nclex prep
The nurse is reinforcing information for a client with chronic obstructive pulmonary disease. Which statements by the client indicate an understanding of the pursed-lip breathing technique? Select all that apply.
"I exhale for 4 seconds through pursed lips." "I inhale for 2 seconds through my nose, keeping my mouth closed."
Client call lights come on while the unlicensed assistive personnel (UAP) sits at a desk and reads a magazine. When the nurse asks the UAP to answer the lights, the UAP says, "Those aren't my clients." What is the best response by the nurse?
"I need you to answer the lights because we want to provide good client care."
The practical nurse (PN) is assisting the registered nurse (RN) to care for a 6-hour-old term newborn of a mother with gestational diabetes. A bedside capillary blood glucose measurement reveals that the newborn's blood glucose level is 45 mg/dL (2.5 mmol/L). The newborn is asymptomatic. Which intervention should the PN anticipate implementing first?
Feed the newborn
Intake and output record Emesis-120 mL Wet diaper 1-50 g Wet diaper 2-52 g Wet diaper 3-46 g *Weight of a dry diaper = 30 g The nurse cares for an 11-lb (5-kg) infant admitted with dehydration and prepares to calculate intake and output over an 8-hour shift. Using the data in the exhibit, calculate the total output in milliliters for the 8-hour shift. Record your answer as a whole number.
178mL 58 g = 58 mL 120 mL + 58 mL = 178 mL
The nurse is collecting data on a client who has arrived at the clinic for pregnancy confirmation and prenatal evaluation. Which of the following findings indicate diagnostic evidence (positive signs) of pregnancy? Select all that apply.
Fetal heart tones detected by Doppler device Visualization of fetus via ultrasound
The nurse performs tracheostomy care for a client with a disposable inner cannula and tracheostomy dressing. Place the steps in the correct order. All options must be used.
Gather supplies and position client Don mask, goggles, and clean gloves Remove soiled dressing Don sterile gloves; remove old disposable cannula and replace with a new one Clean around stoma with sterile water or saline; dry and replace sterile gauze pad
A nurse is discussing the fine motor abilities of a 10-month-old infant with the infant's parent. Which are developmentally appropriate skills for an infant of this age? Select all that apply
Grasps a small doll by the arm Transfers small objects from hand to hand Uses a basic pincer grasp
The home health nurse visits a client with hypertension whose blood pressure has been well controlled on oral valsartan 320 mg daily. The client's blood pressure is 190/88 mm Hg, significantly higher than it was 2 weeks ago. The client reports a cold, a stuffy nose, and sneezing for 3 days. Which question is most appropriate for the nurse to ask?
"Are you taking any over-the-counter medicines for your cold?"
The nurse is evaluating the plan of care for a client diagnosed with social anxiety disorder who has a fear of eating and drinking in public. Which of the following client statements demonstrate an improvement in coping? Select all that apply.
"I sat in the pizza shop and drank a cola while watching people eat and then bought a slice to go." "I started having lunch with my coworkers even though I still become very anxious eating in public." "I went to a coffee house with my boss and focused on an upcoming project while drinking a latte."
A nurse is reinforcing education given to the parents of a child diagnosed with chronic allergic rhinitis that is triggered by household and environmental allergens. Which statements by the parents indicate that the teaching has been effective? Select all that apply.
"My wife plans to wipe down our child's furniture with a damp rag every other day." "Our child needs plastic covers for the mattress and pillow." "We will replace the carpet with hardwood floors throughout the house." reduce exposures,
The nurse is reinforcing teaching for parents of a child diagnosed with fifth disease. Which statement by a parent indicates a need for further teaching?
"Our child's condition is communicable until the rash disappears."
An adult diagnosed with celiac disease 3 weeks ago was placed on a gluten-free diet. The client returns for ambulatory care follow-up, reports continuation of symptoms, and does not seem to be responding
"Tell me what you had to eat yesterday."
The student nurse observes the respiratory therapist (RT) preparing to draw an arterial blood gas from the radial artery. The RT performs the Allen's test and the student asks why this test performed before the blood sample is drawn. Which statement made by the RT is most accurate?
