NCLEX Review 3

The nurse provides care for an adult client prescribed regular insulin before breakfast. The nurse notes the client is nauseated with a blood glucose level of 74 mg/dL (4.1 mmol/L). Which action does the nurse take?

Administers the insulin on time. The insulin or oral agent must be administered as prescribed. Encourage the client to eat soft foods and liquids on breakfast meal tray. Recheck the blood glucose again in 30 to 60 minutes. Because illness can raise the blood glucose level with the regularly prescribed insulin regimen, blood glucose must be monitored every 3 to 4 hours. The client should sip 8 to 12 ounces of liquid per hour if it can be tolerated, to decrease the possibility of dehydration. Substitute easily digested soft foods or liquids if solids are not tolerated.

The client with a postoperative abdominal abscess has a drain inserted. Which nursing assessment is best?

Character of the drainage. OVER amount of the drainage

Which guideline is appropriate for the nurse to give a parent concerning the developmental stage of the 7-year-old child?

Periods of shyness by the child are to be expected.

Due to a sudden rise in a nearby river, the nurse at a day camp evacuates the children to an area away from the river. Which action does the nurse take next?

Place an ID bracelet on each child.This is a priority, as it aids in communication after rescue or recovery. This addresses a pertinent physical need.

The nurse provides care for an older adult client 12 hours after a right total hip replacement. The client appears disoriented to person, place, and time. Which action does the nurse perform first?

Place an abductor pillow between the client's legs. Abduction prevents dislocation of the hip while turning and is the priority intervention. The pillow is important to use because the client is confused and may not follow directions. Assess for pain, rotation, and/or extremity shortening.

The nurse cares for the client recovering from abdominal surgery. During ambulation, the client reports a dull ache in the left leg. Which action does the nurse take first?

Places the client on bedrest with extremity elevated. promotes venous return and decreases venous pressure, relieving pain and edema until health care provider is notified and anticoagulants are started

The client comes to the clinic for the hepatitis B vaccine. The client asks if more than one injection is necessary. Which response by the nurse is best ?

"Additional injections are given at one and six months."

The nurse prepares a client for a bone scan. Which statement is appropriate for the nurse to make to the client?

"Be sure to drink lots of fluid in the time between the tracer injection and the test." The interval between injection of the tracer and the actual scanning is usually 1 to 3 hours. Large amounts of fluid maintain hydration and decrease the radiation dose to the bladder. The client should void immediately before the scan to prevent a distended bladder.

The nurse in the outpatient clinic provides care for a client diagnosed with tuberculosis. The nurse expects to find which statement in the client record?

"Client reports low-grade fever and night sweats." These are symptoms of tuberculosis. Other signs/symptoms include progressive fatigue, lethargy, nausea, anorexia, and weight loss.

The nurse prepares the client for an 0800 outpatient electroconvulsive (ECT) treatment. Which question is most important for the nurse to ask?

"Did you have anything to eat or drink before you came in today?" client given general anesthesia for ECT; NPO after midnight

A client diagnosed with Bell palsy arrives for a health evaluation. Which client statement indicates the need for the nurse to provide additional teaching regarding treatment for the medical diagnosis?

"I like to sleep with the window open." Because Bell palsy causes trigeminal hyperesthesia, the client should protect the face from cold or drafts. This statement requires intervention from the nurse.

The nurse provides medication teaching to a client who is prescribed losartan. The client asks the nurse why the medication is required since lower leg swelling only occurs when standing too long. Which responses will the nurse make to this client? (Select all that apply.)

"It works by dilating blood vessels, which then reduces your blood pressure." "Do you have a bathroom scale at home?" 4."You may feel dizzy at first when taking this medication. Get up slowly to avoid falls."

A client in a same-sex marriage is scheduled for abdominal surgery. During surgery, the client's spouse requests information regarding the client's status. Which response by the nurse is appropriate?

"Let me go back and get an update. I will be right back." The nurse acts as the client's advocate when providing the spouse with accurate information.

The health care provider prescribes cimetidine 300 mg PO qid for the client. The nurse instructs the client about the medication. Which client statement indicates further teaching is needed?

"My stools may change color while I'm on this medication."

