Nclex pass point questions set 1

For the past 24 hours, a client with dry skin and dry mucous membranes has had a urine output of 600 ml and a fluid intake of 800 ml. The client's urine is dark amber. These assessments indicate which nursing diagnosis? Impaired urinary elimination Deficient fluid volume Imbalanced nutrition: Less than body requirements Excess fluid volume

Deficient fluid volume Explanation: Dark, concentrated urine, dry mucous membranes, and a urine output of less than 30 ml/hour (720 ml/24 hours) are symptoms of dehydration or Deficient fluid volume. Decreased urine output is related to deficient fluid volume, not Impaired urinary elimination. Nothing in the scenario suggests a nutritional problem. If a fluid volume excess were present, manifestations would most likely include signs of fluid overload such as edema.

A nurse should expect to administer which medication to a client with gout? aspirin furosemide colchicine calcium gluconate

colchicine Explanation: A disease characterized by joint inflammation (especially in the great toe), gout is caused by urate crystal deposits in the joints. The physician orders colchicine to reduce these deposits and thus ease joint inflammation. Although aspirin reduces joint inflammation and pain in clients with osteoarthritis and rheumatoid arthritis, it isn't indicated for gout because it has no effect on urate crystal formation. Furosemide, a diuretic, doesn't relieve gout. Calcium gluconate reverses a negative calcium balance and relieves muscle cramps; it doesn't treat gout.

The nurse receives an order to administer morphine to a client with an acute myocardial infarction. What is the purpose of this medication? to decrease cardiac output to increase preload and afterload to increase myocardial oxygen demand to decrease myocardial oxygen demand

to decrease myocardial oxygen demand Explanation: Morphine will calm and relax the client and decrease respiratory rate, anxiety, and stress, thus decreasing myocardial oxygen demand. It doesn't have any effect on cardiac output or preload or afterload.

Thirty minutes after a Sengstaken-Blakemore tube is inserted, the nurse observes that the client appears to be having difficulty breathing. What should the nurse do first? Remove the tube. Deflate the esophageal portion of the tube. Determine whether the tube is obstructing the airway. Increase the oxygen flow rate.

Determine whether the tube is obstructing the airway. Explanation: If the gastric balloon should rupture or deflate, the esophageal balloon can move and partially or totally obstruct the airway, causing respiratory distress. The client must be observed closely. No direct action should be taken until the condition is accurately diagnosed.

A client is admitted with bacterial meningitis. Which hospital room is the best choice for this client? a private room down the hall from the nurses' station an isolation room three doors from the nurses' station a semiprivate room with a client who has viral meningitis a two-bed room with a client who previously had bacterial meningitis

an isolation room three doors from the nurses' station Explanation: A client with bacterial meningitis should be kept in isolation for at least 24 hours after admission and, during the initial acute phase, should be as close to the nurses' station as possible to allow maximal observation. Placing the client in a room with a client who has viral meningitis may cause harm to both clients because the organisms causing viral and bacterial meningitis differ; either client may contract the other's disease. Immunity to bacterial meningitis can't be acquired; therefore, a client who previously had bacterial meningitis shouldn't be put at risk by rooming with a client who has just been diagnosed with this disease.

A client had a nephrectomy 2 days ago and is now complaining of abdominal pressure and nausea. The first nursing action should be to auscultate bowel sounds. palpate the abdomen. change the client's position. insert a rectal tube.

auscultate bowel sounds. Explanation: If abdominal distention is accompanied by nausea, the nurse must first auscultate bowel sounds. If bowel sounds are absent, the nurse should suspect gastric or small intestine dilation and these findings must be reported to the physician. Palpation should be avoided postoperatively with abdominal distention. If peristalsis is absent, changing positions and inserting a rectal tube won't relieve the client's discomfort.

