NCLEX Review Questions Fall 2021
After a change-of-shift report, which client would the nurse assess first? 1) Client with possible lung cancer who has just returned to the nursing unit after mediastinoscopy 2) Client with cough whose chest x-ray shows possible active tuberculosis and needs sputum testing 3) Client who has pneumococcal pneumonia and very decreased breath sounds in the right lung base 4) Client who has a chest tube with rapid bubbling in the suction control chamber of the drainage system
1 A client who has just returned to the unit after a procedure using general anesthesia and with possible complications of bleeding or respiratory distress would be assessed immediately after arriving. Because the sputum specimens for the client with possible tuberculosis will be done in the early morning after the client first arises, the teaching about this procedure does not need to be done urgently. Clients with pneumonia frequently have decreased breath sounds over the area of inflammation and consolidation, and this client does not need to be urgently assessed. Bubbling in the suction control chamber indicates that the wall suction may need to be decreased but does not affect the amount of suction on the pleural space and does not need to be immediately addressed by the nurse.
After checking the fetal heart rate of a client after an amniotomy procedure, which intervention by the nurse would be appropriate? 1) Inspecting the perineum 2) Preparing for an immediate birth 3) Measuring the maternal blood pressure 4) Increasing the intravenous fluid rate
1 After the rupture of membranes, the umbilical cord may prolapse if the fetal head does not engage immediately, and this can lead to fetal compromise. The perineal area should be inspected at this time and frequently thereafter for evidence of cord prolapse. Rupture of the membranes does not lead to precipitous birth; it is done to facilitate labor. Rupture of membranes is not associated with maternal blood pressure changes. Increasing the IV rate is appropriate if the client shows signs of dehydration; the data do not indicate this.
A health car provider prescribes B-complex vitamins. Which information will the nurse teach the client? 1) The vitamins may turn the urine bright yellow 2) The daily fluid intake should be increased 3) The vitamins should be taken on an empty stomach 4) Taking the vitamins with a high-fat meal will increase absorption
1 Bright yellow urine is an expected, insignificant side effect of vitamin B complex. There is no need to increase oral fluids; the client may consume the usual daily intake of fluid. Taking the vitamins on an empty stomach may precipitate nausea; therefore they should be taken with food. Vitamin B complex is a water-soluble vitamin, and excess amounts are excreted in urine. Taking the vitamins with a fatty meal will not improve absorption.
Which explanation would the nurse provide to the parents of a child with spasmodic croup who ask why their child is receiving humidified oxygen? 1) It helps prevent drying of membranes 2) It provides a mode of giving inhalant medications 3) It increases the surface tension of the respiratory tract 4) It provides an environment free of pathogenic organisms
1 Humidified oxygen helps reduce inflammation and edema of the upper respiratory tract. Inhalant medications are administered with the use of a nebulizer. The mist has no effect on surface tension in the respiratory tract. Eliminating pathogenic organisms is not the purpose of humidified oxygen.
During a tap water enema, a client reports abdominal cramps. Which action would the nurse take? 1) Clamp the tubing and allow the client to rest 2) Reassure the client and continue the irrigation 3) Pinch the tubing so that less fluid enters the colon 4) Raise the irrigating container to complete the irrigation quickly
1 Rapid instillations of fluid into the colon may cause abdominal cramps. By clamping the tubing, the nurse allows the cramps to subside so the irrigation eventually can be continued. Emotional support will not interrupt the physical response of abdominal cramps. Although pinching the tubing would lessen the fluid entering the colon and raising the irrigating container to complete the irrigation quickly might reduce the force of the fluid, neither of these will eliminate the flow of fluid completely. Increasing the force of flow will increase abdominal cramps.
For a client with the diagnosis of borderline personality disorder, which problem is most likely to underlie angry or hostile behavior? 1) Low self-esteem 2) Inability to test reality 3) Reaction to command hallucination 4) Ineffective verbal communication
1 The client has low self-esteem and reacts by using hostile behavior. People with borderline personality disorder often have identity disturbances. Reality testing and hallucinations are psychotic features that do not accompany personality disorders. Impaired verbal communication can be related to organic causes, such as stroke or dementia, or to thought disturbances, such as schizophrenia.
