Ncclex week three mine

The client calls the office of the primary health care provider (PHCP) and states to the nurse that they were just stung by a bumblebee while gardening. The client is afraid of a severe reaction because their neighbor experienced such a reaction just 1 week ago. Which would be the appropriate nursing action?

Ask the client if they ever sustained a bee sting in the past.

The nurse is caring for a client with a possible ectopic pregnancy. The nurse would perform the following actions in which priority order? Arrange the actions in the order they should be performed. All options must be used.

1.Assess the client for signs of increased pain or vaginal bleeding. 2.Obtain a urine specimen. 3.Prepare the client for ultrasound. 4.Assess the emotional state of the client.

Place in correct order the steps the nurse would use to resolve an ethical dilemma. Arrange the actions in the order that they should be performed. All options must be used.

1.Determine if an ethical dilemma exists. 2.Gather necessary information 3.Clarify values. 4.Verbalize the problem. 5.Identify possible courses of action. 6.Negotiate a plan. 7.Evaluate the plan.

The nurse is caring for a client who is scheduled for surgery. The client states concern about the surgical procedure. How would the nurse initially address the client's concerns?

Ask the client to discuss information known about the planned surgery.

The nurse witnesses a person starting to choke in the hospital cafeteria. Before performing abdominal thrusts, which action would the nurse perform?

Ask the client, "Are you choking?"

The nurse is caring for a 3-hour-old infant and notes that the infant has not eaten since birth, is jittery, and has a weak cry. The mother states that she can't get the baby to eat. Which action would the nurse take first?

Check the blood glucose level.

A child is brought to the emergency room, and the mother reports that the child accidentally swallowed paint thinner after mistaking it for water. The nurse would perform which action first?

Check the circulation, airway, and breathing status of the child.

The nurse is monitoring a postoperative client on an hourly basis. The nurse notes that the client's hourly urine output is 25 mL through an indwelling urinary catheter for the last 2 hours. Based on this finding, which would be the nurse's actions at this time? Select all that apply.

Check the client's overall intake and output record. Gather data about the urinary catheter and check for patency.

A cardiac monitor alarm sounds, and the nurse notes a straight line on the monitor screen. What is the nurse's immediate nursing action?

Check the client.

A client with heart failure who is taking furosemide and digoxin calls the nurse and complains of anorexia and nausea. The nurse would take which action?

Check the result of the potassium level drawn 3 hours ago.

The nurse enters a client's room and finds the client slumped down in the chair. Breathing is shallow and a pulse is present. Based on this data, the nurse determines that which action is the priority?

Check the vital signs and level of consciousness.

The nurse is caring for a child following a cleft palate repair who has elbow restraints in place. The nurse assists in preparing a plan of care and determines that which nursing intervention would receive highest priority regarding the restraints?

Checking color, sensation, and pulses distal to the restraints

A pregnant client experienced a uterine rupture with subsequent fetal death. After ensuring that the client is physiologically stable, the nurse would take which approach as the first step to support the client psychologically?

Collect data regarding how the client perceived the event.

The nurse learns in report that a client is exhibiting Cheyne-Stokes respirations. Based on this data, which action is most appropriate for the nurse to take initially?

Determine the client's ability to follow verbal commands.

Encourage the client to discuss her concerns and desires regarding anesthesia options.

Determine the parents' desires for contact with the newborn.

The nurse is assigned to care for a client with partial-thickness burns to 60% of her body surfaces. On the fourth day after injury, the client's vital signs include an oral temperature of 102.8°F, pulse of 98 beats per minute, respirations of 24 breaths per minute, and blood pressure of 105/64 mm Hg. Parenteral nutrition is infusing at 82 mL/hr. Based on these data, the nurse plans to initially perform which action?

Monitor the client for signs of infection.

A client presents in the emergency department reporting severe nausea, vomiting, and diarrhea for 5 days. The client is weak, has 2+ tenting skin turgor, and states a weight loss of 7 pounds in the last week. At this time, which action would the nurse take?

Obtain orthostatic vital signs.

The nurse has delegated care of a client with chronic obstructive pulmonary disease (COPD) to an assistive personnel (AP). The AP notifies the nurse that the client's vital signs are elevated, and the client is complaining of pain and dyspnea. Which is appropriate regarding the nurse's next action?

The nurse checks the client and gathers additional data before calling the primary health care provider.

15 of 25GO The nurse is caring for a client with metastatic lung cancer. The client was medicated 2 hours ago and now reports a new and sudden sharp pain in the back. The nurse appropriately interprets this finding as possible spinal cord compression. Which would the nurse do next?

Ask the client about numbness and tingling in all the extremities.

A client is scheduled to have an elective cesarean delivery. How would the nurse allay the client's feelings of anxiety?

Encourage the client to discuss her concerns and desires regarding anesthesia options.

A client who experienced a myocardial infarction (MI) tells the nurse that he is fearful about not being able to return to a normal life. Which action by the nurse is therapeutic at this time?

Explore specific concerns with the client.

An adolescent client is admitted to the hospital following an accidental gunshot wound to the foot. The nurse would plan to do which as a first step for the prevention of future injury?

Explore the adolescent's knowledge of gun safety.

The licensed practical nurse (LPN) employed in a long-term care facility is asked to assist in planning implementation of a change in the method of documentation system in the nursing unit. Many problems have occurred as a result of the present documentation system, and the nurse manager determines that a change is required. The LPN understands that which is the initial step in the process of change?

Identify the inefficiency that needs improvement or correction.

The nurse is preparing to administer an intermittent tube feeding to a client with a nasogastric (NG) tube. The nurse checks the residual and obtains an amount of 200 mL. Which actions would the nurse take? Select all that apply.

Listen to the client's bowel sounds. Question the client regarding nausea. Determine whether the client has abdominal distension. Hold the feeding after flushing the tubing with 30 mL saline.

A client who has developed paralysis of the lower extremities is admitted to the hospital. The client shares information with the nurse regarding a severe emotional trauma that occurred 6 weeks ago. The nurse develops a plan of care, knowing which action is the priority?

Look for organic causes of the paralysis.