nclex pass point set 6 study
A client diagnosed with thyroid cancer signed a living will that states the client doesn't want ventilatory support if the condition deteriorates. As the client's condition worsens, the client states, "I changed my mind. I want everything done for me." Which response by the nurse is best? "I'll ask your physician to revoke your do-not-resuscitate order." "Do you understand that you'll be placed on a ventilator?" "What exactly do you mean by wanting 'everything' done for you?" "Maybe you should talk with your family."
"What exactly do you mean by wanting 'everything' done for you?" Explanation: Asking the client what they mean is the best response. The nurse should clarify the client's request and get as much information as possible before notifying the physician of the client's wishes. Asking the physician to revoke the client's do-not-resuscitate (DNR) order makes an assumption about the client's wishes without obtaining clarification of their statement. The client might want aggressive treatment without reversing the DNR order. Asking the client if they understand that they'll be placed on a ventilator places the client on the defensive. Telling the client to talk with family is an inappropriate response; the client has the right to change their treatment plan without input from their family.
The nurse is caring for a client in active labor. The client states, "I feel like I need to push." A sterile vaginal examination reveals that the client is dilated to 8 cm. What is the nurse's best response? "You cannot push yet, you have another 2 cm until you are ready." "Your cervix is not fully dilated. Let's keep breathing through the pressure." "Go ahead and push just a little when you feel the urge." "I will get you some IV pain medication to take the edge off."
"Your cervix is not fully dilated. Let's keep breathing through the pressure." Explanation: Pushing (bearing down) before the cervix is completely dilated may cause edema and tissue damage and may impede fetal descent. This feeling is natural at this stage of labor. Giving the client IV pain medication at 8 cm can cause fetal respiratory distress. Although it is true that the client should not push yet, simply stating that fact will not help the client with the pain or anxiety. Breathing through the pressure is a nonpharmacologic comfort measure.
The registered nurse (RN) is supervising for the evening shift at a long-term care facility. The RN is working with 3 certified nursing assistants (CNA) and a licensed practical/vocational nurse (LPN/VN). Which aspect of care is most appropriately delegated to the LPN/VN? Assessing a client's oxygenation status Assisting a client to ambulate in the hall Administering a client's tube feeding Reminding a client to use the bathroom every 4 hours
Administering a client's tube feeding Explanation: A tube feeding is within the scope of practice of the LPN/VN. The CNA's scope of practice includes assisting a client to ambulate and reminding a client to use the bathroom. Assessing the oxygenation status is more appropriately completed by the RN.
The nurse is preparing a client's preoperative medication. The prescription reads atropine 0.6 mg and meperidine hydrochloride 50 mg IM. The dosage of available atropine is 0.8 mg/mL, and the dosage of available meperidine is 100 mg/mL. What will be the total volume of medication the nurse will administer? Record your answer using two decimal places.
Correct response: 1.25 Explanation: The atropine dosage is calculated as follows:0.6 mg/x mL = 0.8 mg/mL.x = 0.75 mL.The meperidine dosage is calculated as follows:50 mg/x mL = 100 mg/mL.x = 0.5 mL.The total volume to be administered is 1.25 mL.
An adolescent client is using glargine and lispro to manage type 1 diabetes. The nurse reviews the prescription for sliding scale lispro (see exhibit). Lispro subcutaneous give units according to sliding scale:Blood glucose: 70 - 150 mg/dL (3.9 to 8.3 mmol/L) = 0 units151-200 mg/dL (8.4 to 11.1 mmol/L) = 1 unit201-250 mg/dL (11.2 to 13.9 mmol/L) = 2 units251-300 mg/dL (14 to 16.7 mmol/L) = 3 units301-350 mg/dL (16.8 to 19.4 mmol/L) = 4 unitsCall for blood glucose > 350 (19.4 mmol/L)In addition give 1 unit for every 15 grams of carbohydrate.The morning blood glucose is 202 mg/dL (11.2 mmol/L) and the client is going to eat 2 carbohydrate exchanges. The nurse has the client administer how many units of lispro? Record your answer using a whole number.