An infant with congenital heart disease is prescribed digoxin and furosemide upon discharge. Which sign would the nurse instruct the parents to be alert for? 1) Difficulty feeding with vomiting 2) Cyanosis during periods of crying 3) Daily naps lasting more than 3 hours 4) A pulse rate faster than 100 beats/min
1 Vomiting and feeding issues are early signs of digoxin toxicity. Cyanosis is expected in a crying infant with heart disease because the energy expenditure exceeds the body's ability to meet the oxygen demand. Long naps are expected; infants routinely require several naps, and an infant with heart disease requires long rest periods. The pulse rate of an infant receiving digoxin should remain faster than 100 beats/min.
The nurse provides teaching to a client who will begin to receive tube feedings after a total laryngectomy. The nurse concludes that the teaching was understood when the teaching makes which statement about tube feedings? 1) "I will need the tube feedings until healing of the incision is complete." 2) "I will need tube feedings until the gag reflex returns." 3) "I will need tube feedings until the ability to belch is restored." 4) "I will need tube feedings until my oral feedings can be digested."
1) " I will need the tube feedings until healing of the incision is complete." Food should be avoided until the area is healed completely; this will keep the area from becoming irritated and contaminated. Because of the alterations in structure, the gag reflex is no longer present. The ability to belch has no bearing on the decision to resume oral feedings. The ability to tolerate oral feedings is not lost; such feedings are withheld to prevent irritation to the surgical site until healing has taken place.
A laboring primigravida at 7 cm of dilation is administered a prescribed pain medication. Which medication administered requires monitoring of the newborn for respiratory depression? 1) Butorphanol 2) Hydroxyzine 3) Promethazine 4) Diphenhydramine
1) Butorphanol Respiratory depression may occur in the newborn because the duration of action of butorphanol is 3 to4 hours and circulating blood level will be high if birth occurs during that time. Hydroxyzine, promethazine, and diphenhydramine are all antihistamines that have a sedative effect and are administered early in labor to promote sleep and decrease anxiety
By which mechanism do sitz baths aid healing of an episiotomy? 1) Promoting vasodilation 2) Cleansing perineal tissue 3) Softening the incision site 4) Tightening the rectal sphincter
1) Promoting vasodilation Heat causes vasodilation and increased blood supply to the area. Cleansing is performed with a perineal bottle and cleansing solution immediately after voiding and defecation. Sitz baths do not soften the incision site. Neither relaxation nor tightening of the rectal sphincter will speed healing of an episiotomy.
Which statement from a pregnant client with premature rupture of membranes (PROM) demonstrates an understanding of the infection risk? SATA 1) I will report a fever to my doctor 2) I will wipe from front to back when using the bathroom 3) If I have contractions, medications will be administered 4) If I develop chorioamnionitis, my doctor will induce labor 5) I will let my doctor know if I experience foul-smelling vaginal discharge
1, 2, 3, 4, 5 The nurse would provide thorough education on signs of infection, infection prevention, and possible outcomes of infection for pregnant clients with PROM. The client would be instructed on how to keep the genital area clean and advised that nothing is to be introduced into the vagina. The client would be made aware of the importance of being vigilant for signs of infection, such as fever and foul-smelling vaginal discharge, and that these signs would be reported immediately. Clients would be made aware that labor will need to be induced if chorioamnionitis develops. If preterm labor occurs, tocolytic medications can be administered to "buy time" enough for transporting the client to a hospital capable of providing preterm infant care. The additional time also allows antenatal corticosteroids or antibiotics to reach effective levels.
