nclex pass point questions set 2
The nurse is completing the preoperative checklist for a client going to surgery. Which client statement would be of the most concern to the nurse and require that the surgeon be notified immediately? "I am allergic to penicillin." "I had a few sips of water with dabigatran this morning." "I have an advance directive in my chart." "I have an implanted pacemaker."
"I had a few sips of water with dabigatran this morning." Explanation: Dabigatran must not be taken prior to surgery or serious risk of bleeding can result. It is important to note allergies and pacemaker on the preoperative checklist; an advanced directive should also be noted. However, they do not warrant a call to the surgeon.
A client is scheduled for cardiac catheterization. The client reports being nervous because there have been incidents of people dying during this procedure. How would the nurse respond? "Do you have any history of an anxiety disorder we should be aware of?" "All procedures carry some degree of risk and the risk with this one is very low." "What makes you think you will die during the cardiac catheterization procedure?" "Would you like to go over the details of the procedure with me now?"
"Would you like to go over the details of the procedure with me now?" Explanation: The client's statements reflect anxiety about the upcoming procedure, which is normal and should not prompt the nurse to suspect the client has a history of any anxiety disorders, which is a medical diagnosis. Often fear related to procedures is related to uncertainty, so the nurse should offer to clarify the procedure with the client as a first step. The client did not state believing they would die during the procedure, only that the client is aware that others have so the nurse would be inaccurate in summarizing the client's concern in this way. Stating all procedures carry risk and this is a safe one is dismissive of the client's concerns.
A home care nurse is making a visit with a client who has a colostomy. While the nurse is changing the client's appliance, the client's next-door neighbor wants to visit. Which intervention by the nurse is most appropriate? Select all that apply. Cover the appliance and allow the neighbor to enter. Have the neighbor wait in the next room until the appliance is changed. Ask the neighbor to come back in 20 minutes. Suggest that the neighbor come in and receive caregiver education. Tell the neighbor only family is allowed right now.
Correct response: Have the neighbor wait in the next room until the appliance is changed. Ask the neighbor to come back in 20 minutes. Explanation: The home care nurse should either ask the neighbor to wait in the other room or come back in 20 minutes. Client privacy is a priority even in the home care setting. Allowing the neighbor to enter the room violates client privacy and confidentiality. Suggesting the neighbor come in and learn how to change the appliance is inappropriate because the client did not request help from the neighbor.
A child has been exposed to varicella. Which precaution should the nurse institute for infection control? airborne precautions droplet precautions contact precautions indirect contact precautions
Correct response: airborne precautions Explanation: Children with varicella or suspected varicella should be treated under airborne precautions in addition to standard precautions. Varicella is transmitted by airborne nuclei. Droplet precautions are indicated for conditions such as pertussis, meningococcal pneumonia, and rubella. Contact precautions are indicated for conditions such as draining major abscesses, acute viral conjunctivitis, and Clostridium difficile gastroenteritis. Indirect contact is not a method of controlling infection. Rather, it is a mode of transmission involving contamination via some intermediate object, such as an instrument, needle, or dressing, or by hands that are not washed or gloves that are not changed between clients.
What actions does the nurse anticipate completing at the end of the second stage of labor before the delivery of the placenta in a spontaneous vaginal birth of a term newborn? Select all that apply. assigning the Apgar scores administering oxytocin assisting with perineal repairs drying the newborn initiating skin to skin care taking newborn vital signs
Correct response: assigning the Apgar scores drying the newborn initiating skin to skin care taking newborn vital signs Explanation: The second stage of labor ends with birth. Delivery of the placenta normally happens 5 to 30 minutes after birth. It is the nurse's responsibility to note the time of birth and complete or assist with the 1- and 5-minute Apgar scores. The infant should be dried immediately after birth to prevent heat loss from evaporation. Ideally, the infant is then placed skin to skin with the mother. Vital signs on the infant should be taken soon after birth. Oxytocin administration is done to actively manage the fourth stage of labor after the delivery of the placenta. Perineal repairs also happen after the delivery of the placenta.
A 10-year-old male is 24 hours post appendectomy. He is awake, alert, and oriented. He tells the nurse that he is experiencing pain. He has a prescription for morphine 1 to 2 mg PRN for pain. What is the priority nursing action in managing the child's pain? Change the child's position in bed. Obtain vital signs with a pain score. Administer 1 mg morphine as prescribed. Perform a head-to-toe assessment.
