NCLEX
A client taking digoxin reports seeing "yellow halos" around lights. This finding indicates which condition?
Digoxin toxicity
A client with chronic obstructive pulmonary disease (COPD) is experiencing dyspnea. Which position would best facilitate breathing?
High-Fowler's position
A nurse advocates for a client's right to refuse treatment, even if the nurse believes it's not in their best medical interest. Which ethical principle is the nurse demonstrating?
Autonomy
A postpartum client reports heavy vaginal bleeding and a boggy uterus. What is the initial nursing action?
Perform fundal massage
Which characteristic is most indicative of a client experiencing a manic episode?
Grandiose delusions
A client is prescribed NPH insulin. Describe the typical onset, peak, and duration of action for this type of insulin.
Onset: 1-2 hours, Peak: 4-12 hours, Duration: 18-24 hours
A client who just received a terminal diagnosis begins to plan a lavish vacation, denying the reality of their illness. Name the defense mechanism being displayed.
Denial
List two common signs or symptoms of peritonitis.
Severe abdominal pain and rebound tenderness
A client is prescribed furosemide. What class of medication is furosemide, and what is its primary action?
Furosemide is a loop diuretic, which works by increasing urine output to reduce fluid overload.
A nurse is caring for a client with hypokalemia. Which food choice would be most appropriate to recommend?
Baked potato with skin
Describe two essential nursing interventions for the immediate care of a newborn after birth.
Ensure a patent airway and maintain warmth
Identify two priority nursing interventions for a client experiencing an acute myocardial infarction.
Administer oxygen and administer nitroglycerin
Which non-pharmacological intervention is most appropriate for a 6-month-old infant experiencing mild pain?
Offering a pacifier
A client in active labor requests pain medication. Which finding would contraindicate the administration of an opioid analgesic at this time?
Respiratory rate 8 breaths/minute
Explain why a client receiving warfarin therapy needs to have their INR monitored regularly.
To monitor the effectiveness of the medication and ensure the dose is within the therapeutic range, preventing excessive bleeding or clot formation.
Explain the importance of timely and accurate documentation in nursing practice.
Ensures continuity of care, provides legal protection, and facilitates communication among healthcare team members.
What is the expected respiratory rate range for a healthy 3-year-old child?
20-30 breaths/minute
Identify two common signs of increased intracranial pressure (ICP).
Altered level of consciousness and pupillary changes
Which developmental milestone is typically achieved by a 12-month-old infant?
Says first words
Which isolation precaution is required for a client diagnosed with active tuberculosis?
Airborne precautions
The registered nurse (RN) is preparing to delegate tasks to an unlicensed assistive personnel (UAP). Name one task that is appropriate to delegate to the UAP.
Assisting with basic client hygiene
A client states, "I feel so hopeless, like there's no point in trying anymore." What is the most therapeutic response by the nurse?
It sounds like you are feeling really hopeless right now. Can you tell me more about what you're experiencing?
A nurse enters a client's room and finds them unresponsive with no pulse. What is the immediate nursing action?
Initiate chest compressions/begin CPR
A client with type 1 diabetes is found unconscious and diaphoretic. Their blood glucose is 45 mg/dL. What is the immediate nursing intervention?
Administer rapid-acting glucose (e.g., glucagon IM or IV dextrose)
A client requests to see their medical record. What is the nurse's most appropriate response according to patient rights?
You can review it with the medical records department.