A toddler is admitted to the pediatric unit with diarrhea and severe dehydration. After several days of treatment, the child is evaluated. Which clinical findings indicate that the child is rehydrated? SATA 1) Decreased hematocrit 2) Increase in daily weight 3) Negative blood cultures 4) Increased sedimentation rate 5) Decreased blood urea nitrogen (BUN) level
1, 2, 5 A decrease in the hematocrit level indicates that the blood has become less concentrated as hydration improves. The daily weight reading increases with rehydration as water is retained. One liter of fluid weighs 2.2 lb (1 kg). The BUN level will decrease as blood volume increases because the components of the blood are in a more dilute solution. A blood culture will not provide information about hydration. An increased sedimentation rate indicates an inflammatory process, not the state of hydration.
A client is taking an estrogen-progestin oral contraceptive. Which adverse effects from the contraceptive would the nurse teach the client to report to the primary health care provider? SATA 1) Dizziness 2) Chest pain 3) Bloating 4) Nausea 5) Calf tenderness 6) Breast tenderness
1, 2, 5 Early side effects of oral contraceptives include bloating, nausea, and breast tenderness. Although they may be bothersome enough to lead to discontinuation of the contraceptive, these side effects usually subside in several months. Dizziness is not a common side effect and should be reported to the provider. Contraceptives have been associated with thrombophlebitis; clinical manifestations of thrombophlebitis include calf tenderness and redness and heat over the affected area. If the clot travels, it could present as a pulmonary embolism, so chest pain should be reported as well.
Which clients would the medical-surgical nurse identify as appropriate for transfer or discharging to make room for admission of victims of a disaster? SATA 1) 68-year-old client on the 3rd postop day since total knee replacement 2) 30-year-old client receiving intravenous insulin for diabetic ketoacidosis 3) 55-year-old client with bleeding esophageal varices receiving iced lavage 4) 80-year-old client being regulated on medication for transient ischemic attacks 5) 72-year-old client beginning oral anticoagulant therapy for a deep vein thrombosis
1, 4, 5 Clients who are not acutely ill, are stable for transfer to rehabilitation, or have had no critical change in health status for 3 days would be eligible for discharge or transfer to another facility. The client recovering from total knee replacement surgery can be transferred to rehabilitation. The client with transient ischemic attacks can be discharged to home. The client beginning oral anticoagulant therapy for a deep vein thrombus can be discharged to home. The client receiving insulin for diabetic ketoacidosis is unstable and should not be discharged. The client with bleeding esophageal varices is acutely ill and should not be discharged.
A client is concerned about taking hormones for birth control. Which contraceptives, explained to the client by the nurse, have a hormonal component? SATA 1) Oral contraceptives 2) Diaphragm 3) Cervical cap 4) Female condom 5) Foam spermicide 6) Transdermal agents
1, 6 Oral contraceptives have a hormonal component. Transdermal agents have a hormonal component. The diaphragm, cervical cap, and female condom act as barriers. Foam spermicides kill the sperm; there is no hormonal effect.
The nurse provides discharge instructions to the parents of a child who has undergone tonsillectomy. Which statement indicates that the parents need further teaching? 1) I won't let her use a straw to drink 2) Cherry milkshakes will ease the pain 3) I shouldn't let her gargle for at least 10 days 4) She'll be able to play with friends in 1 week
2 A serious post-tonsillectomy complication is hemorrhage; red liquids are contraindicated because they may mask bleeding. Drinking from a straw produces suction, which may traumatize the surgical site and cause bleeding. Likewise, gargling is traumatic to the surgical site and may precipitate bleeding. Hemorrhage may occur as long as 10 days after surgery; regular activity may be resumed after 1 week if there are no complications
Why would the nurse encourage continued health care supervision for a pregnant woman with pyelonephritis? 1) Preeclampsia commonly occurs after pyelonephritis 2) Antibiotic therapy should be administered until the urine is negative 3) Pelvic inflammatory disease may occur with untreated pyelonephritis 4) Nutritional needs change to accommodate the prescribed low-protein diet
2 Health care supervision requires treatment with an appropriate antibiotic until two cultures of urine are negative; recurring pyelonephritis often leads to preterm birth. Preeclampsia is not preceded by specific infections. Pelvic inflammatory disease is associated with infections of the genital, not the urinary, tract. A low-protein diet inhibits fetal development and is contraindicated during pregnancy.
