NCLEX 6 Safe and Effective Care Environment 1. A 68-year-old woman is diagnosed with thrombocytopenia due to acute lymphocytic leukemia.

She is admitted to the hospital for treatment. The nurse should assign the patient (A) to a private room so she will not infect other patients and health care workers. (B) to a private room so she will not be infected by other patients and health care workers. (C) to a semiprivate room so she will have stimulation during her hospitalization. (D) to a semiprivate room so she will have the opportunity to express her feelings about her illness. 2. The nurse teaches a group of mothers of toddlers how to prevent accidental poisoning. Which of the following suggestions should the nurse give regarding medications? (A) Lock all medications in a cabinet. (B) Child proof all the caps to medication bottles. (C) Store medications on the highest shelf in a cupboard. (D) Place medications in different containers. 3. While inserting a nasogastric tube, the nurse should use which of the following protective measures? (A) Gloves, gown, goggles, and surgical cap. (B) Sterile gloves, mask, plastic bags, and gown. (C) Gloves, gown, mask, and goggles. (D) Double gloves, goggles, mask, and surgical cap. 4. A 6-year-old boy is returned to his room following a tonsillectomy. He remains sleepy from the anesthesia but is easily awakened. The nurse should place the child in which of the following positions? (A) Sims. (B) Side-lying. (C) Supine. (D) Prone. 5. A nursing team consists of an RN, an LPN/LVN, and a nursing assistant. The nurse should assign which of the following patients to the LPN/LVN? (A) A 72-year-old patient with diabetes who requires a dressing change for a stasis ulcer. (B) A 42-year-old patient with cancer of the bone complaining of pain. (C) A 55-year-old patient with terminal cancer being transferred to hospice home care. (D) A 23-year-old patient with a fracture of the right leg who asks to use the urinal. Health Promotion And Maintenace 6. An 18-year-old woman comes to the physicians office for a routine prenatal checkup at 34 weeks gestation. Abdominal palpation reveals the fetal position as right occipital anterior (ROA). At which of the following sites would the nurse expect to find the fetal heart tone? (A) Below the umbilicus, on the mothers left side. (B) Below the umbilicus, on the mothers right side. (C) Above the umbilicus, on the mothers left side.

(D) Above the umbilicus, on the mothers right side. 7. The nurse in an outpatient clinic is supervising student nurses administering influenza vaccinations. The nurse should question the administration of the vaccine to which of the following clients? (A) A 45-year-old male who is allergic to shellfish. (B) A 60-year-old female who says she has a sore throat. (C) A 66-year-old female who lives in a group home. (D) A 70-year-old female with congestive heart failure. 8. The nurse performs a home visit on a client who delivered two days ago. The client states that she is bottle-feeding her infant. The nurse notes white, curd-like patches on the newborns oral mucous membranes. The nurse should take which of the following actions? (A) Determine the babys blood glucose level. (B) Suggest that the newborns formula be changed. (C) Remind the caretaker not to let the infant sleep with the bottle. (D) Explain that the newborn will need to receive some medication. 9. A two-month-old infant is brought to the pediatricians office for a well-baby visit. During the examination, congenital subluxation of the left hip is suspected. The nurse knows that symptoms of congenital hip dislocation include (A) lengthening of the limb on the affected side. (B) deformities of the foot and ankle. (C) asymmetry of the gluteal and thigh folds. (D) plantar flexion of the foot.

10. The nurse teaches a 20-year-old primigravida how to measure the frequency of uterine contractions. The nurse should explain to the patient that the frequency of uterine contractions is determined (A) from the beginning of one contraction to the end of the next contraction. (B) from the beginning of one contraction to the end of the same contraction. (C) by the strength of the contraction at its peak. (D) by the number of contractions that occur within a given period of time. Psychosocial Integrity 11. An adolescent male being treated for depression arrives with his family at the Adolescent Day Treatment Center for an initial therapy meeting with the staff. The nurse explains that one of the goals of the family meeting is to encourage the adolescent to: (A) trust the nurse who will solve his problem. (B) learn to live with anxiety and tension. (C) accept responsibility for his actions and choices. (D) use the members of the therapeutic milieu to solve his problems. 12. A 23-year-old-woman comes to the emergency room stating that she had been raped. Which of the following statements BEST desc ribes the nurses responsibility concerning written consent?

(A) The nurse should explain the procedure to the patient and ask her to sign the consent form. (B) The nurse should verify that the consent form has been signed by the patient and that it is attached to her chart. (C) The nurse should tell the physician that the patient agrees to have the examination. (D) The nurse should verify that the patient or a family member has signed the consent form. 13. The nurse cares for an elderly patient with moderate hearing loss. The nurse should teach the patients family to use which of the following approaches when speaking to the patient? (A) Raise your voice until the patient is able to hear you. (B) Face the patient and speak quickly using a high voice. (C) Face the patient and speak slowly using a slightly lowered voice. (D) Use facial expressions and speak as you would normally.

14. A 52-year-old man is admitted to a hospital after sustaining a severe head injury in an automobile accident. When the patient dies, the nurse observes the patients wife comforting other family members. Which of the following interpretations of this behavior is MOST justifiable? (A) She has already moved through the stages of the grieving process. (B) She is repressing anger related to her husbands death. (C) She is experiencing shock and disbelief related to her husbands death. (D) She is demonstrating resolution of her husbands death. 15. After two weeks of receiving lithium therapy, a patient in the psychiatric unit becomes depressed. Which of the following evaluations of the patients behavior by the nurse would be MOST accurate? (A) The treatment plan is not effective; the patient requires a larger dose of lithium. (B) This is a normal response to lithium therapy; the patient should continue with the current treatment plan. (C) This is a normal response to lithium therapy; the patient should be monitored for suicidal behavior. (D) The treatment plan is not effective; the patient requires an antidepressant. Physiological Integrity 16. A 65-year-old patient with pneumonia is receiving garamycin (Gentamicin). It would be MOST important for a nurse to monitor which of the following laboratory values in this patient? (A) Hemoglobin and hematocrit. (B) BUN and creatinine. (C) Platelet count and clotting time. (D) Sodium and potassium.

17. A 22-year-old man is admitted to the hospital with complaints of fatigue and weight loss. Physical examination reveals pallor and multiple bruises on his arms and legs. The results of the patients tests reveal acute lymphocytic leukemia and thrombocytopenia. Which of the following nursing diagnoses MOST accurately reflects his condition?

(A) Potential for injury. (B) Self-care deficit. (C) Potential for self-harm. (D) Alteration in comfort.

18. To enhance the percutaneous absorption of nitroglycerine ointment, it would be MOST important for the nurse to select a site that is (A) muscular. (B) near the heart. (C) non-hairy. (D) over a bony prominence.

19. A man is admitted to the Telemetry Unit for evaluation of complaints of chest pain. Eight hours after admission, the patient goes into ventricular fibrillation. The physician defibrillates the patient. The nurse understands that the purpose of defibrillation is to: (A) increase cardiac contractility and cardiac output. (B) cause asystole so the normal pacemaker can recapture. (C) reduce cardiac ischemia and acidosis. (D) provide energy for depleted myocardial cells. 20. A patient is to receive 3,000 ml of 0.9% NaCl IV in 24 hours. The intravenous set delivers 15 drops per milliliter. The nurse should regulate the flow rate so that the patient receives how many drops of fluid per minute? (A) 21 (B) 28 (C) 31 (D) 42