Elimination & Sensory NCLEX Questions

Which statement by the parent of a child with polycystic kidney disease and stage 2 renal disease indicates the need for more teaching? a) "My child will outgrow this disease." b) "I should feed my child a no-added-salt diet." c) "I can give my child nonsteroidal anti-inflammatory drugs (NSAIDs) for pain." d) "My child may develop cysts in other organs."

"My child will outgrow this disease."

A client with a new ileal conduit asks the nurse when he needs to wear his appliance. What should the nurse tell the client? a) "The appliance must be worn after your meals." b) "You need to wear your appliance after you irrigate." c) "It is only necessary to wear your appliance at night." d) "You need to wear your appliance all the time."

"You need to wear your appliance all the time."

A client begins to experience alcoholic hallucinosis. After administering medication, what is the best nursing intervention? a) Checking the client's blood pressure every 15 minutes b) Offering the client oral liquids every 30 minutes c) Keeping the client restrained in bed d) Providing a quiet environment

Providing a quiet environment

An elderly client asks the nurse how to treat chronic constipation. What is the best recommendation the nurse can make? a) Take a stool softener such as docusate sodium daily. b) Take a mild laxative such as magnesium citrate when necessary. c) Administer a tap-water enema weekly. d) Administer a phospho-soda enema when necessary.

Take a stool softener such as docusate sodium daily.

For the client who has difficulty falling asleep at night because of withdrawal symptoms from alcohol, which are abating, which nursing intervention is likely to be most effective? a) inviting the client to play a board game with the nurse b) allowing the client to sit in the community room until the client feels sleepy c) teaching the client relaxation exercises to use before bedtime d) advising the client to take multiple short naps during the day until symptoms improve

Teaching the client relaxation exercises to use before bedtime

Which measure should the nurse teach the client with adult macular degeneration (AMD) as a safety precaution? a) Turn the head from side to side when walking. b) Place personal items on the sighted side. c) Wear a patch over one eye. d) Lie in bed with the unaffected side toward the door.

Turn the head from side to side when walking.

The client who is in Buck's traction is constipated. A plan of care that incorporates which breakfast would be most helpful in reestablishing a normal bowel routine? a) an orange, raisin bran and milk, and wheat toast with butter b) orange juice, breakfast pastries (doughnut and Danish), and coffee c) corn flakes with sliced banana, milk, and English muffin and jelly d) eggs and bacon, buttered white toast, orange juice, and coffee

an orange, raisin bran and milk, and wheat toast with butter

A client has nephrotic syndrome. To aid in the resolution of the client's edema, the health care provider (HCP) prescribes 25% albumin. In addition to an absence of edema, the nurse should evaluate the client for which expected outcome? a) blood pressure elevation b) cool skin temperature in lower extremities c) crackles in the lung bases d) cerebral edema

blood pressure elevation

A 5-year-old child is brought to the emergency department after injuries sustained in a motor vehicle accident. The child is diagnosed with a cervical spinal cord injury. Which assessment data would the nurse consider as most significant when assessing for signs of cervical spinal cord swelling? a) Urinary retention b) Retinal hemorrhage c) Changes in respiration d) Nausea and vomiting

changes in respiration

A client is admitted to the acute psychiatric care unit after 2 weeks of increasingly erratic behavior. He has been sleeping poorly, has lost 8 lb (3.6 kg), is poorly groomed, exhibits hyperactivity, and loudly denies the need for hospitalization. Which nursing intervention takes priority for this client? a) Involving the client in unit activities b) Administering a sedative as ordered c) Providing adequate hygiene d) Decreasing environmental stimulation

decreasing environmental stimulation

Which finding is expected when the nurse is assessing a child who has sustained full-thickness burns? a) minimal pain b) blistering and a moist appearance c) excessive bleeding d) blanching to the touch

minimal pain

A client seeks care for lower back pain of 2 weeks' duration. Which assessment finding suggests a herniated intervertebral disk? a) Atrophy of the lower leg muscles b) Back pain when the knees are flexed c) Pain radiating down the posterior thigh d) Homans' sign

pain radiating down the posterior thigh

In order to prevent recurrent vasospastic episodes with Raynaud's phenomenon, what should the nurse instruct the client to do? a) Use a vibrating massage device on the hands. b) Increase coffee intake to 2 cups per day. c) Wear gloves when obtaining food from the refrigerator. d) Keep the hands and feet elevated as much as possible.

wear gloves

The nurse is collecting data on a client with a urinary tract infection (UTI). Which statements should the nurse expect the client to make? Select all that apply. a) "I need to urinate frequently." b) "It burns when I urinate." c) "I urinate large amounts." d) "My urine smells sweet." e) "I need to urinate urgently."