Correct response: 4 Explanation: Each carbohydrate food exchange has 15 grams of carbohydrate. Two units are needed to cover the current blood glucose, and 2 units are needed to cover the anticipated carbohydrate intake.
A student nurse inserts a nasogastric tube and begins a tube feeding without a radiological confirmation. The client develops pneumonia and is transferred to the intensive care unit. Which parties are liable for negligence? Select all that apply. the student nurse the nursing instructor the assigned nurse the physician the dietician
Correct response: the student nurse the nursing instructor the assigned nurse Explanation: The student nurse, nursing instructor, and staff nurse are held to the same standard of care. The tube placement should be confirmed by radiology. The physician and dietician were not involved with the tube placement and following the standard of care with a radiology placement confirmation.
A client is receiving spironolactone for treatment of bilateral lower extremity edema. The nurse should instruct the client to make which nutritional modification to prevent an electrolyte imbalance? Increase intake of milk and milk products. Restrict fluid intake to 1,000 mL/day. Decrease foods high in potassium. Increase foods high in sodium.
Decrease foods high in potassium. Explanation: Aldactone is a potassium-sparing diuretic often used to counteract potassium loss caused by other diuretics. If foods or fluids are ingested that are high in potassium, hyperkalemia may result and lead to cardiac arrhythmias. Increasing the intake of milk or milk products does not affect the potassium level. Restricting fluid may elevate all electrolytes due to extracellular fluid volume depletion. By increasing foods high in sodium, water would tend to be retained and so would dilute all electrolytes in the extracellular fluid compartment.
A client with Meniere's disease is having an attack of vertigo. Which nursing intervention is the priority? Instruct the client to remain in bed. Use pillows to support the client's head. Remind the client to ask for assistance when turning. Assist the client to the restroom every hour.
Instruct the client to remain in bed. Explanation: The priority intervention is to have the client remain in bed to prevent falls. The other options are correct; however, client safety is the priority.
When a client has a troponin level of 0.9 ng/mL, which nursing intervention should be implemented? Notify the healthcare provider. Document the finding as the only action. Encourage the client to ambulate. Apply oxygen at 2 L/minute per nasal cannula.
Notify the healthcare provider. Explanation: Troponin is a myocardial cell protein that is elevated in the serum when myocardial damage has occurred during a myocardial infarction. The healthcare provider should be immediately notified when the troponin level is > 0.1 ng/mL. The client should not be ambulated at this time. Applying oxygen is appropriate, although the use of a nasal cannula is not recommended.
A client is in balanced suspension traction to maintain alignment of a fractured tibia. Which activities are safe for the client? Eat while lying flat. Raise the hips using trapeze. Rotate side to side. Flex and extend the ankle on affected side.
Raise the hips using trapeze. Explanation: The client in balanced suspension traction can raise the hips using a trapeze. The client can then use the bedpan. The client can be in a sitting position to eat. The client should not move side to side but can turn toward the affected side. The client should not flex or extend the ankle on the affected side.
The nurse instills 5 mL of normal saline before suctioning a client's tracheostomy tube. Which indicates the instillation is effective? The secretions are thinned. The client coughs. There is minimal friction when the catheter is passed into the tracheostomy tube. There is humidification for the respiratory tract.
The secretions are thinned. Explanation: The primary purpose of instilling 5 mL of normal saline solution before suctioning a tracheostomy tube is to thin the secretions to be suctioned. The saline may stimulate a cough; however, this is not the reason for using saline. The tracheostomy tube is larger than the suction catheter, so the catheter will easily pass into the tube without lubrication. Humidification is provided by a nebulizer if needed.
During a class on exercise for clients with diabetes mellitus, a client asks the nurse educator how often to exercise for 30 minutes. Which exercise frequency would meet the goals of planned exercise? at least once per week at least three times per week at least five times per week every day
at least five times per week Explanation: Clients with diabetes must exercise at least 150 minutes per week to meet the goals of planned exercise — lowering the blood glucose level, reducing or maintaining the proper weight, increasing the serum high-density lipoprotein level, decreasing serum triglyceride levels, reducing blood pressure, and minimizing stress. Thirty minutes five times a week would meet the minimum amount of exercise recommended. Exercising once or even three times per week wouldn't achieve these goals. While exercising every day may be beneficial, it is not required to meet the 150 minutes per week recommendation.