The industrial nurse supervises the health care needs at a local plant. It is announced on the news that a device has exploded in a heavily populated area away from the plant and that individuals near the site have become ill. Several hours later, workers at the plant come to the nurse and demand antibiotics to protect them against potential effects of the device. Which is the best response by the nurse?

"Tell me about how you are feeling. " This assessment helps the nurse to identify specific concerns. The nurse needs to find out more information before determining the appropriate course of action. NOT - the cause of illness has not been identified

The nurse in a long-term care facility reviews the nurse's notes in the client's record. The nurse is most concerned by which entry?

"The client's skin is blanched over the scapular areas."

The client is scheduled for a cardiac catheterization. The nurse teaches the client about the procedure. Which client statement indicates an understanding of the teaching?

"The nurse will be checking my foot pulses after the procedure."

A client returns to the room following an open cholecystectomy. It is most important for the nurse to obtain an answer to which question?

"Was a drain placed during surgery?" During an open cholecystectomy, a Jackson-Pratt (JP) drain is often placed to prevent bile from building up in the peritoneal cavity. A second drain may be placed to drain any blood or fluid that is left in the abdomen. Bile-stained serosanguineous drainage is normal for the first 24 hours after surgery.

The spouse of a client diagnosed with multiple myeloma asks the hospice nurse for pain control suggestions since the prescribed medication makes the client sleepy. Which responses by the nurse are appropriate? (Select all that apply.)

2."Let me show you some techniques of massage, which may help relieve the pain."3."Please locate some of your spouse's favorite music and see if listening to it helps with relaxation." NOT I will contact the HCP to change the pain med. They need to be assessed further.

The nurse provides care for clients on the medical and surgical unit. Which situation requires immediate intervention by the nurse?

A client who had a liver biopsy is resting quietly on his back after the procedure. The client should be lying on his right side for several hours after the procedure in order to promote hemostasis and thereby prevent hemorrhage and bile leakage.

The nurse cares for clients in the emergency department of an acute care facility. Four clients have been admitted during the previous 10 minutes. Which of the following admissions should the nurse see FIRST?

A client with full-thickness burns to the face. face, neck, chest, or abdominal burns result in severe edema, causing airway restriction

The nurse visits a client with newly diagnosed type 1 diabetes. The health care provider placed the client on an 1,800-calorie ADA diet and instructed the client to self-administer 15 units of intermediate-acting insulin each day before breakfast and to check the blood glucose four times a day. At 1700, the nurse discovers the client has not eaten since 1200 and has just returned from jogging. The client's vital signs are BP 110/80 mm Hg, pulse 120/min, respirations 18/min, and temperature 98.2°F (36.8°C). Which value does the nurse anticipate the client's blood glucose to be?

50 mg/dL (2.8 mmol/L). Normal fasting blood glucose is 70 to 99 mg/dL (3.89 to 5.49 mmol/L). Because the client self-administered insulin and has not eaten, the nurse should anticipate the client's blood glucose to be low. Hypoglycemia symptoms include cool, clammy skin; diaphoresis; nervousness; weakness; hunger; confusion; headache; slurred speech; and, if left untreated, progression to coma.

The triage nurse prioritizes clients to be evaluated in the emergency department. Which client does the nurse assess first? A 3-year old with a fever, an earache, and vomiting since yesterday.2.A 5-year old reporting leg and arm pain after falling from a treehouse.3.A 21-year old at 8 weeks' gestation reporting unilateral abdominal pain.4.A 40-year old who reports nausea, general anxiety, and is diaphoretic.

A 40-year old who reports nausea, general anxiety, and is diaphoretic. Treat as potential MI.

The nurse has four new admissions. Each client has a prescription for an IV to be started. It is most important for the nurse to start the IV for which client?

A client experiencing a sickle cell crisis. Hydration is important during a painful sickling crisis. Increasing the fluid volume dramatically reduces pain, increases perfusion, and decreases complications such as acute chest syndrome. IV access is also essential for proper pain management.

The nurse sees four clients for an annual health assessment. To which of these clients does the nurse offer the meningococcal immunization?

A first-year college student who lives in a residence hall. Due to past outbreaks of bacterial meningitis in dormitories, first-year college students living in a residence hall should be immunized against bacterial meningitis.

The nurse cares for a client who has just returned to his room after a scleral buckling procedure was completed to repair a detached retina. Which of the following is the MOST important nursing action?