Obtain vital signs with a pain score. Explanation: The child is in pain and needs intervention, but before the nurse can determine how to proceed, it is essential to know the client's pain score to determine the appropriate morphine dose. In addition, the nurse cannot evaluate the effectiveness of the pain medication if there is no pain score prior to administering the medication. Changing the child's position and administering pain medication may be helpful to relieve the child's pain, but the nurse must first know the severity of the pain before determining the appropriate intervention. The nurse must perform a head to toe assessment, but it is not the priority in managing the child's pain.
The nurse cares for a client of a different cultural background. What is the best way for the nurse to provide culturally competent care to the client? Plan and implement care in a way that is sensitive to the needs of the client. Ask the client to explain the reasons for certain cultural preferences. Assure the client that all cultural preferences will be respected by staff. Introduce the client to other clients on the unit who share the same culture.
Plan and implement care in a way that is sensitive to the needs of the client. Explanation: Providing culturally competent nursing care means that care is planned and implemented in a way that is sensitive to the needs of individuals, families, and groups from diverse cultural populations within society. To provide culturally competent care, the nurse does not need to ask the client to explain the reasons for the client's beliefs. Assuring the client that the client's cultural preferences will be respected is dismissive and presumes the behavior of others instead of actively creating culturally competent interventions in the plan of care. Introducing the client to other clients makes the assumption that clients of similar cultural backgrounds will share interests and a desire to interact with each other. Making such an assumption is not a culturally competent approach.
The nurse evaluates the effectiveness of the client's postoperative plan of care. Which outcome is expected for a client with an ileal conduit? The client verbalizes the understanding that physical activity must be curtailed. The client will place an aspirin in the drainage pouch to help control odor. The client demonstrates how to catheterize the stoma. The client will empty the drainage pouch frequently throughout the day.
The client will empty the drainage pouch frequently throughout the day. Explanation: It is important that the client empty the drainage pouch throughout the day to decrease the risk of leakage. The client does not normally need to curtail physical activity. Aspirin should never be placed in a pouch because aspirin can irritate or ulcerate the stoma. The client does not catheterize an ileal conduit stoma.
Following an education session on proper hand hygiene, the nurse educator observes a nurse washing hands before entering a client's room. Which observation would alert the nurse educator to the need for further education? The nurse dries from finger tips down toward elbows. The nurse dries from forearms up toward fingers. The nurse keeps hands lower than elbows while washing. The nurse uses at least 3 to 5 mL of liquid soap.
The nurse dries from forearms up toward fingers. Explanation: Hand hygiene procedures involve drying from the fingers toward the forearm and discarding the paper towel. The other options should be included in hand hygiene practices.
The nurse is teaching an older adult how to prevent falls. The nurse should tell the client to: turn on bright lights in the room so the client can see items in the room. instruct the client to rise slowly from a supine position. encourage the client to not use assistive devices because they reduce independence. instruct the client not to exercise painful joints.
instruct the client to rise slowly from a supine position. Explanation: Normal age-related changes can predispose older adults to falling and include vision, hearing, cardiovascular, musculoskeletal, and neurological changes. One of the most common problems facing older adults is the loss of tissue elasticity that affects the arteries. This loss of elasticity results in a decrease in tissue recoil and leads to changes in blood pressure with position changes. When they rise too quickly from a supine position, they feel light-headed and dizzy and can fall. The nurse should instruct clients to change positions slowly and to dangle the legs a few minutes when arising from a supine position. When aging, the lens of the eye becomes sensitive to very bright light which can causes a glare and visual disturbances that can lead to falls. Rooms should be well lit, but not with bright lights that cause a glare. Neurological changes are seen in impaired reflexes and thus postural instability. This loss of postural stability leads to falls. The need of assistive devices (hand rails, cane, walkers) helps reduce falls and promote independence. If joint pain develops and remains untreated, it can cause older adults to become sedentary or immobile. This disuse of muscles contributes to muscle weakness and falls. Nursing interventions should be directed at encouraging regular ambulation and joint movement (range of motion).
The nurse observes a client with an onset of heart failure having rapid, shallow breathing at a rate of 32 breaths/minute. What blood gas analysis does the nurse anticipate finding initially? metabolic acidosis metabolic alkalosis respiratory acidosis respiratory alkalosis
respiratory alkalosis Explanation: At first, arterial blood gas analysis may reveal respiratory alkalosis as a result of rapid, shallow breathing. Later, there is a shift to metabolic acidosis as gas exchange becomes more impaired. Respiratory acidosis and metabolic alkalosis are incorrect options.