• "I need to urinate frequently." • "It burns when I urinate." • "I need to urinate urgently."

A client who had transurethral resection of the prostate has dribbling urine after his Foley catheter is removed on the second postoperative day. The nurse notes that the client had 200 mL of urine output in the last 8 hours with a 1,000 mL intake. The nurse should first: a) assess for bladder distention. b) apply a condom catheter. c) obtain a urine specimen for culture. d) teach the client Kegel exercises.

assess for bladder distention.

When assessing an 18-year-old primipara who gave birth to a viable neonate under epidural anesthesia 24 hours ago, the nurse determines that the fundus is firm but to the right of midline. Based on this finding, the nurse should further assesses for: a) uterine inversion. b) paralytic ileus. c) perineal hematoma. d) urinary retention.

urinary retention.

A nurse is caring for a client with severe burns and receiving fluid resuscitation. Which finding indicates that the client is responding to the fluid resuscitation? a) blood pressure of 94/64 mm Hg b) urine output of 30 mL/h c) serum sodium level of 136 mEq/L (136 mmol/L) d) pulse rate of 112 bpm

urine output of 30 mL/h

A nurse is caring for a client who underwent a lumbar laminectomy 2 days ago. Which finding requires immediate intervention? a) Urine retention or incontinence b) More back pain than the first postoperative day c) Paresthesia in the dermatomes near the wounds d) Temperature of 99.2° F (37.3° C)

urine retention or incontinence

One day after cataract surgery the client is having discomfort from bright light. The nurse should advise the client to: a) attach sun shields to existing eyeglasses when in direct sunlight. b) use sunglasses that wrap around the side of the face when in bright light. c) dim lights in the house and stay inside for one week. d) patch the affected eye when in bright light.

use sunglasses that wrap around the side of the face when in bright light

Allopurinol is prescribed for a client who has chronic gout. Which comment indicates that the client understands how to take the allopurinol? a) "I will take the medication whenever my joints hurt." b) "I should drink plenty of fluids when taking allopurinol." c) "I should not take aspirin when taking allopurinol." d) "I must take this drug on an empty stomach."

"I should drink plenty of fluids when taking allopurinol."

The nurse is teaching a young woman about using oxcarbazepine to control seizures. The nurse determines teaching is effective when the client states: a) "I must weigh myself weekly to check for sudden gain in weight." b) "Since I am 28 years old, I should not delay starting a family." c) "I will need a higher dose of oral contraceptive when on this drug." d) "I will use one of the barrier methods of contraception."

"I will use one of the barrier methods of contraception."

A client with quadriplegia is in spinal shock. What finding should the nurse expect? a) Absence of reflexes along with flaccid extremities b) Spasticity of all four extremities c) Hyperreflexia along with spastic extremities d) Positive Babinski's reflex along with spastic extremities

Absence of reflexes along with flaccid extremeties

The parents of an infant with a colostomy are concerned that their child's colostomy bag is filling up frequently with gas. What is the most appropriate response by the nurse? a) "Place a few pin pricks in the bag." b) "Don't worry. This is a normal occurrence." c) "Restrict the intake of bottled formula." d) "Open the bag slightly whenever this happens."

"Open the bag slightly whenever this happens."

A 7-month-old female infant is admitted to the hospital with a tentative diagnosis of Hirschsprung's disease. When obtaining the infant's initial health history from the parents, which statement made by the mother would be most important? a) "Sometimes she gets colds." b) "Her rectal temperature is 99.4° F (37.4 °C)." c) "She gets constipated often." d) "She spits up occasionally."

"She gets constipated often."

