nclex review
A mother of a 3-year-old is concerned because the child is still insisting on a bottle at nap time and at bedtime. The nurse would make which suggestion to the mother?
"Allow the bottle if it contains water."
The client is admitted to the hospital with a diagnosis of suspected Hodgkin's disease. Which signs and symptoms of the client are associated with Hodgkin's disease?
Fatigue Weakness Night sweats Enlarged lymph nodes
When collecting data on a pregnant client, the nurse includes which question to determine whether the client is at risk for toxoplasmosis parasite infection?
"Do you have any cats as house pets, and if so, do you ever come in contact with their soiled kitty litter?"
The mother of an infant newly diagnosed with cystic fibrosis is being taught proper nutritional needs for the infant. The nurse determines that the mother understands nutritional needs when the mother gives which response?
"I know I need to monitor my infant's stools, and if there are more than four stools a day, I will increase the pancreatic enzyme."
A client reporting recent right eye discomfort is diagnosed with chalazion of the right eye. The nurse reinforces instructions to the client regarding care to the eye. Which statement by the client indicates an understanding of the measures?
"I should apply warm packs to my eye."
The nurse is reinforcing discharge instructions to the mother of a child who needs eye drops in the left eye. Which statement by the mother indicates a need for further teaching?
"I will give the medication directly on the eyeball."
The nurse reinforces home care instructions to the parents of an infant following surgical intervention for imperforate anus and tells the parents about the procedure for anal dilation. Which statement by the parents indicates the need for further teaching?
"I will insert a glycerin suppository before the dilation.
The nurse reinforces instructions to a client with myxedema about the dosage, method of administration, and side effects of levothyroxine sodium. Which statement by the client indicates an understanding of the nurse's instructions?
"I will report any episodes of palpitations, chest pain, or dyspnea.
The nursing student is asked to describe the size of the uterus in a pregnant client at the end of pregnancy. Which response by the student indicates an understanding of the anatomy of this structure?
"The uterus is round and weighs approximately 1000 grams."
The nurse is assisting in performing Leopold's maneuvers. The client asks the purpose of the procedure. How would the nurse respond to the client?
-"Leopold's maneuvers are used to determine fetal position." -"Leopold's maneuvers assist in determining the degree of descent into the pelvis of the presenting part." -"Leopold's maneuvers assist in determining the point of maximal intensity of the fetal heart rate on the maternal abdomen."
A client has an inoperable abdominal aortic aneurysm (AAA). Which measure would the nurse anticipate reinforcing when teaching the client?
Antihypertensives
A child is admitted to the hospital with a probable diagnosis of nephrotic syndrome. Which findings would the nurse expect to observe?
Ascites Anorexia Proteinuria Periorbital and facial edema
The nurse tells the group that when performing chest compressions on adults, the sternum would be depressed to at least which depth?
2 inches
A client informs the nurse that she has been taking acarbose as prescribed. The nurse determines that a therapeutic effect of the medication has occurred if which laboratory value is noted?
A 2-hour postprandial serum glucose of 120 mg/dL
While collecting data on a client being prepared for an adrenalectomy, the nurse obtains a temperature reading of 100.8° F. The nurse analyzes this temperature reading as which?
A finding that needs to be reported immediately
The nurse is collecting data on a client with the diagnosis of anorexia nervosa. Which findings are indicative of anorexia nervosa?
A high achiever Personality changes Lanugo over the back and extremities
The nurse will be caring for several older adults who will be undergoing general anesthesia. Which older adult will require the closest monitoring for a prolonged effect of anesthesia?
An older adult with increased amount of fatty tissue
digoxin
Anorexia and nausea are two of the common symptoms associated with digoxin toxicity, which is compounded by hypokalemia
The nurse is administering a dose of a prescribed diuretic to an assigned client. The nurse would plan to monitor the client for hypokalemia as a side effect of therapy if the client is receiving which medication?
