NCLEX Review Study Guide
2 100% VERIFIED
ANSWERS CORRECT
2024/2025
A clinic nurse is assessing a client who has had a cast applied to the lower left
arm 1 week ago. The client tells the nurse that the skin is being irritated by the
edges of the cast. What is the appropriate action on the part of the nurse
Place small pieces of tape over the rough edges of the cast
A nurse developing a plan of care for a client with HIV infection identifies several
concerns. List them in order of priority, from highest to lowest.
1 Possible infection
2 Decreased nutrition
3 Fatigue
4 Despair
An emergency department nurse has a physician's prescription to irrigate a
client's ears. List in order of priority the steps that the nurse should take in
performing this procedure.
1 Use an otoscope to ensure that the tympanic membrane is intact.
2 Warm tap water to body temperature.
3 Fill an irrigating syringe with warm water.
4 Insert the irrigating solution by directing the solution toward the wall of the ear canal.
5 Document the completion of the procedure and how the client tolerated it.

The nurse is preparing to administer a tube feeding by way of a nasogastric tube.
Which action does the nurse carry out as a priority before starting the flow of the
solution?
Checking for gastric residual volume and assessing tube placement
A client with schizophrenia says to the nurse, "I decided not to take my
medication because it can't help. I am the only one who can help me." Which
nursing response is therapeutic in this situation?
"Your doctor wants you to continue this medication because it's helping you. Do you
recall needing to be hospitalized because you stopped your medication?"
A client is brought to the emergency department by ambulance, and diabetic
ketoacidosis is suspected. Blood samples are taken, and the nurse obtains
supplies that will be needed to treat the client. Which type of insulin does the
nurse take from the medication supply room for intravenous (IV) administration?
Regular (Humulin R)
A nurse is assessing a client who is experiencing chest pain. Which of the
following observations indicates to the nurse that the pain is most likely a result
of angina?
The pain is relieved by rest and nitroglycerin.
While being seen by a physician, a client complains of persistent fever, malaise,
and night sweats. On physical examination, the physician palpates enlarged
lymph nodes, and the client states that the nodes are painless. Hodgkin's
lymphoma is suspected, and several diagnostic studies are performed. Which
characteristic of this type of lymphoma does the nurse expect to note while
reviewing the results of the diagnostic studies?
Reed-Sternberg cells on biopsy of a lymph node

A client with chronic renal failure who will require dialysis three times a week for
the rest of his life says to the nurse, "Why should I even bother to watch what I
eat and drink? It doesn't really matter what I do if I'm never going to get better!"
On the basis of the client's statement, the nurse determines that the client is
experiencing which problem?
Powerlessness
Tolbutamide (Orinase) is prescribed to a client whose type 2 diabetes mellitus
has not been controlled with diet and exercise alone. The nurse provides
instructions to the client about the medication. Which statement by the client
indicates a need for further instruction?
"I can have a beer or glass of wine as long as I stay within my daily dietary restrictions."
A client with adenocarcinoma of the ovary is scheduled to undergo
chemotherapy with cyclophosphamide after total abdominal hysterectomy with
bilateral salpingo-oophorectomy. What does the nurse instruct the client to do
during chemotherapy? Select all that apply.
-Drink copious amounts of fluid and void frequently
-Avoid contact with any individual who has signs or symptoms of a cold
A nurse reviews arterial blood gas values and notes a pH of 7.50 and a Pco2 of 30
mm Hg. The nurse interprets these values as indicative of:
Respiratory alkalosis
A school nurse observing a child with Down syndrome is participating in a
physical education class and notes that the child is experiencing a diminution in
motor abilities. The nurse asks to see the child and conducts an assessment,
during which the child complains of neck pain and loss of bladder control. What
is the appropriate action by the nurse in this situation?
Contacting the child's physician to report the findings

2024-2025 NCLEX Review Study Guide 2 with Answers (53 Solved Questions)

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