After total hip replacement, a client is receiving epidural analgesia to relieve pain. Which action is a nursing priority for this client? a) Assessing capillary refill time b) Changing the catheter site dressing every shift c) Keeping the client flat in bed d) Assessing for sensation in the legs

Assessing for sensation in the legs

A client is frustrated and embarrassed by urinary incontinence. Which measure should the nurse include in a bladder retraining program? a) Restricting fluid intake to reduce the need to void b) Establishing a predetermined fluid intake pattern for the client c) Encouraging the client to increase the time between voidings d) Assessing present voiding patterns

Assessing present voiding patterns

A nurse is preparing to teach students in a health class about hearing pathways. Place the following steps in chronological order to match how the nurse would describe the normal pathway of sound wave transmission and hearing to the class. All options must be used. 1 2 3 4 5 Collection of the sound waves in the pinna. Transmission of vibrations through the hammer, anvil, and stirrup. Stimulation of nerve impulses in the inner ear. Interpretation of sound by the cerebral cortex. Transmission of vibrations to the auditory area of the cerebral cortex.

Collection of the sound waves in the pinna. Transmission of vibrations through the hammer, anvil, and stirrup. Stimulation of nerve impulses in the inner ear. Transmission of vibrations to the auditory area of the cerebral cortex. Interpretation of sound by the cerebral cortex.

The nurse is teaching a client with multiple sclerosis about prevention of urinary tract infection (UTI) and renal calculi. Which of the following nutrition recommendations by the nurse would be the most likely to reduce the risk of these conditions? a) Eat foods and ingest fluids that will cause the urine to be less acidic. b) Drink a large amount of fluids, especially milk products, and eat a diet that includes multiple sources of vitamin D. c) Eat foods containing vitamins C, D, and E, and drink at least 2 L of fluid a day. d) Increase fluids (2500 mL/day) and maintain urine acidity by drinking cranberry juice.

Increase fluids (2500 mL/day) and maintain urine acidity by drinking cranberry juice.

A client has been diagnosed with an intestinal obstruction and has a nasogastric tube set to low continuous suction. Which acid-base disturbance is this client at risk for developing? a) Metabolic alkalosis b) Respiratory acidosis c) Metabolic acidosis d) Respiratory alkalosis

Metabolic alkalosis

A nurse is caring for a child with celiac disease. How should the nurse evaluate the effectiveness of nutritional therapy? a) Measure blood urea nitrogen and serum creatinine levels. b) Measure intake and output. c) Monitor vital signs every 4 hours. d) Monitor the appearance, size, and number of stools.

Monitor the appearance, size, and number of stools.

Which measure included in the care plan for a client in the fourth stage of labor requires revision? a) Have the client spend time with the neonate to initiate breast-feeding. b) Perform perineal assessments for swelling and bleeding. c) Check vital signs and fundal checks every 15 minutes. d) Obtain an order for catheterization to protect the bladder from trauma.

Obtain an order for catheterization to protect the bladder from trauma.

A client returned from surgery eight hours ago and has not voided. Which action should the nurse take first? a) Palpate over the synthesis pubis for fullness. b) Catheterize the client with a straight catheter. c) Call the physician to report the client's condition. d) Tell the client to bear down and try to void.

Palpate over the synthesis pubis for fullness.

After a laminectomy, a client has a palpable bladder and reports lower abdominal discomfort with voiding 60 to 80 mL of urine every 4 hours. The vital signs are BP 110/88 mm Hg, HR 86 bpm, and RR of 20 breaths/min. What is the best nursing intervention? a) Offer the client a warm compress, and observe for worsening discomfort. b) Perform a bladder scan, and obtain an order for urinary catheterization. c) Administer the prescribed analgesic, and repeat the client's vital signs in 20 minutes. d) Reassure the client that this is a normal voiding pattern.

Perform a bladder scan, and obtain an order for urinary catheterization.

When obtaining the nursing history of a client who has diabetes mellitus, the nurse should assess the client for which of the following early symptom of renal insufficiency? a) Dysuria. b) Oliguria. c) Hematuria. d) Polyuria.

Polyuria.

Which clinical finding should a nurse look for in a client with chronic renal failure? a) Metabolic alkalosis b) Polycythemia c) Hypotension d) Uremia

Uremia

Through the prevention of postoperative complications, the nurse promotes rapid convalescence. Which of the following would be most indicative of a potential postoperative complication in a client that requires further observation? a) Moderate amount of serous drainage on the surgical dressing b) Blood pressure of 100/70 mm Hg c) Temperature of 37.6°C (99.7°F) d) Urinary output of 20 mL/hr over 2 hours

Urinary output of 20 mL/hr over 2 hours

An 11-year-old girl comes into the health care provider's office stating dysuria. The nurse suspects a urinary tract infection. Which findings on the laboratory report is consistent with a urinary tract infection? a) Ketones: positive. b) Glucose: positive. c) pH 7.8. d) WBCs: 20 per high-power field.