"The Allen's test is done to determine the patency of the ulnar artery." Instruct the client to make a tight fist (if possible) Occlude the radial and ulnar arteries using firm pressure The radial artery site at the wrist is preferred for collecting an arterial blood gas sample because it is near the surface, easy to palpate and stabilize, and has good collateral supply from the ulnar artery. The patency of the ulnar artery must be confirmed by performing a modified Allen's test to assure adequate circulation to the hand before proceeding with the arterial blood gas collection.
fifth disease
("slapped face," or erythema infectiosum) is a viral illness caused by the human parvovirus and affects mainly school-age children. The virus spreads via respiratory secretions, and the period of communicability occurs before onset of symptoms. The child will have a distinctive red rash on the cheeks that gives the appearance of having been slapped. The rash spreads to the extremities and a maculopapular rash develops, which then progresses from the proximal to distal surfaces. The child may have general malaise and joint pain that are typically well controlled with nonsteroidal anti-inflammatory drugs such as ibuprofen. Affected children typically recover quickly, within 7-10 days.
The parent of a 2-year-old tells the nurse at the well-child clinic, "I am concerned because my child does not like to be cuddled, does not respond when called by name, and does not make eye contact when being fed." What is the priority question for the nurse to ask when completing the health history?
How many words can your child say?" The concerns presented by this child's parent are suggestive of a developmental delay and very possibly autism spectrum disorder (ASD).
The nurse is reinforcing discharge teaching about lymphedema prevention for a client who had a total mastectomy. Which of the following instructions should the nurse include? Select all that apply.
Avoid keeping the arm on the operative side in a dependent position for prolonged periods Do not permit blood pressure measurements or injections in the arm on the operative side Notify the health care provider if the arm on the operative side seems swollen or larger Sleep on the nonoperative side or on the back, with the arm on the operative side elevated
The nurse is preparing to administer the prescribed 25 units of neutral protamine Hagedorn insulin and sliding-scale regular insulin. The client's blood glucose level is 237 mg/dL (13.2 mmol/L). How many units of insulin will the nurse administer in an injection? Record your answer using a whole number. Refer to Exhibit.
30 units Five units of regular insulin are needed to address the client's blood glucose reading of 237 mg/dL (13.2 mmol/L) in addition to the scheduled 25 units of NPH insulin, equaling a total of 30 units.
The nurse is caring for a client following a transsphenoidal hypophysectomy. Which clinical findings would the nurse recognize as signs that the client may be developing diabetes insipidus? Select all that apply
Excess oral water intake High urine output Increased serum osmolality
A 10-year-old weighs 99 lb (44.9 kg) and has a BMI of 24.8 kg/m2 (>95th percentile). The licensed practical nurse (LPN) is collaborating with the registered nurse (RN) to formulate a weight loss plan. Which is most important for the nurse to determine?
Family's readiness for change
A client tells the nurse of wanting to lose 20 lb (9 kg) in time for the client's daughter's wedding, which is 16 weeks away. How many calories (kcal) will the client have to eliminate from the diet each day to meet this goal?
625 kcal/day A reduction or energy expenditure of 3,500 calories (kcal) will result in a weight loss of 1 lb (0.45 kg). To lose 20 lb (9 kg), the client needs to reduce intake by a total of 70,000 kcal (3500 kcal x 20 lb [9 kg] = 70,000 kcal). Over a period of 16 weeks, this would require a daily reduction of: 625 kcal (70,000 kcal / [16 weeks x 7 days] = 625 kcal/day)
A client postoperative from a transurethral prostatectomy has a triple-lumen, indwelling urinary catheter and is receiving continuous bladder irrigation of sterile normal saline solution at 175 mL/hr. The nurse empties the urine drainage bag for a total of 2300 mL at the end of the 8-hour shift. How many milliliters (mL) should the nurse document as the net urine output for the shift? Record your answer using a whole number.
900mL ????
The initial prenatal laboratory screening results of a client at 12 weeks gestation indicate a rubella titer status of nonimmune. What will the nurse anticipate as the plan of care for this client?
Administer MMR vaccine immediately postpartum
Which actions would the nurse expect to be included in the care plan for a client hospitalized for bipolar disorder, acute manic episode? Select all that apply.
Assign the client to a private room Choose clothing for the client Schedule the client for physical activity with a staff member
client receiving total parenteral nutrition reports nausea, abdominal pain, and excessive thirst. What is the best action for the nurse to take?