Bumetanide
carbamazepine
Carbamazepine acts by depressing synaptic transmission in the central nervous system (CNS). Because of this, the client should avoid driving or doing other activities that require mental alertness until the effect on the client is known. The client should use protective clothing and sunscreen to avoid photosensitivity reactions. The medication may cause dry mouth (not excessive salivation), and the client should be instructed to provide good oral hygiene and use sugarless candy or gum as needed. The medication should not be abruptly discontinued because it could cause return of seizures or status epilepticus. Fever and sore throat should be reported to the primary health care provider (PHCP).
A client with heart failure who is taking furosemide and digoxin calls the nurse and complains of anorexia and nausea. The nurse would take which action?
Check the result of the potassium level drawn 3 hours ago
A client is admitted to the psychiatric unit with a diagnosis of bipolar affective disorder and mania. The nurse identifies which signs/symptoms or behaviors as requiring immediate intervention?
Constant physical activity and poor oral intake
A manic client is placed in a seclusion room after an outburst of violent behavior, including physical assault on another client. As the client is secluded, which action would the nurse perform?
Inform the client that she is being secluded to help regain control of herself.
A 4-year-old child is being transported to the trauma center from a local community hospital for treatment of a burn injury that is estimated as covering over 40% of the body. The burns are partial- and full-thickness burns. The nurse is asked to prepare for the arrival of the child and gathers supplies anticipating that which will be prescribed initially?
Insertion of a Foley cathete
The nurse is reviewing the laboratory studies on a client receiving dantrolene sodium. Which laboratory test(s) would identify an adverse effect associated with the administration of this medication?
Liver function tests
A client begins to drain small amounts of red blood from a tracheostomy tube 36 hours after a supraglottic laryngectomy. The licensed practical nurse would perform which action?
Notify the registered nurse
The nurse is attending an agency orientation meeting about the nursing model of practice implemented in the facility. The nurse is told that the nursing model is a team nursing approach. The nurse determines that which describes the team-based model of nursing practice?
Nursing staff are led by the nurse when providing care to a group of clients.
The nurse is monitoring the behavior of the client and understands that the client with anorexia nervosa manages anxiety by which action?
Observing rigid rules and regulations
The primary health care provider is discharging a client with a diagnosis of chronic heart failure. Which health maintenance instructions would the nurse reinforce in the discharge teaching plan?
Obtain annual influenza vaccination Avoid adding salt to foods or in cooking Report a weight gain of 3 or more pounds in a week.
A client with a phobia will be treated for the condition using a behavior modification technique known as systematic desensitization. The nurse describes the components of this form of therapy to the client and reinforces which client instruction
The client will be introduced to short periods of exposure to the phobic object while in a relaxed state.
The nurse is asked to test the visual acuity of a client using a Snellen chart. The nurse prepares to perform the test, knowing that which procedure accurately identifies this visual acuity test?
The right eye is tested, followed by the left eye, and then both eyes are tested.
The nurse is assisting to administer acetylcysteine to a client admitted with acetaminophen overdose. Before this medication is given, the nurse ensures which factor is in place?
The stomach is empty from emesis or lavage.
The nurse plans care understanding that the primary reason clients experience vasodilation in septic shock is because
There is a release of endotoxins from bacteria.
The nurse is completing a medication reconciliation form for a client. Which is a primary purpose of this process?
To compare a client's medication prescriptions to all of the medications the client is taking at home
In providing initial care to the newborn following delivery, what is the nurse's priority action?
Turn the infant's head to the side.
The nurse has given medication instructions to a client beginning anticonvulsant therapy with carbamazepine. The nurse determines that the client understands the use of the medication if the client knows to perform which activity?
Use sunscreen when outside.
The nurse has completed client teaching about heart failure and prescribed medications that include digoxin and furosemide. The nurse documents that the teaching goals have been met if the client states knowing to report which symptom?