A pediatric nurse preceptor working on an oncology floor goes to see if the new graduate nurse caring for a 3-year-old terminally ill child requires assistance. The preceptor finds the new nurse in the lounge crying. What is the preceptor's best action? Give the graduate some privacy. Ask the graduate what has caused the crying. Offer to call the chaplain to offer the graduate support. Let the nurse manager know about the situation.

Ask the graduate what has caused the crying. Explanation: Caring for acute or chronically ill children can be emotionally and physically stressful. A preceptor to a new nurse should be supportive and empathetic by asking about the new nurse's feelings. It is not appropriate for the preceptor to make judgments about the new nurse, and it is not acceptable for the preceptor to talk with the nurse manager about the issue at this time. It is not unusual for a nurse to need time to emotionally adjust to a new situation or new client population. Many times the chaplain can offer emotional and spiritual support that the nurse needs, but the preceptor offering support is the primary need.

The client with Cushing's disease needs to modify dietary intake to control symptoms. In addition to increasing protein, which strategy would be most appropriate? Increase calories. Restrict sodium. Restrict potassium. Reduce fat to 10%.

Restrict sodium. Explanation: A primary dietary intervention is to restrict sodium, thereby reducing fluid retention. Increased protein catabolism results in loss of muscle mass and necessitates supplemental protein intake. The client may be asked to restrict total calories to reduce weight. The client should be encouraged to eat potassium-rich foods because serum levels are typically depleted. Although reducing fat intake as part of an overall plan to restrict calories is appropriate, fat intake of less than 20% of total calories is not recommended.

The nurse observes that when a client with Parkinson's disease unbuttons the shirt, the upper arm tremors disappear. Which statement best guides the nurse's analysis of this observation about the client's tremors? The tremors are probably psychological and can be controlled at will. The tremors sometimes disappear with purposeful and voluntary movements. The tremors disappear when the client's attention is diverted by some activity. There is no explanation for the observation; it is a chance occurrence.

The tremors sometimes disappear with purposeful and voluntary movements. Explanation: Voluntary and purposeful movements often temporarily decrease or stop the tremors associated with Parkinson's disease. In some clients, however, tremors may increase with voluntary effort. Tremors associated with Parkinson's disease are not psychogenic but are related to an imbalance between dopamine and acetylcholine. Tremors cannot be reduced by distracting the client.

A client with antisocial personality disorder smokes in prohibited areas and refuses to follow other unit and facility rules. The client persuades others to do the client's laundry and other personal chores, splits the staff, and will work only with certain nurses. The care plan for this client should focus primarily on: consistently enforcing unit rules and facility policy. isolating the client to decrease contact with easily manipulated clients. engaging in power struggles with the client to minimize manipulative behavior. using behavior modification to decrease negative behavior by using negative reinforcement.

consistently enforcing unit rules and facility policy. Explanation: Firmness and consistency regarding rules are the hallmarks of a care plan for a client with a personality disorder. Isolation is inappropriate and violates the client's rights. Power struggles should be avoided because the client may try to manipulate people through them. Behavior modification usually fails because of staff inconsistency and client manipulation.

The nurse assesses an adolescent client with lethargy, retractions of the intercostal spaces, a persistent expiratory wheeze, diminished breath sounds, tachycardia, and tachypnea. Arterial blood gas results are pH 7.10; PCO2 80 mm Hg (10.64 kPa); PO2 35 mm Hg (4.66 kPa), HCO3 29 mEq/l (29 mmol/l). What is the priority condition the nurse must address? respiratory acidosis change in mental status increased heart rate breathing pattern

respiratory acidosis Explanation: Based on the results of the arterial blood gases, this client is in respiratory acidosis. The nurse must address this quickly because it could lead to respiratory failure. If the nurse addresses the respiratory acidosis quickly, which means also addressing the cause of the imbalance, the client may not experience respiratory failure. Additionally, assessment data, vital signs, and laboratory work will begin to normalize.

