NCLEX prep

While making rounds, the nurse enters a client's room and finds the client on the floor between the bed and the bathroom. In which order of priority from first to last should the nurse take the actions? All options must be used.

1) Assess the client's current condition and vital signs. 2) If no acute injury, get help, and carefully assist the client back to bed. 3) Notify the client's health care provider (HCP) and family. 4) Document as required by the facility.

What instructions should the nurse give to the parents of an 8-year-old child with asthma who is being switched from parenteral steroid therapy to a daily dose of oral prednisone?

"Have the child take the dose with meals to prevent gastric irritation." Prednisone causes severe gastric upset. Therefore, it should be given with food.

A client is brought to the health clinic for a routine checkup. To assess the client's vision, the nurse should ask

"How are you doing in school?" The nurse should ask about school because a client's poor progress in school may indicate a visual disturbance.

The effectiveness of selective serotonin reuptake inhibitor (SSRIs) therapy, in a client with post traumatic stress disorder (PTSD), can be verified when the client states

"I'm sleeping better now." Selective serotonin reuptake inhibitors are used to treat sleep problems, nightmares, and intrusive thoughts in individuals with PTSD.

A charge nurse completing a deceased client's chart audit notes that the chart contains a copy of the client's advance directive and the do-not-resuscitate (DNR) order. While reviewing the nurses' notes, the charge nurse finds documentation of a code blue and cardiopulmonary resuscitation with a physician entry to "Discontinue code blue due to existing advanced directives and DNR from client." What does the charge nurse conclude? Select all that apply.

- The physician was correct to stop resuscitation efforts. - By calling a code blue, the nurse disregarded the client's advance directives and DNR order.

When making rounds on the pediatric neurology unit, the nurse manager notes that, when giving IV medications, many of the staff nurses are disconnecting the flush syringe first and then clamping the intermittent infusion device. The nurse manager is concerned that the nurses do not understand the benefits of positive pressure technique and turbulence flow flush in preventing clots. After the nurse manager discusses the problem with the staff educator, which intervention would be the most effective way to improve the nursing practice?

Create a poster presentation on the topic with a required posttest. A poster presentation is an eye-catching way to disseminate information that can be used to educate nurses on all shifts.

A mother brings her 2-year-old child to the clinic because of her concerns about the child's nutritional status. For the last week, he has refused to eat anything except animal crackers and peanut butter and jelly sandwiches. Which measure would be most appropriate for the nurse to suggest?

Do not worry about this behavior because food fads usually last only a short time. During the toddler years, food preferences and appetite are changeable.

A nurse is caring for a primigravid client at 40 weeks gestation in active labor. Assessments include: cervix 5 cm dilated; 90% effaced; station 0; cephalic presentation, FHR baseline is 135 bpm and decreases to 125 bpm shortly after onset of 5 uterine contractions and returns to baseline before the uterine contraction ends. Based on this assessment what action should the nurse take first?

Document findings on the woman's medical record, and continue to monitor labor progress. The nurse would document these findings as "early" decelerations.

A client is receiving chemotherapy for cancer. The nurse reviews the client's laboratory report and notes that the client has thrombocytopenia. To which nursing diagnosis should the nurse give the highest priority?

Ineffective tissue perfusion: Cerebral, cardiopulmonary, GI These are all appropriate nursing diagnoses for the client with thrombocytopenia.

After the nurse teaches the parent of a child with a spica cast about skin care, which parental action would indicate the need for additional teaching?

application of powder to the skin under the cast Powder should not be applied to the skin beneath the cast because powder can cause irritation and skin breakdown.

A client is using an over-the-counter nasal spray containing pseudoephedrine to treat allergic rhinitis. Which instruction about this medication would be most appropriate for the nurse to provide for the client?

Overuse of pseudoephedrine can lead to increased nasal congestion. Overuse of nasal spray containing pseudoephedrine can lead to rhinitis medicamentosa, which is a rebound effect causing increased swelling and congestion.