WBCs: 20 per high-power field

A nurse is developing a teaching plan for a client who has recently been diagnosed with open angle glaucoma. The healthcare provider ordered pilocarpine 0.25% ophthalmic drops, two drops to eyes each eye four times a day. How should the nurse instruct the client to instill the eye drops? Select the correct order.

Wash your hands Take top off the medication bottle and place on a clean cloth Using a tissue or cotton gently pull the skin below the eye downward Put two drops into the conjuctival sac of the right eye Close your eye Using your finger and a tissue place gentle pressure on the nasolacrimal duct for 30 to 60 seconds

A client who has had ulcerative colitis for the past 5 years is admitted to the hospital with an exacerbation of the disease. Which factor is of greatest significance in causing an exacerbation of ulcerative colitis? a) changing to a modified vegetarian diet b) walking 2 miles (3.2 km) every day c) a demanding and stressful job d) beginning a weight-training program

a demanding and stressful job

What observation should the nurse instruct the client with an ileostomy to report immediately? a) absence of drainage from the ileostomy for 6 or more hours b) temperature of 99.8° F (37.7° C) c) passage of liquid stool from the stoma d) occasional presence of undigested food in the effluent

absence of drainage from the ileostomy for 6 or more hours

The nurse is planning care for a client who has sustained a spinal cord injury. The nurse should assess the client for: a) tingling in the fingers. b) loss of vibratory sense. c) anesthesia below the level of the injury. d) pain below the site of the injury.

anesthesia below the level of the injury.

A client who is paraplegic cannot feel the lower extremities and has been positioned on the side. The nurse should inspect which area that is a potential pressure point when the client is in this position? a) occiput b) sacrum c) ankles d) heel

ankles

A nurse is caring for a client with a spinal cord injury. The client is experiencing blurred vision and has a blood pressure of 204/102 mm Hg. What should the nurse do first? a) Control the environment by turning the lights off and decreasing stimulation for the client. b) Position the client on the left side. c) Check the client's bladder for distention. d) Administer pain medications.

check the clients bladder for distention

A client with a history of cystitis is admitted to the hospital with a diagnosis of pyelonephritis. The nurse should assess the client for: a) suprapubic pain. b) urine retention. c) costovertebral tenderness. d) dysuria.

costovertebral tenderness.

The nurse determines that interventions for decreasing fluid retention have been effective when the nurse makes which assessment in child with nephrotic syndrome? a) increased caloric intake b) decreased heart rate c) increased respiratory rate d) decreased abdominal girth

decreased abdominal girth

The nurse determines that interventions for decreasing fluid retention have been effective when the nurse makes which assessment in child with nephrotic syndrome? a) increased respiratory rate b) increased caloric intake c) decreased heart rate d) decreased abdominal girth

decreased abdominal girth

The nurse caring for a client with diabetes realizes that the client has a higher risk of developing cataracts and should also assess the client for indications of: a) background retinopathy. b) neuropathy. c) proliferative retinopathy. d) diabetic retinopathy.

diabetic retinopathy

The nurse should specifically assess a client with prostatic hypertrophy for: a) difficulty starting the flow of urine. b) voiding at less frequent intervals. c) painful urination. d) increased force of the urine stream.

difficulty starting the flow of urine.

The nurse is assisting a client with a stroke who has homonymous hemianopia. The nurse should understand that the client will: a) eat food on only half of the plate. b) not be able to swallow liquids. c) forget the names of foods. d) have a preference for foods high in salt.

eat food on only half of the plate.