Check the client's blood glucose A complication of total parenteral nutrition (TPN) is hyperglycemia, as evidenced by excessive thirst, increased urination, abdominal pain, headache, fatigue, and blurred vision.
The nurse working on a medical-surgical unit receives change-of-shift report on several clients. Which client should the nurse see first?
Client after a placement of an arteriovenous graft 3 days ago with a temperature of 100.9 F (38.3 C) could be sign of post op infection
A client is being discharged with a prescription for apixaban after being treated for a pulmonary embolus. Which clinical data is most concerning to the nurse?
Client takes indomethacin for osteoarthritis Concurrent NSAID use (eg, indomethacin, ibuprofen, meloxicam) significantly increases the risk of bleeding
The licensed practical nurse (LPN) rounds on four clients. Which finding is the priority for the LPN to report to the registered nurse?
Client with sickle cell disease whose pain rating has increased from 3 to 9 on a scale of 0-10 over the last hour
A client with AIDS treated for intractable seizures is transferred from the intensive care unit to the medical unit. There are 4 semiprivate room beds available. Which room assignment does the nurse recognize as the best option for this client?
Client with upper gastrointestinal bleed does not increase the chances of infection
The home health nurse visits a 75-year-old client with mild Alzheimer dementia who recently moved in with a caregiver. Which observations would cause the nurse to suspect neglect? Select all that apply.
Client's eyeglasses have been visibly broken for 1 month Client's prescription medication is expired Client breaks eye contact when discussing caregiver Client has lost 8 lb (3.63 kg) in the previous 4 weeks
A client diagnosed with endometrial cancer is receiving brachytherapy. Which interventions does the nurse anticipate for this client? Select all that apply.
Cluster care to limit each staff member's time in the room to 30 minutes a shift Place a sign on the client's door stating "Caution, Radioactive Material" Remind family members and visitors to stay at least 6 ft (1.82 m) away from the client Use a lead apron when providing direct client care to reduce exposure to radiation Wear a radiation film badge while in the client's room to monitor radiation exposure
The nurse responds to the call light of a client with chronic obstructive pulmonary disease (COPD) who says, "I can't breathe." The client seems to be having difficulty breathing and is nervous and tremulous. Vital signs are stable, oxygen saturation is 92% on 2 L, and there are clear breath sounds bilaterally. Which intervention would be most appropriate at this time?
Coach the client through controlled breathing exercises
A client with methicillin-resistant Staphylococcus aureus (MRSA) bacteremia has been receiving IV vancomycin for the last 3 days. Which blood test trend is most important for the nurse to review when preparing to administer this medication?
Creatinine levels Vancomycin can cause nephrotoxicity, which occurs most often in clients who already have some degree of renal impairment. Serum creatinine levels should be monitored daily during IV vancomycin treatment to look for an increase in level over a few days. If an increasing trend is identified, the nurse should consult with the health care provider (HCP) and/or pharmacist before administering the dose.
The nurse observes a client who is postoperative left total knee replacement use a cane. Which action by the client indicates an understanding of the correct technique when walking down the stairs?
Descends with the cane on the step first, followed by the left leg, and then the right leg Clients should hold the cane on the stronger side
A client started a 24-hour urine collection test at 6:00 AM. The unlicensed assistive personnel (UAP) reports discarding a urine specimen of 250 mL at 10:00 AM by mistake but adding all specimens to the collection container before and after that time. What action should the nurse take?
Discard urine and container, and restart the 24-hour urine collection tomorrow morning
The nurse at a mental health clinic is performing a suicide risk screening on four clients experiencing depression. Which client does the nurse recognize as being most at risk for suicide?
Divorced male client with Parkinson disease who was recently laid off from his job
A client with uncontrolled hypertension is prescribed clonidine. What instruction is most important for the clinic nurse to reinforce with this client?
Don't stop taking this medication abruptly
Allen's test
Instruct the client to open the fist; the palm will be white if both arteries are sufficiently occluded Release the pressure on the ulnar artery; the palm should turn pink within 15 seconds as circulation is restored to the hand, indicating patency of the ulnar artery (positive Allen's test) If the Allen's test is positive, the arterial blood gas can be drawn; if negative and the palm does not return to a pink color, an alternate site (eg, brachial artery, femoral artery) must be used
The precepting nurse supervising a graduate practical nurse would need to intervene when the graduate nurse violates the Health Insurance Portability and Accountability Act with which action? Select all that apply.
