NCLEX Guide to success

A client with a retroperitoneal abscess is receiving gentamicin (Garamycin). Which signs should the nurse monitor?

Select all that apply:
1. Hearing
2. Urine output
3. Hematocrit (HCT)
4. Blood urea nitrogen (BUN) and creatinine levels
5. Serum calcium level

The nurse has developed a relationship with a client who has an addiction problem. Which information would indicate that the therapeutic interaction is in the working stage?

Select all that apply:
1. The client addresses how the addiction has contributed to family distress.
2. The client reluctantly shares the family history of addiction.
3. The client verbalizes difficulty identifying personal strengths.
4. The client discusses the financial problems related to the addiction.
5. The client expresses uncertainty about meeting with the nurse.
6. The client acknowledges the addiction's effects on the children.

The nurse is assessing a 2-year-old client diagnosed with bacterial meningitis. Which of the following signs and symptoms of meningeal irritation is the nurse likely to observe?

Select all that apply: Nclex SATA
1. Generalized seizures
2. Nuchal rigidity
3. Positive Brudzinski's sign
4. Positive Kernig's sign
5. Babinski reflex
6. Photophobia

The nurse is assessing the level of consciousness of a client who suffered a head injury. She uses the Glasgow Coma Scale and determines that the client's score is 15. Which responses did the nurse assess in this client?

Select all that apply: Nclex SATA
1. Spontaneous eye opening
2. Tachypnea, bradycardia, and hypotension
3. Unequal pupil size
4. Orientation to person, place, and time
5. Motor response to pain localized
6. Incomprehensible sounds

The nurse is caring for a client with a complete T5 spinal cord injury. Upon assessment, the nurse notes flushed skin, diaphoresis above T5, and a blood pressure of 162/96 mm Hg. The client reports a severe, pounding headache. Which nursing interventions would be appropriate for this client?

Select all that apply: Nclex SATA
1. Elevating the head of the bed 90 degrees
2. Loosening constrictive clothing
3. Using a fan to reduce diaphoresis
4. Assessing for bladder distention and bowel impaction
5. Administering antihypertensive medication
6. Placing the client in a supine position with legs elevated

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36. Nurse Jeff is performing a skin assessment on a client with a facial lesion. It appears as a well-defined, red, scaling, thickened bump. This type of skin lesion refers to?

A. Kaposi's Sarcoma
B. Melanoma
C. Squamous cell carcinoma
D. Basal cell carcinoma

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2. A chemotherapeutic agent known to cause alopecia is prescribed for a patient. To maintain the patient’s self-esteem, the nurse plans to

A. Suggest that the patient limit social contacts until regrowth of the hair occurs
B. Encourage the patient to purchase a wig or hat and wear it once hair loss begins
C. Have the patient wash the hair gently with a mild shampoo to minimize hair loss
D. Inform the patient that hair loss will not be permanent and that the hair will grow back

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5. In caring for a victim of sexual assault, which task is most appropriate for an LPN/LVN?

A. Provide emotional support and supportive communication
B. Assess immediate emotional state and physical injuries
C. Ensure that the “chain of custody” is maintained
D. Collect hair samples, saliva swabs, and scrapings beneath fingernails

14. Nurse Arya assesses for evidence of positive symptoms of schizophrenia in a newly admitted client. Which of the following symptoms are considered positive evidence? Select all that apply.

A. Anhedonia
B. Delusions
C. Flat affect
D. Hallucinations
E. Loose associations
F. Social withdrawal

14. Nurse Arya assesses for evidence of positive symptoms of schizophrenia in a newly admitted client. Which of the following symptoms are considered positive evidence? Select all that apply.

A. Anhedonia
B. Delusions
C. Flat affect
D. Hallucinations
E. Loose associations
F. Social withdrawal

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17. A woman who is six months pregnant is seen in antepartal clinic. She states she is having trouble with constipation. To minimize this condition, the nurse should instruct her to

A. Increase her fluid intake to three liters/day
B. Request a prescription for a laxative from her physician
C. Stop taking iron supplements
D. Take two tablespoons of mineral oil

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