Ask the client if he is nauseated. assessment; is important to prevent nausea and vomiting, would increase intraocular pressure, could cause damage to area repaired

The health care provider prescribes acetaminophen 650 mg PO for a client with an allergy to codeine. The nurse administers acetaminophen with codeine PO. The nurse then notifies the health care provider and administers diphenhydramine 50 mg IM as prescribed. After informing the client of the error, which action is most important for the nurse to take?

Ask the client to remain in bed for 3-4 hours. The combination of acetaminophen with codeine and diphenhydramine can cause drowsiness and increase the client's risk for falls. The nurse should request that the client stay in bed for several hours to reduce this risk.

The nurse prepares the client for a paracentesis. It is most important for the nurse to take which action?

Ask the client to void just before the procedure. Prevents puncture of bladder

At approximately 2000 hours the nurse begins to open the nurses' notes for the 0700 - 1900 shift. The last entry is noted for 0400 and there is no signature. Which response by the nurse is most appropriate?

Begin documenting on the next line below the last entry and make a note for the previous nurse to make a late entry to complete the record.

A client with type 2 diabetes mellitus is prescribed pioglitazone and metformin. Which client health history information causes the nurse to question the prescription of these medications? (Select all that apply.)

Being 6 weeks pregnant. Pioglitazone is contraindicated. Metformin use cautiously. 4.History of heart failure. Pioglitazone is contraindicated. 5.History of lactic acidosis. Metformin is contraindicated.

The nurse assesses a client who received a blunt head injury from a motorcycle crash. Which finding indicates a basal skull fracture?

Bloody or clear drainage from the auditory canal.

The nurse cares for the client diagnosed with venous thromboembolism (VTE) of the left leg. Which nursing goal is appropriate for the client?

Decrease inflammatory response in the affected extremity and prevent embolus formation.

The client exhibits symptoms of myxedema. The nursing assessment should reveal which of the following?

Decreased temperature. - everything is slowed down

The nurse observes late decelerations of the fetal heart rate while the client is receiving oxytocin IV to stimulate labor. Which actions should the nurse take?

Discontinue the oxytocin infusion. Turn client to the left side. Aid in blood flow to placenta. Apply oxygen at 8 L/min by mask. Increase the primary IV infusion flow rate.

The nurse observes a student nurse assess neonates in the nursery. Which student nurse action requires intervention by the nurse?

Documenting a negative red light reflex in a neonate who is two days old. A negative (absent) red light reflex indicates a severe neurological deficit, possibly caused by increased intracranial pressure. It must be evaluated immediately.

A client is scheduled to receive a hemodialysis treatment this morning. Which medication does the nurse hold for administration after the hemodialysis treatment is finished? (Select all that apply.)

Doxazosin 2 mg PO every day.2.Captopril 100 mg PO bid. Vancomycin 500 mg IV every 6 hours.Antimicrobials are removed with the dialysate solution and should be held until after the procedure is completed.

The nurse provides care to a client who is prescribed chlordiazepoxide. Which client observation is of most concern to the nurse? - ANtianxiety

Drowsiness and blurred vision. are adverse reactions and should be reported to the health care provider. Additional side effects include constipation, slurred speech, dermatitis, anorexia, polyuria, pancytopenia, and thrombocytopenia. Administer after meals or with milk to decrease the GI irritation.

The client had an aortic aneurysm resection 2 days ago. A complete blood count reveals a very low red blood cell count. The nursing assessment is most likely to reveal which information?

Fatigue and exertional dyspnea. Tiredness and difficulty obtaining enough oxygen. Pallor and dizziness.Low red cell levels cause paleness and lack of oxygen causes dizziness, especially on changing position. Malaise and tachycardia. Malaise or tiredness comes from low red cell/oxygen levels; tachycardia is the body's way of attempting to compensate for the low oxygen levels.

The nurse provides care to a client with a peripherally inserted central catheter (PICC) for treatment of metastatic cancer. Which findings will the nurse expect 4 days after the catheter placement? (Select all that apply.)

Feels no resistance when flushing the catheter with saline. Measures the exposed (nontunneled) portion of the catheter as being 18 cm for the past 2 days.5.Notes a vesicant medication is prescribed to be administered through the catheter.6.Learns during hand-off communication that the client showered for morning care.

