NCLEX - PN Pre-Test

Which criterion should the nurse determine are characteristics of scabies?

- It appears as burrows or fine, grayish-red lines - It is transmitted by close personal contact with an infected person - It is endemic among schoolchildren and institutionalized populations - Household members and contacts of the infected child need to be treated at the same time that the child is being treated.

The nurse is instructing a client with osteomalacia about appropriate food items to include in the diet. Which food items should be included?

- Milk - Wild caught salmon Rationale: Osteomalacia is the softening of bone tissue characterized by inadequate mineralization of osteoid. It is the adult version of rickets and vitamin D deficiency in children. Milk provides the best source of vitamin D. Oily fish, especially wild caught such as salmon and mackerel, are also rich in vitamin D.

The nurse reviews the phenytoin level of a client who is taking phenytoin. The nurse notes that the drug level is 9 mcg/mL. Which should the nurse anticipated to be prescribed for the client?

An increase in the present dosage Rationale: The dosing objective is to produce phenytoin levels between 10 and 20 mcg/mL. Levels below 10 mcg/mL are too low to control seizures.

The nurse explains to the client who underwent umbilical hernia repair that is important to do which after discharge?

Avoid coughing Rationale: coughing is avoided to prevent disruption of the sutured tissue, which could occur because of the location of this surgical procedure; however, frequent deep breathing exercises are important.

A client with angina pectoris is experiencing chest pain. The nurse administers a sublingual nitro tablet to the client. The client's pain is unrelieved. Which vital sign is most important for the nurse to check before administering a second dose of the medication?

Blood pressure Rationale: Nitro acts directly on the smooth muscle of the blood vessels, causing relaxation and dilation. As a result, hypotension can occur. Check BP before second nitro!

The nurse is reinforcing dietary instructions to a client prescribed probenecid. Which food should the nurse encourage the client to continue to eat?

Spinach Rationale: Probenecid inhibits the reabsorption of uric acid by the kidneys and promotes excretion of uric acid in the urine. Clients should avoid excessive purine intake (organ mets, sardines, scallops, anchovies, broth, mincemeat, herring, shrimp, mackerel, gravy, and yeast)

The nurse is caring for a client who has placenta previa. The nurse understands that a cervical exam should not be performed because it could have which consequence?

Cause hemorrhage Rationale: The placenta is implanted low in the uterus, a cervical exam could cause the disruption of the placenta and initiate profound hemorrhage.

The nurse is reinforcing discharge instructions to a Chinese client prescribed dietary modifications. During the teaching session, the client continually turns away from the nurse. Which nursing action is most appropriate?

Continue with the instructions, verifying client understanding. Rationale: Many Chinese people are uncomfortable with face-to-face communication, especially when direct eye contact is involved.

A child has a basilar skull fracture. Which PHCP's prescription should the nurse question?

Suction via the nasotracheal route PRN Rationale: nasotracheal suctioning is contraindicated in a child with a basilar skull fracture. Because of the location of the injury, the catheter may be introduced into the brain.

A client with AIDS has histoplasmosis. Which sign/symptoms should the nurse expect the client to experience?

Dyspnea Rationale: histoplasmosis is an opportunistic fungal infection that can occur in the client with AIDS. The infection begins as a respiratory infection and progress to disseminated infection. S&S include fever, dyspnea, cough, and weight loss. There may be enlargement of lymph nodes, liver, and spleen as well.

A 3-year old is seen in the health care clinic, and a diagnosis of encopresis is made. The nurse reviews the record, expecting to note which sign as evidence of this disorder?

Evidence of soiled clothing Rationale: Encopresis is defined as fecal incontinence and is a major concern if the child is constipated. Signs include soiled clothing, scratching, or rubbing the anal area because of irritation, fecal odor w/o apparent awareness by the child, and social withdrawal.

A client newly diagnosed with CKD will be receiving peritoneal dialysis. During the infusion of the dialysate, the client complains of abdominal pain. Which action by the nurse is appropriate?

Explain that the pain will subside after the first few exchanges Rationale: Pain during the inflow of dialysate is common during the first few exchanges because of peritoneal irriation; however, it disappears after a week or two.

A child has epistaxis. Which treatment is appropriate for epistaxis?

Have the child sit up and lean forward Rationale: Nosebleed. Correct treatment involves having client sit up and lean forward.

The nurse is caring for a child with mumps. The nurse monitors the child for which sign/symptoms that is indicative of a common complication of mumps?

Nuchal rigidity (inability to flex the neck forward) Rationale: The most common complication of mumps is aseptic meningitis, which the virus being identified in the CSF. Common signs include nuchal rigidity, lethargy, and vomiting.

The nurse is initiating CPR on an adult client. The nurse show place the hands in which position to begin chest compressions?

On the lower half of the sternum

The nurse is evaluating the effects of care for the client with DVT. Which limb observations should the nurse note as indicating the least success in meeting the outcome criteria for this problem?

Pedal edema that is 3+ Rationale: symptoms of DVT include leg warmth, redness, edema, tenderness, and enlarged calf. If the problem is not resolved, or is minimally resolved, these symptoms will remain.