A nurse is caring for a client who has left homonymous hemianopsia following a recent cerebral vascular accident (CVA). Which nursing diagnosis should take the highest priority? risk for injury impaired physical mobility activity intolerance impaired verbal communication

risk for injury Explanation: Left homonymous hemianopsia causes loss of vision in half of the right visual field so clients cannot see past the midline without turning the head to that side, leaving the client at risk for injury. The client who has had a stroke may have impaired physical mobility, activity intolerance, and impaired verbal communication but these are not the priority according to Maslow's hierarchy of needs.

A nurse is talking to a neighbor who asks about reoccurring symptoms of gnawing epigastric pain following meals and heartburn. Recognizing these symptoms, what suggestion could the nurse make? Avoid alcohol and nonsteroidal anti-inflammatory medications. Lay flat on your right side after meals. Cut back to 2 large meals each day. Sip green tea throughout the day.

Avoid alcohol and nonsteroidal anti-inflammatory medications. Explanation: Peptic ulcer disease is characterized by dull, gnawing pain in the midepigastric region or the back that worsens with eating. There are several recommendations to improve symptoms. Avoid all coffee and other sources of caffeine as well as alcohol and tobacco. Avoid milk and milk products as well, they increase acid secretion. Eat smaller amounts of food more frequently. Don't let your stomach go empty for long periods of time. Drink peppermint tea and chamomile teas frequently.

The nurse leading a group session for parents of children diagnosed with oppositional defiant disorder. The nurse should give which recommendation for discipline? Avoid limiting the child's use of the television and computer for punishment. Be consistent with discipline while assisting with ways for the child to more positively express anger and frustration. Use primarily positive reinforcement for good behavior while ignoring any demonstrated bad behavior. Use time-out as the primary means of punishment for the child regardless of what the child has done.

Be consistent with discipline while assisting with ways for the child to more positively express anger and frustration. Explanation: Consistent discipline and alternative methods of anger management are two important tools for parents who have a child with oppositional defiant disorder. Consistent discipline sets limits for the child. Helping the child learn more appropriate ways to manage anger assists the child in living within societal expectations. Avoiding restriction of television and computer time for punishment or using time-out as the primary means of punishment has not been suggested as an appropriate management method. Typically, using many strategies is more effective. Ignoring bad behavior could be dangerous and does not reinforce to the child that limits on behavior exist in society.

While assessing a client's spine for abnormal curvatures, the nurse notes lordosis. Identify the area of the spine that is affected by lordosis.

Lordosis is characterized by an accentuated curve of the lumbar area

A Jewish client requests an orthodox diet while hospitalized. The nurse should refer this request to which team member? dietitian health care provider (HCP) unit case manager rabbi in pastoral care

dietitian Explanation: The dietary department should meet with the client to ensure that the foods are available and prepared according to religious beliefs. On admission, the client should be asked whether there are special dietary needs. The dietary department should be notified of these special needs, and a dietary representative should meet with the client and family when possible. The HCP should be consulted if a requested food is contrary to a prescribed diet restriction. The unit case manager does not need to be contacted regarding a dietary request. The rabbi is not involved in dietary requests.

A client has had an adrenalectomy. What is the priority goal for this client in the first 24 hours after surgery? beginning oral nutrition promoting self-care activities preventing adrenal crisis ambulating in the hallway

preventing adrenal crisis Explanation: The priority in the first 24 hours after adrenalectomy is to identify and prevent adrenal crisis. Monitoring of vital signs is the most important evaluation measure. Hypotension, tachycardia, orthostatic hypotension, and arrhythmias can be indicators of pending vascular collapse and hypovolemic shock that can occur with adrenal crisis. Beginning oral nutrition is important, but not necessarily in the first 24 hours after surgery, and it is not more important than preventing adrenal crisis. Promoting self-care activities is not as important as preventing adrenal crisis. Ambulating in the hallway is not a priority in the first 24 hours after adrenalectomy.