The arterial blood gas (ABG) results of a client with diabetic ketoacidosis (DKA) are pH 7.2, PaCO2 35 mm Hg, HCO3 17 mEq/L, and PaO2 89 mm Hg. Which health care provider prescription requires the nurse to intervene?

Give sodium bicarbonate, per prescription. Sodium bicarbonate is only given if the pH is 6.9 or lower.

The client had abdominal surgery 4 days ago. The client has been coughing and says it "feels like something gave." The nurse observes the edges of the incision have separated and a small loop of the bowel protrudes through the incision. In which position does the nurse place the client?

Head of the bed elevated 15° low Fowler's; reduces stress on suture line; client may also be placed supine with hips and knees bent

The charge nurse on a cardiac care unit makes assignments. Which client is appropriate to assign to a float nurse from the medical-surgical unit? (Select all that apply.)

People who don't need specialized assessments and have not been determined to be stable. A client scheduled for insertion of an implantable cardioverter-defibrillator device. 3.A client receiving albumin and blood transfusions for hypotension. 4.A client receiving intermittent intravenous cefazolin for endocarditis.

A 4-month-old infant is admitted to the pediatric intensive care unit with a temperature of 105°F (40.5°C). The infant is irritable, and the nurse observes nuchal rigidity. Which assessment finding indicates an increase in intracranial pressure?

High-pitched cry.

Which of the following nursing actions is important for safe administration of oxytocin?

Palpate the uterus frequently. assessment; oxytocin stimulates the uterus to contract, which necessitates frequent assessment of the uterus; prolonged tetanic contraction can lead to a ruptured uterus

The nurse cares for the client diagnosed with Cushing's syndrome. Which nursing action is the priority?

Instigate measures to prevent fluid overload. respirations are the first priority; clients with Cushing's syndrome are prone to fluid overload and heart failure due to sodium and water retention

While the nurse irrigates a client's NG tube, an LPN/LVN approaches the nurse to report that a different client is hemorrhaging from the rectum. Which action by the nurse is most appropriate?

Instruct the LPN/LVN to take over the irrigation of the NG tube while the nurse assesses the other client.

The nurse provides care for a client admitted for the surgical repair of a detached retina in the left eye. Which intervention does the nurse include in the client's postoperative plan of care?

Limit the movement of both eyes.

The nurse makes rounds on the postpartum unit. The nurse notes that a client's uterus is relaxed. The nurse should take which actions?

Massage the fundus until firm. Put the infant to the client's breast. Assess the bladder for fullness.

The client is seen in the emergency department with severe right-flank pain. The client is 20 pounds overweight, lives a sedentary lifestyle, and was treated for urinary tract calculi 4 years ago. Which nursing action is most important?

Measure and strain the client's urine. will document passage of calculus and allow composition to be analyzed

When administering antipsychotic medications parenterally, which action should the nurse take FIRST?

Monitor the client's blood pressure while the client is sitting and standing before and after each dose is given. primary concern with postural hypotension caused by medication and preventing an injury from a fall; monitoring vital signs will provide data to address this concern also: nurse should know sign and symptoms of neuroleptic malignant syndrome (pallor, tachycardia, hypertension or hypotension, diaphoresis, fever, convulsions, loss of bladder control, respiratory distress, severe muscle stiffness, tiredness); identify it early; notify health care provider; administer emergency care as needed nurse should know sign and symptoms of neuroleptic malignant syndrome (pallor, tachycardia, hypertension or hypotension, diaphoresis, fever, convulsions, loss of bladder control, respiratory distress, severe muscle stiffness, tiredness); identify it early; notify health care provider; administer emergency care as needed"

The nurse provides care to a client diagnosed with acute renal failure secondary to severe kidney infection. During the oliguric phase, which assessment finding does the nurse expect to observe? (Select all that apply. )

Normal urine specific gravity ranges from 1.010 to 1.030. During the oliguric phase of acute renal failure, urine specific gravity typically decreases (if the primary cause is prerenal) or remains within normal limits (if the primary cause is intrarenal). Azotemia, which is a classic sign of acute renal failure, refers to the buildup of nitrogenous waste products in the bloodstream. Hallmarks of azotemia include increased serum BUN and increased serum creatinine. 3) CORRECT - With acute renal failure, pruritus (itching) may occur. Although some scientists believe a buildup of urea in the bloodstream contributes to this condition, research has not yet conclusively identified the cause of pruritus in relationship to kidney dysfunction. 4) CORRECT - With acute renal failure, the buildup of metabolic waste products in the bloodstream may cause nausea and vomiting. 5) CORRECT - Normal potassium ranges from 3.5 to 5 mEq/L (3.5 to 5 mmol/L). Acute renal failure causes impaired filtration of fluid and electrolytes. During the oliguric phase, an increase in serum potassium (hyperkalemia) is typically seen.