A client with an opioid addiction has been taking 40 mg/day of methadone. She is now in the prenatal clinic and is 3 months' pregnant. Which plan of care would the prenatal nurse anticipate? 1) Withdraw the methadone slowly over the next several weks 2) Continue the prescribed methadone to prevent withdrawal symptoms 3) Temporarily discontinue the methadone to improve maternal and neonatal outcome 4) Leave the methadone maintenance program during the pregnancy and reenter it after the birth
2 Methadone and buprenorphine are the recommended treatment options for pregnant women with opioid addiction. Although the medications cross the placenta, they are considered safer for the fetus and newborn than the acute opioid detoxification that would result if the medications were not administered. Withdrawing the medications slowly over the next several weeks is not recommended. Detoxification from methadone or buprenorphine takes longer than several weeks. Discontinuing methadone or buprenorphine treatment can lead to withdrawal problems and put the client at risk for a return to opioid abuse. If the medications are discontinued during the pregnancy, both client and fetus will be at risk.
An unconscious adolescent with type 1 diabetes is brought to the emergency department. The blood glucose level is 742 mg/dL. Which finding would the nurse expect during the initial assessment? 1) Pyrexia 2) Hyperpnea 3) Bradycardia 4) Hypertension
2 Rapid breathing (hyperpnea) is an attempt by the respiratory system to eliminate excess carbon dioxide; it is a characteristic compensatory mechanism for correcting metabolic acidosis. An increase in temperature (pyrexia) will occur if an infection is present; it is not a response to hyperglycemia. Tachycardia, not bradycardia, results from the hypovolemia of dehydration. Hypotension, not hypertension, may result from the decreased vascular volume associated with hyperglycemia.
Which clinical manifestation would the nurse expect the client who has a tumor of the cerebellum to exhibit? 1) Absence of knee-jerk reflex 2) Inability to coordinate movement 3) Change in level of consciousness 4) Failure to execute voluntary movements
2 The cerebellum is involved in the synergistic control of muscle action. Below the level of consciousness, it functions to produce smooth, steady, coordinated, and efficient movements. The brain is not involved in a simple reflex arc. The cerebrum is responsible for the level of consciousness and voluntary motor function.
Which parent education would the nurse provide when teaching an infant's parents about the major cause of iron-deficiency anemia? 1) Blood disorders 2) Overfeeding of milk 3) Lack of adequate iron reserves from the mother 4) Introduction of solid foods too early for adequate absorption
2 Milk is an inadequate source of iron. Milk ingested in large amounts to the exclusion of solid foods after 4 to 6 months of age often results in iron-deficiency anemia. Anemia is a type of blood disorder. Iron stores received from the mother in the last trimester usually are adequate for the infant's first 4 to 5 months. Lack of absorption of solid foods that are introduced too early is not the cause of anemia in infants.