A 45-year-old client is admitted to the facility with excruciating paroxysmal facial pain. The client reports that the episodes occur most often after feeling cold drafts and drinking cold beverages. Based on these findings, the nurse determines that the client is most likely suffering from which neurologic disorder? Bell's palsy trigeminal neuralgia migraine headache angina pectoris

trigeminal neuralgia Explanation: Trigeminal neuralgia, a painful disorder of one or more branches of cranial nerve V (trigeminal), produces paroxysmal attacks of excruciating facial pain. Attacks are precipitated by stimulation of a trigger zone on the face. Triggering events may include light touch to a hypersensitive area, a draft of air, exposure to heat or cold, eating, smiling, talking, or drinking hot or cold beverages. It occurs most commonly in people older than age 40. Bell's palsy is a disease of cranial nerve VII that produces unilateral or bilateral facial weakness or paralysis. Migraine headaches are throbbing vascular headaches that usually begin to occur in childhood or adolescence. Headache pain may emanate from the pain-sensitive structures of the skin, scalp, muscles, arteries, and veins; cranial nerves V, VII, IX, and X; or cervical nerves 1, 2, and 3. Occasionally, jaw pain may indicate angina pectoris.

The nurse is preparing a community education program about preventing hepatitis B infection. Which information should be incorporated into the teaching plan? Hepatitis B is relatively uncommon among college students. Frequent ingestion of alcohol can predispose an individual to development of hepatitis B. Good personal hygiene habits are most effective at preventing the spread of hepatitis B. The use of a condom is advised for sexual intercourse.

The use of a condom is advised for sexual intercourse. Explanation: Hepatitis B is spread through exposure to blood or blood products and through high-risk sexual activity. Hepatitis B is considered to be a sexually transmitted disease. High-risk sexual activities include sex with multiple partners, unprotected sex with an infected individual, male homosexual activity, and sexual activity with IV drug users. College students are at high risk for development of hepatitis B and are encouraged to be immunized. Alcohol intake by itself does not predispose an individual to hepatitis B, but it can lead to high-risk behaviors such as unprotected sex. Good personal hygiene alone will not prevent the transmission of hepatitis B.

A 6-month-old child is taken to the pediatrician, and the parent states that the child is not growing like other children of similar age in other families. The birth weight of the child was 7 pounds 11 ounces, (3,495 g) and the current weight is 11 pounds 2 ounces (5,057 g). Based on these findings, what does the nurse tell the parent? "Your infant's weight is within the normal range based on the infant's age. No further action is required." "Your infant's weight is below the normal range based on the infant's age. Let's start with a few questions regarding your infant's eating habits." "You should not compare your infant's weight based on other infants of the same age because each child's weight gain differs. No further action is required." "Your infant's weight is above the normal range based on the infant's age. Let's start with a few questions regarding your infant's eating habits".

Your infant's weight is below the normal range based on the infant's age. Let's start with a few questions regarding your infant's eating habits." Explanation: Birth weight usually doubles by age 6 months and triples by age 1 year. Therefore, this infant should weigh 14 lb (6.4 kg). Watchful waiting or no action is detrimental to the infant's growth and development. Comparison to other children is not helpful. Asking about the child's eating habits will help the nurse get a better understanding of potential causes of the low birth weight. The parents should be advised that the birth weight is below normal.

When assessing an infant with an undescended testis, the nurse should be alert for which symptom? abnormal lower extremity reflexes a history of frequent emesis a bulging in the inguinal area poor weight gain

a bulging in the inguinal area Explanation: When an anomaly is found in one system, such as the genitourinary system, that system requires a more focused assessment to reveal other conditions that also may be occurring. A bulging in the inguinal area may suggest an inguinal hernia. Also, hydrocele or an upper urinary tract anomaly may occur on the same side as the undescended testis. A neuromuscular problem, not a genitourinary problem such as undescended testes, would most likely be the cause of abnormal lower extremity reflexes. A history of frequent emesis may be caused by pyloric stenosis or viral gastroenteritis. Poor weight gain might suggest a metabolic or a feeding problem.