The child comes to the school nurse with a honey-colored crusted lesion below the right nostril. Which action does the nurse take first ?

Notifies the child's parents. describes impetigo, highly infectious superficial bacterial infection; notify parents so they can contact the health care provider

Nutrition during pregnancy:

Protein increases modestly. Not triple. Calories do not increase in first trimester. Second - addl 340. Third alld 462. Iron requirements double. Sodium requirements increase slightly. Zinc requirements increase.

The nurse provides care for a client diagnosed with a flaccid bladder following a spinal cord injury. The nurse teaches the client about dietary changes. Which beverage selected by the client indicates the teaching is effective? (Select all that apply.)

Prune juice - minimize UTI Cranberry juice - Minimize UTI Blueberry juice - minimize UTI

The nurse provides care for a client diagnosed with hyperthyroidism. Which intervention does the nurse include in the plan of care for this client?

Quiet environment. This client is in a hypermetabolic state, so a physically and mentally restful environment is helpful.

The nurse provides care for a client in the emergency department (ED) who is shaking and crying after witnessing a friend being shot with a gun. The nurse observes the client to be severely anxious. Which interventions does the nurse include in the client's plan of care? (Select all that apply.)

Remain with the client. Administer prescribed lorazepam 1 mg orally. Provide privacy for the client. Write down important information.

The nurse notes one of the staff members caring for clients has a watery discharge from the right eye and the eye appears red. Which nursing action is best?

Send the staff member home and notify the supervisor.

The nurse cares for clients in the hospital. Which nursing activities best promote nighttime rest for elderly hospitalized clients?

Tell the client how to call for help if needed. Postpone explanation of further tests the client will need. Identify normal evening bedtime routines.

The nurse cares for the client in the third trimester of pregnancy. The client has proteinuria, blood pressure of 154/92, and +3 pitting edema of the fingers. The nurse is most concerned by which additional assessment finding?

The client reports epigastric pain. is usually indicative of an impending convulsion

The nurse provides care for a client after a left below-the-knee amputation. Which observation by the nurse requires immediate follow-up?

The client reports persistent pain after receiving pain medication. Could be infection, circulation issue, etc. NOT inability to read a book. Could be due to stress.

The visiting nurse instructs a client how to use esophageal speech following a total laryngectomy. Which of the following actions, if performed by the client, indicates teaching is effective?

The client swallows air and then eructates it while forming words with his mouth.

When caring for a client with a nursing diagnosis of rape trauma syndrome, acute phase, the nurse should consider which of the following the MOST important initial goal for the client?

The client will begin to express her reactions and feelings about the assault before leaving the emergency room.

The nurse provides care for a client after a thoracotomy. The client has a chest tube drainage system in place. Which observation most concerns the nurse?

The level of the fluid in the water-seal chamber does not move.

The nurse plans the schedule for administering bromocriptine. Which information is correct?

The medication should be taken with meals. Will decrease GI upset

The nurse supervises the newly licensed nurse during the insertion of a vascular access device (VAD) on an older adult client. The client has a history of type 2 diabetes mellitus, diastolic heart failure, and a right mastectomy 15 years ago. The client has a BUN of 24 mg/dL (8.57 mmol/L), a blood pressure of 92/60 mm Hg, and a heart rate of 96 bpm. Which observation concerns the nurse?

The nurse cleans the right hand with an antiseptic solution prior to insertion of the VAD. The client had a right mastectomy and the use of the right arm should be avoided. Also, even though the hand is often recommended, there is increased risk of hematoma and infiltration with an older adult client.

The nurse provides care for clients in the outpatient clinic and receives four phone calls. Which call does the nurse return first?

The parent of a toddler calls to report that their child swallowed a nickel. The nurse should immediately evaluate to determine if the toddler is having respiratory difficulty due to airway obstruction.

