NCLEX

Which nursing interventions would the nurse implement when caring for a client newly diagnosed with acute, viral hepatitis B? SELECT ALL THAT APPLY 1. Offer small, frequent meals to prevent nausea 2. Promote rest periods between periods of activity 3. Provide a diet high in fat and low in carbohydrates 4. Teach the client not to share razors or tooth brushes with others 5. Teach the client to abstain from drinking alcohol

1,2,4,5

The nurse is assessing a client with rheumatoid arthritis who is being considered for adalimumab therapy. Which statement made by the client needs FURTHER investigation? 1. "I am taking an antibiotic for a urinary tract infection." 2. "I had a negative tuberculosis skin test 2 weeks ago." 3. "I just received my yearly flu shot a week ago." 4. "I will continue taking naproxen at night to help with pain."

1. "I am taking an antibiotic for a urinary tract infection."

A client is 1-day postoperative abdominoplasty and is discharged to go home with a Jackson-Pratt (JP) closed wound system drain in place. The nurse teaches the client how to care for the drain and empty the collection bulb. Which statement indicates that the client NEEDS FURTHER INS-TRUCTION? 1. "I'll empty the JP bulb when it is totally full so that I don't have to unplug it so many times." 2. I'll pull the plug on the JP bulb and pour the drainage into the measurable specimen cup." 3. "I'll squeeze the JP bulb from side to side as I hold it in my hand." 4. "While the JP bulb is totally compressed, I'll clean the spout with alcohol and replace the plug."

1. "I'll empty the JP bulb when it is totally full so that I don't have to unplug it so many times."

A client is able to partially bear weight and follow the nurse's instructions Which would be the MOST APPROPRIATE method for the nurse to use to safely transfer this client? 1. 1 person stand and pivot with gait belt and walker. 2. 1 person standby assist with walker 3. 2 person motorized stand assist lift. 4. 2 person stand and pivot with gait belt and walker.

1. 1 person stand and pivot with gait belt and walker.

The nurse is caring for a 7 year old child diagnosed with nephrotic syndrome who will be discharged soon. which statement by the parent indicates the need for REINFORCEMENT of teaching/ 1. "Cutting down an added salt will be good for the whole family." 2. "I'll organize a lot of playdates to keep my child 's spirit up." 3. "I'll restrict my child's fluids if I notice swelling or weight gain." 4. :Ill test for protein in my child's urine everyday."

2. "I'll organize a lot of playdates to keep my child 's spirit up."

The nurse provides teaching about methotrexate to a 28 year old client with rheumatoid arthritis. Which client statement indicates the need for FURTHER instruction regarding this drug ? 1. "I know my resistance to germs will be lower, so I should get a flu shot this year." 2. "I should take precautions to prevent pregnancy while I take this medicine." 3. "I will have an eye examination every 6 months to check the damage caused by my medication." 4."It will be a difficult change for me, but I will not have wine with dinner anymore."

3. "I will have an eye examination every 6 months to check the damage caused by my medication."

A client with a diagnosis of schizophrenia with catatonia has recently been admitted to the psychiatric unit. Which of the following is the PRIORITY nursing diagnosis? 1. Impaired social interaction 2. Impaired verbal communication 3. Risk for deficient fluid volume 4. Risk for impaired skin integrity

3. Risk for deficient fluid volume

A pregnant client comes to the labor and delivery unit stating the water just broke at home. On assessment of the client's perineal area, the nurse visualizes a loop of umbilical cord protruding from the vagina. Which nursing intervention would be appropriate? 1. Apply suprapubic pressure 2. Perform Leopold maneuvers 3. Perform the McRoberts maneuver 4. Position the client on hands and knees.

4. Position the client on hands and knees.