Weight gain of 2 to 3 pounds in a few days
The nurse obtains a health history from a mother of a 15-month-old child before administering a measles, mumps, and rubella (MMR) vaccine. Which is essential information to obtain before the administration of this vaccine?
allergy to eggs
A long-term care nurse is caring for an older client taking cimetidine. The nurse would observe this client frequently for which most common central nervous system (CNS) side effect of this medication?
confusion
The nurse is reinforcing dietary instructions to a client diagnosed with acute glomerulonephritis. The nurse determines that the client understands the information presented if the client states the intention to do which action?
limit protein intake
The nurse is collecting data from a pregnant client with a history of cardiac disease. The nurse is checking for venous congestion. The nurse inspects which area, knowing that venous congestion is most commonly noted where?
vulva
The nurse is monitoring a client receiving baclofen for side effects related to the medication. Which would indicate that the client is experiencing a side effect?
Drowsiness
The nurse is developing a teaching plan for a client following a radical mastectomy and includes measures that will assist in preventing lymphedema of the affected arm. The nurse would include which interventions when reviewing instructions with the client to prevent this complication?
Elevate the affected arm on a pillow higher than the heart Instruct the client to perform simple arm exercises in the affected arm daily. Inspect the arm daily and notify the primary health care provider of redness or swelling.
The nurse is preparing the client for eye testing, and the examiner is planning to test the eyes using the confrontational method. What would the nurse tell the client about the purpose of the test?
Examines visual fields or peripheral vision
A client newly diagnosed with chronic kidney disease 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.
The nurse is assigned to care for a child who is suspected of having glomerulonephritis. The nurse reviews the child's record and notes that which findings are associated with the diagnosis of glomerulonephritis?
Headache Red-brown urine Periorbital edema
low protein diet rationale
Rationale:The diet for the client with acute glomerulonephritis is generally high in calories and low in protein. This diet inhibits protein catabolism and allows the kidneys to rest. In acute glomerulonephritis, it is important to protect the kidneys while they are recovering their function.
antihypertensive rationale for AAA
Rationale:The medical treatment for abdominal aortic aneurysm is controlling blood pressure. Hypertension creates added stress on the blood vessel wall, increasing the likelihood of rupture.
A client who excessively uses alcohol and who is motivated to stop tells the nurse, "I know that there is a medication that can help people like me quit drinking." Which medication would the nurse explain is available for this purpose?
Disulfiram
The nurse is reinforcing instructions to the parents of an infant with a ventriculoperitoneal shunt. The nurse plans to include which instruction?
"Call the primary health care provider if the infant has a high-pitched cry.
The nurse is reviewing the postoperative primary health care provider's (PHCP'S) prescriptions for a 3-week-old infant with Hirschsprung's disease admitted to the hospital for surgery. Which prescriptions documented in the child's record would the nurse question?
Take temperature measurements rectally Start clear liquid diet after 8 hours postoperative
The client with a diagnosis of gastric ulcer has a prescription for oral sucralfate four times daily. The nurse reinforces instructions to the client about which adverse or side effect that can occur while taking this medication?
Constipation
The nurse is assisting in developing a plan of care for a paranoid client who experiences religious delusions. Which short-term goal would be most appropriate?
Develops a relationship to help reduce the frequency of the delusions
The nurse is collecting data from a client who has a history of untreated cataracts. The nurse checks the client for which associated manifestation?
Difficulty with driving a car at night
The nurse has a prescription to give ear drops to a 2-year-old child. To administer the drops, the nurse would pull the pinna of the ear in which direction?
Downward and backward
The health care team is performing high-quality cardiopulmonary resuscitation (CPR) on a client in cardiac arrest. Once the client is attached to a monitor, it is determined that a shock is not advised. CPR is continued, and the nurse determines what additional action would be taken next by the health care team?
Prepare to administer epinephrine
heart failure rationale
Rationale: Clients with heart failure should immediately report weight gain, loss of appetite, shortness of breath with activity, edema, persistent cough, and nocturia.
Rationale for anorexia nervosa
Rationale:Clients with anorexia nervosa have the desire to please others. Their need to be correct or perfect interferes with rational decision-making processes. These clients are moralistic. Rules and rituals help the clients manage their anxiety.