A client returns to the intensive care unit after coronary artery bypass graft surgery, which was complicated by a prolonged cardiopulmonary bypass and hypotension. After 3 hours in the unit, the client's condition stabilizes. Which assessment finding indicates a potential complication related to this occurrence? reports of "stomach pain" blood urea nitrogen level (BUN) of 40 mg/dL hypoactive bowel sounds urinary output of 30 mL/hour
blood urea nitrogen level (BUN) of 40 mg/dL Explanation: The BUN is elevated and indicative of renal hypo-perfusion and damage related to the prolonged bypass and hypotension. The other findings are expected following surgery but require monitoring.
A client with acute renal failure has the following laboratory results. Based on these findings, which of the following should the nurse administer?hemoglobin 9.2 g/dLblood urea nitrogen 22 mg/dLcreatinine 0.7 mg/dLpotassium 4.8 mEq/L calcium gluconate potassium chloride furosemide erythropoietin
erythropoietin Explanation: Erythropoietin assists in the production of red blood cells, which are low as evidenced by the hemoglobin level. All other laboratory values are within normal limits.
A 12-year-old child is sent home for pediculosis after being at camp for 1 week. The mother thinks others at camp have it. The mother asks the nurse how her son could have gotten pediculosis. How should the nurse reply? "Children at camp usually get it from the animals here." "Children who sleep close to someone who has it get it more easily." "He probably got it at basketball practice." "Usually the kids get it at camp in the pool."
"Children who sleep close to someone who has it get it more easily." Explanation: Children at camp are at higher risk for developing pediculosis because of the close contact with others. Pediculosis is spread person to person or on other objects that are shared, such as helmets, combs, or other personal items used near the hair.Lice are not transmitted by animals or pets or during swimming.
According to Erikson's psychosocial theory of development, an 8-year-old child would be in which stage? trust versus mistrust initiative versus guilt industry versus inferiority identity versus role confusion
industry versus inferiority Explanation: In middle childhood, the 6- to 12-year-old child is mastering the task of industry versus inferiority. The trust versus mistrust task is in infancy (birth to 1 year). In early childhood, the 1- to 3-year-old child is in the stage of initiative versus guilt. Identity versus role confusion occurs during adolescence.
Which nursing intervention is most important in preventing septic shock? administering IV fluid replacement therapy as ordered obtaining vital signs every 4 hours for all clients monitoring red blood cell counts for elevation maintaining asepsis of indwelling urinary catheters
maintaining asepsis of indwelling urinary catheters Explanation: Maintaining asepsis of indwelling urinary catheters is essential to prevent infection. Preventing septic shock is a major focus of nursing care because the mortality rate for septic shock is as high as 90% in some populations. Very young and elderly clients (those younger than age 2 or older than age 65) are at increased risk for septic shock. Administering IV fluid replacement therapy, obtaining vital signs every 4 hours on all clients, and monitoring red blood cell counts for elevation do not pertain to septic shock prevention.
While examining a client's leg, a nurse notes an open ulceration with visible granulation tissue in the wound. Until a wound specialist can be contacted, which type of dressing should the nurse apply? dry sterile dressing sterile petroleum gauze moist sterile saline gauze povidone-iodine-soaked gauze
moist sterile saline gauze Explanation: Moist sterile saline dressings support wound healing and are cost-effective. Dry sterile dressings adhere to the wound and debride the tissue when removed. Petroleum supports healing but is expensive. Povidone-iodine is used as an antiseptic cleaning agent but because it can irritate epithelial cells, it shouldn't be left on an open wound.
A 9-year-old child is placed on a liquid preparation of ferrous sulfate for the treatment of iron deficiency anemia. The nurse is teaching the parents about the side effects of ferrous sulfate. Which of the following statements is the most appropriate information for the nurse to convey to the parents? "The child's stool pattern may increase in frequency." "Have the child take the medicine through a straw." "Be sure the child wears sunscreen while taking this medication." "Watch the child for problems with gait or balance."
