Nclex NCSBN

The nurse is collecting data from a client with an acute Myocardial infraction (MI) .
Which of
the following findings would be consistent with an acute MI?
SATA
1) Nausea and vomiting

2) Diaphoresis
3) Dyspnea – shortness of breadth
4) Nailbed splinter hemorrhages
5) Petechiae
6) Dizziness and fatigue
A nurse is collecting data with COPD patient. Which of the following findings would be a priority to
report to the charge nurse ?
1. The client reports getting tired easily
2. The client reports having increased sputum production in the morning
3. The client's breathing is shallow
4. The clients sputum is yellow
The nurse is preparing for a client for a emergency surgery to repair a depressed skull fracture.
Which of the following for actions are essential for the nurse to make ?
1. Determining the time that the client last ate
2. Showing the client a picture of the postoperative would drainage system
3. Telling the client what will occur in the post anesthesia care unit (PACU)
4. Checking the client's corneal reflex

The nurse is assisting to admit a client with active pulmonary tuberculosis TB. Which of the
following actions should the nurse take prior to the client’s arrival?
1) Assign the client to room with client who has pertussis if a private room is not available
2) Have a particular respirator mask available for client transport
3) Have a particular respirator mask available for staff who care for the client
4) Post a sign outside the room restricting pregnant women from entering the room
- again post
The nurse is contributing to staff education conference about advance directives. Which of the
following information should the nurse recommend including ?
SATA
1) Advance directives support a client’s ethical right autonomy
2) A client’s may designate another person to make health care decisions for
the client
3) Health care facilities must ask clients if they have completed an advance directive
4) Advance directives indicates a client; s treatment wishes for acute diagnoses
5) A living will must be witnesses by a client’s attorney
The nurse is talking with the parent of 3 month old client . The client expresses concern
that the infant in unable to roll over. Which of the following would be an appropriate
response for the nurse to make ?
1) We should inform your child’s primary health care provider about this delay
2) Most infants are able to roll over between ages 4 to 6 months
3) Does your infant smile in response to your smile ?
4) Is your infant able to pick up objects
The nurse is caring for client with pertussis . Which of the following infection control
precautions should the nurse implement ?
1) Place a stethoscope in the client’s room to be used for the client only
2) Wear gloves when checking the client’s pulse
3) Wear a protective gown when bathing the client
4) Wear a surgical mask when assisting the client to eat
The nurse in a long term facility is making client care assignments for UAP. Which of the
following statements by the nurse would provide a UAP directions for the assignment ?
1) Client’s who are UNable to ambulate should be assisted to ambulate after meals
2) Notify me if any develops an abnormal temperature
3) Check the meal trays distributed to client’s with DM type 1
4) Obtain vital signs first for the client with Hypertension and report the results to me
The nurse is caring for client who has active TB . Which of the following infection control
precautions should the nurse implement ?
1) Put on sterile gloves to administer prescribed medications to the client

2) Perform hand hygiene prior to checking the client’s vital signs
3) Wear a particular respirator mask when assisting the client’s to bathe
4) Wear a protective gown if clothing may be soiled
5) Close the door after entering client’s room
The nurse has reinforced teaching with a client who has an ileal conduit. Which of the following
statements by the client would indicate a correct understanding of the teaching ?
1) I will need to awaken several times at night to empty the pouch

2) I can expect mucus in my urine
3) The stoma should be a dark purple color
4) I will need to limit by fluid intake
The charge nurse in a long term care facility has completed client care assignments for UAP.
Which of the following statements by the change nurse provides best directions to UAP
regarding the assignment?
1) Record your assigned client’s vital sign before you take mid-morning break
2) Weigh your assigned client’s before breakfast with the scale used 1 day ago
3) Help the clients who eat their meals in the dining room with breakfast
4) Measure the amount of your assigned client intake and output regularly
The nurse is caring for client who is prescription of darbepoetin 0.45mcg/kg , subcutaneously.
The client weighs 190lb (86KG) . The nurse has 100 mcg.ml solution available. How many ML
should the nurse administer with each dose ?

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The nurse is collecting data from a client with an acute Myocardial infraction (MI) .

1) Nausea and vomiting

1. The client reports getting tired easily

2. The client reports having increased sputum production in the morning

3. The client's breathing is shallow

4. The clients sputum is yellow

1. Determining the time that the client last ate

2. Showing the client a picture of the postoperative would drainage system

4. Checking the client's corneal reflex

2) Have a particular respirator mask available for client transport

1) Advance directives support a client’s ethical right autonomy

4) Advance directives indicates a client; s treatment wishes for acute diagnoses

5) A living will must be witnesses by a client’s attorney

1) Put on sterile gloves to administer prescribed medications to the client

1) I will need to awaken several times at night to empty the pouch

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