked about any cultural or religious concerns, he advises the nurse of the great importance of prayer time at certain times each day. A few days later, the same nurse is caring for the client and realizes that he has a procedure scheduled the next day at the same time as prayer time.

>Which is the most appropriate response of the nurse in this situation?

A client presents to the ER complaining of palpitations, dyspnea, and dizziness. An electrocardiogram is ordered. The EKG shows a ventricular rate of 130bpm with irregular narrow QRS complexes and absent p waves.

>The nurse reviews the EKG and identifies the rhythm as:

A client is admitted with advanced liver disease. The nurse is reviewing his labs and notes an ammonia level of 225 micrograms/milliliter.

>Which complication of liver disease does the nurse anticipate with this level of ammonia?