"Have the child take the medicine through a straw." Explanation: Staining of the teeth is a common side effect when ferrous sulfate is taken in liquid form. Drinking from a straw helps minimize this. The other options are not side effects related to this particular medication.
A physician orders supplemental oxygen for a client with a respiratory problem. Which oxygen delivery device should the nurse use to provide the highest possible oxygen concentration? nasal cannula venturi mask simple mask nonrebreather mask
nonrebreather mask Explanation: A nonrebreather mask provides the highest possible oxygen concentration — up to 95%. A nasal cannula doesn't deliver concentrations above 40%. A Venturi mask delivers precise concentrations of 24% to 44%, regardless of the client's respiratory pattern, because the same amount of room air always enters the mask opening. A simple mask delivers 2 to 10 L/minute of oxygen in uncontrollable concentrations.
After teaching a client about lorazepam, which client statement indicates the need for further teaching? Select all that apply. "I can chew sugarless gum if my mouth feels dry." "I can adjust the dosage when I feel more anxious." "I shouldn't drink alcohol." "I can take lorazepam with food if I get nauseous." "I can stop taking lorazepam immediately if I need to."
"I can adjust the dosage when I feel more anxious." "I can stop taking lorazepam immediately if I need to." Explanation: Lorazepam, a benzodiazepine, is used as an antianxiety agent and depresses the central nervous system (CNS). Benzodiazepines cause physical dependence and tolerance and should never be stopped abruptly because withdrawal symptoms can occur. Slow tapering is required to minimize withdrawal symptoms.The client should not adjust the dosage when feeling anxious because of tolerance and the possibility of overdose.Common CNS adverse effects are drowsiness, fatigue, and incoordination. Other adverse effects such as dry mouth can be helped by rinsing the mouth and using sugarless gum and candy.The drug can be taken with food if the client experiences nausea.The use of alcohol and other CNS depressants can further CNS depression.
When the nurse is developing a teaching plan for a client about the medications prescribed for depression, which component is most important for the nurse to include? pharmacokinetics of the medication current research related to the medication management of common adverse effects dosage regulation and adjustment
Correct response: management of common adverse effects Explanation: Compliance with medication therapy is crucial for the client with depression. Medication noncompliance is the primary cause of relapse among psychiatric clients. Therefore, the nurse needs to teach the client about managing common adverse effects to promote compliance with medication. Teaching the client about the medication's pharmacokinetics may help the client to understand the reason for the drug. However, teaching about how to manage common adverse effects to promote compliance is crucial. Current research about the medication is more important to the nurse than to the client. Teaching about dosage regulation and adjustment of medication may be helpful, but typically the HCP, not the client, is the person in charge of this aspect.
A child, who uses an inhaled bronchodilator only when needed for asthma, has a best peak expiratory flow rate is 270 L/min. The child's current peak flow reading is 180 L/min. How does the nurse interpret this reading? The child's asthma is under good control, so the routine treatment plan should continue. The child needs to use a short-acting inhaled beta2-agonist medication. This is a medical emergency requiring a trip to the emergency department for treatment. The child needs to use inhaled cromolyn sodium.
The child needs to use a short-acting inhaled beta2-agonist medication. Explanation: The peak flow of 180 L/min is in the yellow zone, or 50% to 80% of the child's personal best. This means that the child's asthma is not well controlled, thereby necessitating the use of a short-acting beta2-agonist medication to relieve the bronchospasm. A peak flow reading greater than 80% of the child's personal best (in this case, 220 L/min or better) would indicate that the child's asthma is in the green zone or under good control. A peak flow reading in the red zone, or less than 50% of the child's personal best (135 L/min or less), would require notification of the health care provider (HCP) or a trip to the emergency department. Cromolyn sodium is not used for short-term treatment of acute bronchospasm. It is used as part of a long-term therapy regimen to help desensitize mast cells and thereby help to prevent symptoms.