A client with type 1 diabetes mellitus is conscious but confused, weak, diaphoretic, and having heart palpitations. What is the nurse's priority action?

Provide 15 to 20 grams of a fast-acting oral carbohydrate. The client is exhibiting signs of hypoglycemia. Since the client is conscious, the first intervention is to give a fast-acting oral carbohydrate, such as orange juice, hard candy, or honey.

When teaching the client to care for an ileal conduit, the nurse instructs the client to empty the appliance frequently. Which outcome indicates that the client is following instructions?

The seal around the stoma is intact. If the appliance becomes too full, it is likely to pull away from the skin completely or to leak urine onto the skin; thus if the seal is intact, the client is emptying the appliance regularly.

The parent of a 2-week-old infant brings the child to the clinic for a checkup. The parent expresses concern about the baby's breathing because the infant breathes quickly for a while and then breathes slowly. The nurse interprets this finding as an indication of what factor?

a normal pattern in infants of this age The infant is exhibiting periodic breathing, which is normal in infants of this age.

Which adolescent would the nurse determine needs further evaluation?

a young adolescent boy who restricts his food and fluid intake to be able to box in a lower weight class Restricting intake to lose weight is a first step toward an eating disorder for males as well as females, so this behavior should be investigated further, especially since males of this age are usually unconcerned about their weight.

The nurse is working at the local family planning clinic completing family education. When devising a teaching plan, in which client group would the nurse stress the importance of an annual Papanicolaou test?

clients infected with the human papillomavirus (HPV) Annual Papanicolaou testing is a screening to detect potential precancerous and cancerous cells in the endocervical canal of the female reproductive system.

While providing care for a hospitalized infant, a nurse is summoned to the phone. The caller requests information about the infant's condition. The nurse should:

determine the caller's identity before responding. The nurse must identify the caller before giving information or refusing to give information.

A nurse-manager appropriately behaves as an autocrat in which situation?

directing staff activities if a client experiences a cardiac arrest In a crisis situation, the nurse-manager should take command for the benefit of the client.

An antenatal primigravid client has just been informed that she is carrying twins. The plan of care includes educating the client concerning factors that put her at risk for problems during the pregnancy. The nurse realizes the client needs further instruction when she indicates carrying twins puts her at risk for which complication?

group B streptococcus Group B Streptococcus is a risk factor for all pregnant women and is not limited to those carrying twins.

The nurse instructs the unlicensed assistive personnel (UAP) on how to care for a client with chest tubes that are connected to water-seal drainage. The nurse should instruct the UAP to:

mark the time and amount of drainage on the collection container. It is appropriate for a UAP to mark the time of measurement and fluid level on the collection container.

A child, age 4, is brought to the clinic for a routine examination. When observing the tympanic membrane, the nurse identifies which color as normal?

pinkish gray The tympanic membrane normally appears pinkish gray, shiny, and translucent. A light pink, deep red, or yellowish white tympanic membrane is abnormal.

What would be the priority treatment of a client who has reported severe lower right quadrant pain that has now resolved?

preparation for emergency surgery Preparing for emergency surgery is the priority at this point to determine whether there is a ruptured appendix.

A nurse is assigned to a client with a cardiac disorder. The nurse should question an order to monitor the client's body temperature by which route?

rectal When caring for a client with a cardiac disorder, the nurse should avoid using the rectal route to take temperature.

A 47-year-old client has been taking prescribed medication for an intestinal ulcer. During a routine office visit for blood pressure monitoring, the client reports he is no longer able to have sexual intercourse with his spouse. The nurse determines that this is most likely the result of:

ulcer medication. Impotence in men is a lesser known side effect of ulcer medications prescribed for them. Impotence can occur at any time and is not age related.

The nurses teaches a parent to take a neonate's temperature with a disposable digital thermometer. Where does the nurse tell the parent to place the thermometer?

under the neonate's arm The correct method of assessing a neonate's temperature is to place the thermometer under the neonate's arm for an axillary reading.