Interprets the results of a client's diagnostic testing to the unit clerk Accesses the medical record of a client not currently assigned, but previously cared for, to assess client improvement Advises the client transport technician, "This client has fragile bones due to cancer, so move the client very carefully."
A client without prenatal care gives birth to a newborn at term gestation. The client denies opioid or other illicit drug use during pregnancy. When monitoring the newborn, which of the following signs would indicate neonatal abstinence syndrome to the nurse? Select all that apply.
Irritability and restlessness Nasal congestion and frequent sneezing Poor feeding and loose stools
An elderly war veteran with prostate cancer and coronary artery disease is hospitalized for urosepsis. The client becomes angry with one of the unlicensed assistive personnel (UAP) who is trying to help the client bathe. Later, the UAP expresses frustration with the client to the nurse. Which statement would be the most appropriate response?
Let's go together to ask about the client's concerns."
The nurse is providing care to a 1-year-old recently diagnosed with failure to thrive. Which intervention is the priority nursing action for this child?
Observe the child feeding
The nurse is performing an assessment on a 39-week neonate an hour after a spontaneous vaginal delivery. What are common expected newborn findings? Select all that apply.
Plantar creases up the entire sole Skin on the nose blanches to a yellowish hue Toes fan outward when the lateral sole surface is stroked
A client is being discharged after having a coronary artery bypass grafting x 5. The client asks questions about the care of chest and leg incisions. Which instructions should the nurse reinforce? Select all that apply.
Report any redness, swelling, warmth, or drainage from your incisions Wash incisions daily with soap and water in the shower and gently pat them dry Wear an elastic compression hose on your legs and elevate them while sitting
An elderly client with depression, diabetes mellitus, and heart failure has received a new digoxin prescription for daily use. Which client assessment indicates that the nurse should follow up on serum digoxin levels frequently?
Serum creatinine is 2.3 mg/dL (203 µmol/L) The drug is excreted almost exclusively by the kidney. BUN and creatinine levels are measurements of kidney function. The normal range for creatinine is 0.6-1.3 mg/dL (53-115 µmol/L).
The nurse is reinforcing teaching to parents about childhood nutrition and feeding practices. The nurse recognizes that which snack is best for a toddler?
Slice of cheese
When ascending stairs, the client should:
Step up with the stronger leg first Move the cane next, while bearing weight on the stronger leg Finally, move the weaker leg
A 2-year-old in the emergency department is suspected of having intussusception. Which assessment finding should the nurse expect?
Stools mixed with blood and mucus
The nurse is assisting with procedural moderate sedation (conscious sedation) at a client's bedside. The unlicensed assistive personnel (UAP) comes to the door and indicates that the client in the next room needs the nurse right now. How should the nurse respond?
Tell the UAP to tell the charge nurse about the needs of the client in the next room
A client with social anxiety disorder is receiving treatment at the local community mental health center. Which situation most likely caused the client to seek therapy?
The client's boss has asked the client to represent the company at an upcoming convention
A client with chronic kidney disease has received a continuous intravenous infusion of heparin for 5 days. The nurse reviews the coagulation studies and the medication administration record. Which prescription would the nurse question?
Vitamin K
A home health nurse is supervising a home health aide who is changing the dressing for a client with a chronic heel wound. Which actions by the aide indicate adherence to appropriate infection control procedures? Select all that apply.
Wash hands prior to putting on gloves and after removing them Open a sterile container of 4 x 4's using the outermost corner to peel back the cover Pull glove off over the soiled dressing to encase it before disposal
The nurse is caring for a client with Clostridium difficile colitis. Which of the following infection control measures by the nurse are appropriate? Select all that apply.
Wears a single-use, disposable gown during client care Requests that the client be assigned to a single-client room hand hygiene, gloves, gown, private room
client was struck on the head by a baseball bat during a robbery attempt. The nurse gives shift report to the oncoming nurse and conveys that the client's current Glasgow Coma Scale score is a "10." Which other information is most important for the reporting nurse to include?
client's Glasgow Coma Scale score was "11" one hour ago