A client complains of vertigo. The nurse anticipates that the client may have a problem with which portion of the ear? a) Tympanic membrane b) Middle ear c) Inner ear d) External ear

inner ear

Six hours after undergoing an abdominal hysterectomy, a client has a strong urge to void and voids 25 mL into the bedpan. Based on these data, the nurse determines that the client: a) is probably dehydrated and needs additional intravenous fluids. b) has developed a urinary tract infection and needs antibiotics. c) is experiencing urine retention and needs to be catheterized. d) needs more time to try to void and tells the client to try again in 1 hour.

is experiencing urine retention and needs to be catheterized

When preparing to administer a tap water enema, in which position should the nurse place the client? a) supine b) semi-Fowler's c) right lateral d) left Sims'

left Sims'

The client has just had a total knee replacement for severe osteoarthritis. When assessing the client, which finding should lead the nurse to suspect possible nerve damage? a) dislocation b) numbness c) bleeding d) pinkness

numbness

Clients with diabetes mellitus require frequent vision assessment. The nurse should instruct the client about which vision problem most likely to be associated with diabetes mellitus? a) retinopathy b) glaucoma c) cataracts d) astigmatism

retinopathy

An older adult has vertigo accompanied with tinnitus as the result of Ménière's disease. The nurse should instruct the client to restrict which dietary element? a) fluids b) sodium c) protein d) potassium

sodium

A 3-year old with dehydration has vomited three times in the last hour and continues to have frequent diarrhea stools. The child was admitted 2 days ago with gastroenteritis caused by rotavirus. The child weighs 22 kg, has a normal saline lock in his right hand, and has had 30 mL of urine output in the last four hours. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse calls the health care provider (HCP) with the recommendation for: a) beginning an IV antibiotic. b) giving a dose of loperaminde. c) establishing a Foley catheter. d) starting a fluid bolus of normal saline.

starting a fluid bolus of normal saline.

Choice Multiple question - Select all answer choices that apply. Which information should the nurse include in the discharge plan for a client with multiple sclerosis who has an impaired peripheral sensation? Select all that apply. a) Avoid kitchen activities because of the risk of injury. b) Carefully test the temperature of bath water. c) Wear warm clothing when outside in cold temperatures. d) Avoid hot water bottles and heating pads. e) Inspect the skin daily for injury or pressure points.

• Carefully test the temperature of bath water. • Wear warm clothing when outside in cold temperatures. • Avoid hot water bottles and heating pads. • Inspect the skin daily for injury or pressure points.

The nurse is caring for a child whose mother is deaf and untrusting of staff. She frequently cries at the bedside, but refuses intervention from social work or the chaplain. Which issue is most important for the nurse to address with the mother to promote a trusting relationship? a) The mother's fear that the staff do not respect her b) The mother's feelings of loss of control over her child c) Communication barriers between the mother and staff d) Lack of knowledge about the child's illness and treatment

Communication Barriers

A client is color blind. The nurse understands that this client has a problem with: a) rods. b) aqueous humor. c) cones. d) lens.

Cones

A client is admitted to the psychiatric unit with a diagnosis of functional neurologic symptom disorder. Since witnessing a beating at gunpoint, the client is paralyzed. Which action should the nurse initially focus on when planning this client's care? a) Exploring personal relationships that may be related to the paralysis b) Helping the client identify any stressors or psychological conflicts c) Teaching the client to deal with any limitations of the paralysis d) Helping the client identify and verbalize his/her feelings about the incident

Helping the client identify and verbalize his/her feelings about the incident

A child, age 6, is brought to the health clinic for a routine checkup. To assess the child's vision, the nurse should ask: a) "How are you doing in school?" b) "Do you have any problems seeing different colors?" c) "Do you have trouble seeing at night?" d) "Do you have problems with glare?"

How are you doing in school

A nurse is planning care for an adult who is hospitalized for diarrhea and dehydration. The client is receiving intravenous fluids but continues to have watery stools. The nurse reviews the intake and output record for the last 24 hours (view the chart). Which action should the nurse take? a) Administer an antiemetic. b) Have the client suck on ice chips. c) Increase fluids. d) Restrict fluids.

Increase fluids.

A nurse is caring for a woman who delivered a term neonate at 6 a.m. At 4 p.m., the woman has a distended bladder and is reporting pain of 5 on a scale of 1 to 10. The nurse reviews the client's output record (see accompanying image). What should the nurse do first? a) Use an in-and-out catheter to empty the bladder. b) Apply a warm, moist towel over the bladder. c) Administer acetaminophen with codeine d) Ask the woman to sit on the toilet while the nurse runs water from the faucet.

Use an in-and-out catheter to empty the bladder.