The nurse is reviewing the ABG results of the client. pH is 7.30 and PCO2 is 50 mm Hg. The nurse determines the client is experiencing respiratory acidosis. Which additional labs should the nurse expect to note in this client?

Potassium 5.4 mEq/L Rationale: serum potassium levels are often high in acidosis as the body attempts to maintain electroneutrality during buffering.

The client with peptic ulcer disease has been prescribed to take cimetidine. The nurse determines that which is the primary action of this medication?

Protects the gastric mucosa Rationale: Cimetidine is a histamine antagonist and works by inhibiting histamine action.

The nurse observes that a client with a NG tube connected to continuous gastric suction is mouth breathing, has dry mucous membranes, and has a foul breath odor. When planning care, which nursing intervention would be best to maintain the integrity of this client's oral mucosa?

Use diluted mouthwash and water to swab the mouth after brushing teeth. Rationale: After the NG tube is in place, mouth care is extremely important. Frequent oral hygiene may be required to prevent or care for dry, irritated mucous membranes.

A client diagnosed with chronic gastritis has been told that is too little intrinsic factor being produced. The nurse should explain that which therapy will be prescribed to treat the problem?

Vitamin B12 injections Rationale: Insufficient intrinsic factor results in the inability to absorb vitamin B12, which must then be supplemented by the parenteral route.

The nurse in the ED is preparing to administer syrup of ipecac to a 7 month old child. Which response should the nurse expect?

Vomiting Rationale: syrup of ipecac is a medication that may be prescribed for the induction of emesis. It is indicated following ingestion of some poisons.

Thrombolytic therapy was administered to a client following an acute inferior MI. The nurse giving discharge instructions to the client evaluate a need for further teaching when the client makes what statement?

"I will apply pressure for 10 minutes for minor bleeding." Rationale: Client teaching includes reporting a temperature over 104F (indicator of internal bleeding).

A client states, "I don't want you to touch me. I'll take care of myself!" The nurse should respond with what therapeutic statement?

"Sounds like you're feeling pretty troubled by all of us. Let's work together so you can do everything for yourself as you request."

A nurse is caring for a client who has ALS. The nurse notes that the client is severely dysphagic, what should the nurse include in the plan of care?

- Allowing the client sufficient time to eat - Providing oral hygiene after each meal - Maintaining a suction machine at the bedside Rationale: The client who is severely dysphagic is at risk for aspiration. Swallowing is assessed frequently.

The nurse is suctioning an endotracheal tube for an ICU client who is being mechanically ventilated. 5 minuted after suctioning, which primary outcomes should tell the nurse that the suctioning has been successful?

- Clear lung sounds - Increase in O2 saturation - Heart rate on monitor WNL

Which clients would the nurse determine is at risk for development of metabolic alkalosis?

- Client who has been vomiting for 2 days - Client receiving oral furosemide 40 mg daily Rationale: metabolic alkalosis is caused by any condition that creates the acid-base imbalance through either an increase in bases or deficit of acids, such as the client vomiting for 2 days and the client receiving furosemide therapy.

A client with a history of victim abuse has which S&S of the physical effects of living with a severe level of anxiety or chronic stress?

- Irritability - Hypertension - GI disturbances

The nurse caring for a client who has been diagnosed with stage 3 Alzheimer's disease should expect to observe which behaviors in the client?

- Misplacing a valuable object - Difficulty coming up with the right word

A newly pregnant client is asking how to prevent neural-tube birth defects. The nurse reinforces which food choices to include in the diet?

- Oranges - Broccoli - Grapefruit Rationale: Folic acid (folate) is found in these food items. Folic acid helps prevent neural tube birth defects.

Which are age-related changes to the eyes?

- Presbyopia - Arcus senilis - Yellow-tinged sclera - Decreased ability to see in dim light Rationale: Arcus senilis is an opaque ring outlining the cornea that sometimes results from the deposition of fatty globules. The sclera develops a yellowish tinge from fatty deposits. The ciliary muscle has less ability to allow the eye to accommodate (presbyopia). Pupil size becomes smaller, reducing the ability to see dim light.

The nurse is monitoring a new mother for signs of postpartum depression. Which observations in the mother indicated the need for further data collection r/t this form of depression?

- Shows a lack of interest in eating - Lacks the ability to concentrate on tasks - Complains of feeling tired all the time Rationale: The woman experiencing pp depression show less interest in her surroundings and loss of her usual emotional response toward the family. The woman is also unable to show pleasure or love and may have intense feelings of unworthiness, guilt, and shame. Generalized fatigue, complaints of health, and difficulty concentrating are also present.

The nurse is assisting in caring for a client admitted to the ED with diabetic ketoacidosis. The nurse anticipated that the PHCP will prescribe which type of insulin for IV administration to treat this disorder?

Regular Rationale: Regular insulin is a short-acting insulin and can be administered by the IV route.

A newborn is diagnosed with hiatal hernia. The nurse recognizes that the mother understand this condition when she makes which statement?

"My baby has a portion of the stomach protruding through the esophageal hiatus of the diaphragm."

The nurse is told in a report that the client has hypocalcemia. Which signs should the nurse expect to note?

- Tetany - A positive Chvostek's sign - A positive Trousseau's sign Rationale: A low calcium level tends to cause muscle irritability.