Fundamentals NCLEX-RN Practice Exam — Set 3

A client receiving continuous NG tube feeding develops abdominal distension and has had no bowel movement in 3 days. Which action should the nurse take first?

Which statement by a client with a new colostomy indicates correct understanding of pouching system care?

A client receiving TPN has a blood glucose of 289 mg/dL. Which action should the nurse take first?

A PICC line dressing is damp and the insertion site appears reddened. Which action should the nurse take first?

A client receiving home oxygen via nasal cannula makes which statement that indicates a need for further teaching?

A client asks why the NG tube has two lumens. Which response is correct?

A client receiving a transfusion reports itching and hives on chest and arms; vital signs are stable. Which action should the nurse take?

Discharge teaching for a new permanent pacemaker: which instruction is correct?

Two days post-colostomy, the stoma is edematous and dark red. The client asks if it should look like that. Which response is correct?

Six hours after Foley removal, a client cannot urinate. Bladder scan shows 450 mL. Which action should the nurse take?

A confused client with a fall history is agitated and pulled out the IV twice. Which action should the nurse take first?

Which action is correct when providing tracheostomy care for a new tracheostomy?

In which position should the nurse place an adult client to administer a cleansing enema?

A client receiving IV potassium chloride shows tall, peaked T waves on telemetry. Which action should the nurse take?

A client with newly diagnosed celiac disease should avoid which of the following foods?

A client transfused 2 hours ago reports low back pain and dark urine. BP 90/50, HR 110. Which action should the nurse take first?

A client receiving enteral feedings via NG tube develops diarrhea. Which action should the nurse take?

When transferring a client with left-sided weakness from bed to chair, where should the chair be positioned?

A client with a chest tube has no tidaling in the water-seal chamber. Which interpretation is most likely?

Which food is most likely to cause odor for a client with a colostomy?

After intradermal PPD injection, a small bleb forms at the site. Which action should the nurse take?

A client with 3 days of vomiting and diarrhea has Na 131, K 3.2, Cl 90. Which acid-base imbalance is most likely?

Which finding in a client with a new ileostomy requires immediate notification of the provider?

During NG tube insertion, the client begins coughing and has difficulty breathing. Which action should the nurse take?

A chest tube drainage system is knocked over and cracks. Which action should the nurse take first?

Which statement about daily weights by a client with HF indicates correct understanding?

Which lab value should the nurse monitor to evaluate therapeutic effect of a continuous heparin infusion?

A client with a central line develops fever, chills, and hypotension. CLABSI is suspected. Which action should the nurse take first?

A client newly prescribed furosemide makes which statement that indicates a need for further teaching?

A nasogastric tube may be displaced after coughing. Which action verifies tube placement?

A client postoperative abdominal surgery is on a clear liquid diet. Which item is allowed?

Before starting a transfusion of PRBCs, which action MUST the nurse take?

Which food choice indicates understanding of a low-sodium diet?

A staff member delivers a meal tray to a client with a sealed prostate radiation implant. Which action is appropriate?

Eight hours post-appendectomy, vital signs are T 101.2°F, HR 100, BP 110/70, RR 22. Which action should the nurse take first?