Which liquid should the nurse administer to a client who is intoxicated on phencyclidine (PCP) to hasten excretion of the chemical? a) milk b) cranberry juice c) grape juice d) water

cranberry juice

The nurse should assess clients with chronic open-angle glaucoma (COAG) for: a) colored light flashes. b) eye pain. c) decreasing peripheral vision. d) excessive lacrimation.

decreasing peripheral vision.

When a client is recovering as expected from spinal anesthesia the nurse should assess: a) rate of capillary refill in the toes. b) level of consciousness. c) degree of response to pinpricks in the legs and toes. d) rate and depth of respirations.

degree of response to pinpricks in the legs and toes.

A nurse is caring for a client admitted with a diagnosis of exacerbation of myasthenia gravis. Upon assessment of the client, the nurse notes the client has severely depressed respirations. The nurse would expect to identify which acid-base disturbance? a) Respiratory acidosis b) Metabolic alkalosis c) Metabolic acidosis d) Respiratory alkalosis

respiratory Acidosis

A client with Guillain-Barré syndrome has paralysis affecting the respiratory muscles and requires mechanical ventilation. When the client asks the nurse about the paralysis, how should the nurse respond? a) "The paralysis caused by this disease is temporary." b) "You'll first regain use of your legs and then your arms." c) "It must be hard to accept the permanency of your paralysis." d) "You'll be permanently paralyzed; however, you won't have any sensory loss."

"The paralysis caused by this disease is temporary."

A nurse is conducting a physical examination of a 4-month-old child. Upon assessing the pupils, the nurse notes a white pupil opening in the left eye. The parents express concern that the infant is unable to grasp objects placed nearby and does not respond to facial expressions. The parents ask the nurse what is wrong with their child's vision. What is the best response by the nurse? a) "There's a cataract in the left eye that should be surgically removed." b) "Your child has an eye infection that can easily be treated." c) "There appears to be something obstructing your child's vision." d) "Unfortunately, your child is going blind in the left eye."

"There appears to be something obstructing your child's vision."

A nurse is providing health teaching focusing on urinary tract infections to a group of adolescent girls. One of the girls tells the nurse that she has heard of a condition called honeymoon cystitis and wants to know what it is. Which statement by the nurse is the most appropriate response? a) "This condition results from irritation and inflammation from sexual activity." b) "This is a fictitious condition used to prevent sexual experiences in young women." c) "This is a very serious condition that occurs immediately following a honeymoon." d) "This condition occurs after the first sexual experience and causes little harm."

"This condition results from irritation and inflammation from sexual activity.

The nurse is assessing a client who is 4 hours postpartum. Based on the findings documented by the nurse, which action is most appropriate at this time? a) Ask the client to empty her bladder. b) Straight-catheterize the client immediately. c) Raise the head of the bed. d) Straight-catheterize the client for half of her urine volume. e) Call the client's primary health-care provider for direction. f) Notify the charge nurse of the assessment findings.

Ask the client to empty her bladder.

The nurse is caring for a client with polydipsia and large amounts of urine with a specific gravity of 1.003. Which disorder is anticipated? a) Diabetes mellitus b) Diabetes insipidus c) Diabetic ketoacidosis d) SIADH secretion

Diabetes insipidus

A client with Crohn's disease is scheduled for a barium enema. What should the plan of care include today to prepare for the test tomorrow? a) Order a high-fiber diet. b) Avoid dairy products. c) Serve the client a regular diet. d) Encourage plenty of fluids.

Encourage plenty of fluids.

A client is diagnosed with pyelonephritis. Which nursing action is a priority for care now? a) Ensure sufficient hydration. b) Monitor hemoglobin levels. c) Insert a urinary catheter. d) Stress the importance of the use of long-term antibiotics.

Ensure sufficient hydration.

A client is diagnosed with pyelonephritis. Which nursing action is a priority for care now? a) Stress the importance of the use of long-term antibiotics. b) Monitor hemoglobin levels. c) Insert a urinary catheter. d) Ensure sufficient hydration.

Ensure sufficient hydration.

Parents of a 3-week-old healthy newborn ask the nurse why their daughter is intermittenly cross-eyed. The nurse's best response is: a) "An eye patch may be necessary for 6 weeks to correct you child's vision." b) "Your child will likely need an ophthalmology consult." c) "It is normal to have eye crossing in the newborn period." d) "Surgery may be necessary to correct your child's vision."