An elderly patient is admitted to the hospital for treatment of a fractured femur. The patient's spouse tells the nurse that the patient has become very hard of hearing. The nurse might expect the patient to exhibit which of the following characteristics?

The patient appears suspicious of strangers. suspiciousness results from interference with communication

A client has hemodynamic monitoring using a Swan-Ganz catheter. The nurse is aware this type of monitoring will provide which information?

The pressure in the ventricles. CVP readings measure the pressure in the right ventricle, and the Swan-Ganz catheter measures the pulmonary artery wedge pressure, which is an indirect reading of the pressure in the left ventricle. These pressures give an indication of the fluid pressures.

The nurse observes the student nurse check the placement of a nasogastric (NG) tube prior to administering an intermittent feeding. Which student nurse actions require an intervention by the nurse?

The student nurse positions a stethoscope on the upper abdomen and listens as air is introduced into the NG tube. air injected to lungs, pharynx or esophagus may transmit similar sound The student nurse places the end of the NG tube in a cup of water and watches for bubble formation. ot considered acceptable procedure; if tube placed in lungs, may cause bubbling

The nurse provides care to a client who is believed to have developed tuberculosis. The nurse implements which steps when collecting the client's sputum specimen? (Select all that apply.)

Use a suction catheter to obtain the specimen if needed. Offer oral care before collecting the sputum specimen.Oral care should be routinely offered to the client, including prior to collection of the sputum specimen. Good oral hygiene may help prevent contamination of the specimen by microorganisms in the oral cavity. Send the specimen to the laboratory immediately.

The nurse teaches a client newly diagnosed with diabetes mellitus about proper foot care. Which instructions will the nurse include in the teaching plan? (Select all that apply.)

Wash and dry feet every day. Those diagnosed with diabetes mellitus should wash their feet daily and dry them carefully, especially between the toes. 3.Have a podiatrist cut the toenails.4.Check the feet daily for injuries.5.Never walk barefoot.

The nurse provides care for the client diagnosed with active tuberculosis (TB). It is important for the nurse to take which action?

Wear a mask and gloves when in direct contact with the client. Airborne precautions are required. Airborne precautions include the use of an N95 mask when in the room with the client. Gloves are worn to comply with standard precautions.

A client receives parenteral nutrition (PN). To determine the client's tolerance of this treatment, the nurse should assess which physiological sign?

if the client is being properly hydrated with hypertonic IV such as PN, urine output needs to be at least 30 ml/h; other nursing action includes assessment of blood glucose levels

The nurse cares for the client with a long history of alcohol and drug dependence. It is most important for the nurse to include which action as part of discharge planning?

Encourage participation in Alcoholics Anonymous (AA) meetings with a sponsor. self-help groups have greatest success rate as a sustained support system in the community

A 2-year-old is admitted to the pediatric unit with numerous bruises, a fractured left humerus, and several lacerations with unexplained origin. The nurse identifies which of the following as a priority nursing action?

Report the findings to the child protection agency.

The nurse in the community mental health center talks individually with a client with generalized anxiety disorder and who has been attending center programs for 4 months. Which statement made by the client best indicates that the anxiety is resolving?

"I am sleeping 7 hours a night and my dreams are calm." Sleeping well indicates major resolution of anxiety, as the sleeping and dreaming both reflect and affect body, mind, and spirit and are not conscious processes. In anxious states, there is a disturbed sleep pattern, sleep deprivation, and fatigue. Intrusive thoughts, worrying, fear, and/or replaying traumatic events contribute to difficulty falling asleep and/or staying asleep.

The nurse plans care for a client with toxic shock syndrome. Which client statement causes the nurse the most concern?

"I vomited 12 times in the past 24 hours. " This amount of vomiting could lead to fluid volume deficit. Symptoms of toxic shock syndrome include a sudden onset of fever, hypotension, and rash.

The nurse performs discharge teaching for a client treated for cervical cancer with a cesium 137 implant. The nurse learns that the client works 40 hours per week in a factory and has a toddler and preschooler at home. Which client statement indicates that further teaching is needed?

"I will abstain from sexual intercourse and not use tampons for 2 weeks."

The charge nurse is making client assignments for the nursing team. Which client will the charge nurse assign to the LPN/LVN?