It is normal to have eye crossing in the newborn period

What assessment findings would the nurse expect to find with a client with progressive myasthenia gravis? a) Muscle weakness, difficulty swallowing, double vision, and difficulty speaking b) Muscle inflammation, choking when eating, nearsightedness, and painful joints c) Muscle pain, difficulty speaking, headaches, and arthritic changes d) Atrophy of the muscles, difficulty chewing, strabismus, and difficulty moving

Muscle weakness, difficulty swallowing, double vision, and difficulty speaking

The nurse teaches the father of an infant hospitalized with gastroenteritis about the next step of the treatment plan once the infant's condition has been controlled. The nurse should determine that the father understands when he explains that which intervention will occur with his infant? a) Blood will be drawn daily to test for anemia. b) The infant will receive clear liquids for a period of time. c) Formula and juice will be offered. d) The infant will be allowed to go to the playroom.

The infant will receive clear liquids for a period of time.

During the period of spinal shock, the nurse should expect the client's bladder function to be: a) uncontrolled. b) atonic. c) spastic. d) normal.

atonic.

Which nursing intervention for catheter care should have the highest priority? a) irrigating the catheter with several milliliters of normal saline solution b) cleaning the area around the urethral meatus c) changing the location where the catheter is taped to the client's leg d) clamping the catheter periodically to maintain muscle tone

cleaning the area around the urethral meatus

When preparing a client for a scheduled colonoscopy, the nurse should tell the client that this procedure will involve: a) cleansing the bowel with laxatives or enemas. b) administering an antibiotic to decrease the risk of infection. c) placing the client on a full-liquid diet 48 hours before the procedure. d) administering meperidine IM to prevent pain during the procedure.

cleansing the bowel with laxatives or enemas.

While assessing a male neonate whose mother desires him to be circumcised, the nurse observes that the neonate's urinary meatus appears to be located on the ventral surface of the penis. The health care provider (HCP) is notified because the nurse suspects which complication? a) phimosis b) hydrocele c) epispadias d) hypospadias

hypospadias

When preparing to administer a tap water enema, in which position should the nurse place the client? a) supine b) semi-Fowler's c) left Sims' d) right lateral

left sims

A client is being treated for acute low back pain. The nurse should report which of these clinical manifestations to the health care provider (HCP) immediately? a) pain in the lower back that radiates to the hip b) pain in the lower back when the leg is lifted c) new onset of footdrop d) diffuse, aching sensation in the L4 to L5 area

new onset of footdrop

After undergoing a barium enema, which finding indicates that the infant has adequately evacuated the barium? a) absence of fecal mass in the lower abdomen b) stool guaiac that is negative c) stools that progress from clay-colored to brown d) bowel sounds of 30 per minute

stools that progress from clay-colored to brown

A client requires behavioral therapies to decrease or eliminate urinary incontinence. Which procedures would the nurse expect to include in the teaching plan for this client? Select all that apply.

• Scheduled voiding. • Kegel exercises. • Biofeedback.

In the fourth stage of labor, a full bladder increases the risk of what postpartum complication? a) Shock b) Disseminated intravascular coagulation (DIC) c) Infection d) Hemorrhage

Hemorrhage

A client is admitted to the recovery room after cystoscopy with biopsy. Before the nurse can discharge the client, the nurse should be sure the client: a) has received the first dose of pain medication. b) has no blood in the urine. c) has voided. d) has a bowel movement.

has voided.

While assessing a term neonate on a home visit to a primiparous client 2 weeks after a vaginal birth, the nurse observes that the neonate is slightly jaundiced and the stool is a pale, light color. The nurse notifies the health care provider (HCP) because these findings indicate which problem? a) Rh isoimmunization b) biliary atresia c) ABO incompatibility d) esophageal varices

biliary atresia

What should the nurse do to prevent catheter associated urinary tract infection (CAUTI)? Select all that apply. a) Provide perineal care several times a day. b) Encourage the client to drink 3,000 mL of fluids a day. c) Monitor the temperature as an indicator of the infection. d) Recommend the health care provider (HCP) prescribe antibiotics. e) Change the catheter daily.

• Provide perineal care several times a day. • Encourage the client to drink 3,000 mL of fluids a day. • Monitor the temperature as an indicator of the infection.