A client in skin traction. This is a stable client with an expected outcome. The LPN/LVN can provide care for this client.

Following a train accident, the nurse triages a group of victims. When the nurse asks how one of the clients is feeling, the client states matter-of-factly, "Look at all the rescue trucks. It 's like watching a movie. " Which defense mechanism does the nurse identify that the client is using?

1) CORRECT— Dissociation is an unconscious separation of painful feelings from a difficult situation, idea, or object. The client is focusing on what is happening around them, not to them. 2) INCORRECT - Regression is a return to an earlier level of development and the comfort measures associated with that level of functioning. 3) INCORRECT - Projection is attributing one 's own feelings that are unacceptable to someone else, or blaming someone else for one 's own problems. 4) INCORRECT - Denial is an unconscious refusal to admit an unacceptable idea or behavior or the feelings associated with it.

A pediatric client is admitted to the cardiology unit after experiencing sudden chest pain and dizziness. A diagnosis of supraventricular tachycardia (SVT) is made. If the client experiences another episode of chest pain and dizziness, which action does the nurse implement?

Ask the client to stick the thumb in the mouth, close the mouth around it, and then blow on the thumb as if it were a trumpet. This is a form of the vagal or Valsalva maneuver, which can stop SVT. Blowing should occur for 30 to 60 seconds. Other possible vagal maneuvers include ice to the face, holding the breath and then bearing down, or massaging the carotid artery on only one side of the neck. If vagal maneuvers do not work, intravenous adenosine, an anti-dysrhythmic agent, may be given.

The nurse provides care to a client who just underwent left modified radical mastectomy. When assisting the client with positioning, the nurse implements which action?

Elevate the client's left arm on a pillow. Following modified radical mastectomy, the client should be placed in semi-Fowler position. To promote lymphatic drainage without compromising circulation, the arm on the affected side should be elevated on a pillow. Elbow flexion or dependent positioning of the arm may impede lymphatic drainage and compromise circulation.

The nurse assesses a client diagnosed with a detached retina. Which observation or client report supports this diagnosis?

Experiencing bright flashes of light (i.e., photopsia) and reporting loss of a portion of the visual field are signs of a detached retina. The client may also report a "cobweb,""hairnet," "curtain," or ring in the field of vision. The visual loss is painless, and peripheral or central vision may be affected; the area of vision loss corresponds inversely to the area of detachment.

The nurse teaches a client who is prescribed prednisone for systemic lupus erythematosus (SLE). Which information related to prednisone does the nurse include in the teaching plan? (Select all that apply.)

Report symptoms of infection - causes immunosuppression. Do not discontinue meds abruptly. Report unusual weight gain. Avoid vaccination.

The nurse cares for the 8-lb, 8-oz newborn. The infant's history indicates the mother was given magnesium sulfate IV 4 g in 250 mL D5W several hours before delivery. The nurse is most concerned if which finding is observed?

Respirations 18/min. magnesium sulfate can cause slowing of respirations and hyporeflexia; normal respirations 30-60/min

The nurse plans care for a neonate diagnosed with Tetralogy of Fallot. Which action does the nurse implement when providing care to this client?

Select a nipple with a larger hole for formula feeds. This allows the neonate to obtain nourishment easily. The nurse should ensure that the neonate exerts minimal effort to eat, as any work of eating will increase oxygen demand. The heart is not able to support an increased oxygen demand, and the neonate may easily become hypoxic during feeds.

The client diagnosed with Addison's disease is admitted with pneumonia. The nurse suggests salted broth for lunch. The appropriateness of this decision is based on which statement about Addison's disease?

Sodium intake should be increased during periods of stress. with decrease in aldosterone, there is an increased excretion of sodium; sodium intake should be increased

The nurse cares for the child diagnosed with a fractured right femur. The child is in balanced suspension traction with a Thomas splint and Pearson attachment. The nurse finds the weights on the floor and the child's feet touching the foot of the bed. Which nursing action is most appropriate?

Steady the traction and ask the child to bend the left leg and push up in bed.

To maintain client safety, the nurse should have which of the following equipment readily available when inserting an Ewald tube?

Suction equipment. Ewald tube is a large, orogastric tube designed for rapid lavage; insertion often causes gagging and vomiting, suction equipment must be immediately available to reduce the risk of aspiration