An older adult with a history of small cell lung carcinoma reports muscle cramping, thirst, and fatigue. The primary health care provider diagnoses the client with a pituitary disorder and is treating the client accordingly. Which is an effective outcome of treatment? 1) Urine output of 10L/day 2) Urine specific gravity less than 1.025 3) Urine osmolarity of 80 mOsm/kg 4) Serum osmolarity of 600 mOsm/kg
2) Urine specific gravity less than 1.025 Small cell lung cancer is a risk factor of syndrome of inappropriate antidiuretic hormone (SIADH). Muscle cramping, thirst, and fatigue are clinical manifestations of SIADH. Because the specific gravity is less than 1.025 after treatment, the outcome is considered positive. In SIADH the specific gravity is greater than 1.025. A serum osmolarity of 600 mOsm/kg indicates central diabetes insipidus. A urine output 10 L/day and a urine osmolarity of 80 mOsm/kg indicate diabetes insipidus
Which information would the registered nurse provider to the nursing student regarding identifying and eliminating potential hazards? SATA 1) If an incident occurs, document in the client's medical record that an occurrence report has been filed 2) Ensure that the three principles of The Joint Commission's Universal Protocol are adhered to before starting a surgery on a client 3) Refrain from depending on the use of electronic monitoring devices completely because they are not always reliable 4) File an occurrence report in case of an error in technique when administering medication intravenously 5) Document that the health care provider was contacted, the information that was conveyed, and the response in the occurrence report
2, 3, 4
A pregnant client with a history of heart disease asks how she can relieve her occasional heartburn. Which statement indicates that the client understands the teaching the nurse has provided? 1) "I should lie down for an hour after I eat" 2) "I shouldn't drink more than 32 ounces of fluid a day" 3) "I won't take antacids that contain sodium" 4) "I plan to eat 3 large meals throughout the day"
3 Antacids containing sodium may increase fluid retention, which increases the workload of the heart and is therefore not recommended. Lying down for 1 hour after eating will exacerbate heartburn because it promotes gastric regurgitation. Fluid intake should be approximately 2 quarts (64 ounces, 2000 mL) a day and does not directly address the heartburn, which is the client's question. Three large meals a day will distend the stomach, which could result in heartburn. Small frequent meals, spaced throughout the day, are preferred.
The nurse is caring for a client with severe dyspnea who is receiving oxygen via a Venturi mask. Which action would the nurse take when caring for this client? 1) Assess frequently for nasal drying 2) Keep the mask tight against the face 3) Monitor oxygen saturation levels when the client is eating 4) Set the oxygen flow at the highest setting that the client can tolerate
3 Because the mask cannot be worn when eating, the client may become hypoxic. A nasal cannula may be needed to deliver oxygen while the client is eating. Nasal drying usually is not a problem with the use of a Venturi mask. Nasal drying occurs more frequently when a nasal cannula is used. Too tight a fit for the mask is uncomfortable and may cause damage to the skin. The mask should fit snugly but not be too tight. The oxygen should be set at the level prescribed by the health care provider.
A client with emphysema reports increased shortness of breath and becoming increasingly anxious. The health care provider prescribes oxygen at 1 L/min via nasal cannula. The nurse recognizes that this prescription is appropriate for which reason? 1) The client does not need any more than 1 L/min 2) High concentrations of oxygen cause alveoli to rupture 3) High concentrations of oxygen eliminate the respiratory drive 4) The oxygen at 1 L/min should be enough to diminish the anxiety
3 Clients with emphysema are used to low levels of oxygen and high levels of carbon dioxide. Oxygen is the stimulus for breathing for these clients instead of the natural breathing stimulus. Too much oxygen will knock out the stimulus to breathe. High concentrations of oxygen will not cause a rupture. The client actually could need more oxygen; however, if a higher concentration is given, it will knock out the respiratory drive. The oxygen is being given because of the shortness of breath.
While counseling the parents of an adolescent with anemia related to an inadequate diet, the nurse explains that several different nutrients, including protein, iron, and vitamin B12, are involved. Which other nutrient would the nurse include in the teaching? 1) Calcium 2) Thiamine 3) Folic acid 4) Riboflavin
3 Folic acid acts as a necessary coenzyme in the formation of heme, the iron-containing protein in hemoglobin. Calcium is not involved in the production of red blood cells. Thiamine is a coenzyme in carbohydrate metabolism. Riboflavin is a control agent for energy production and tissue formation
After a gastrojejunostomy (Billroth II) for cancer of the stomach, a client returns to a regular diet. After eating lunch, the client becomes diaphoretic and experiences palpitations. Which would the nurse conclude is the probable cause of these clinical manifestations? 1) Intolerance of fatty foods 2) Dehiscence of the surgical incision 3) Extracellular fluid shift into the bowel 4) Diminished peristalsis in the small intestine
3 Hypertonic food increases osmotic pressure and pulls fluid from the intravascular compartment into the intestine (Dumping syndrome). Increased carbohydrates, not fats, are responsible for the increased osmotic pressure often associated with dumping syndrome. Dehiscence is separation of the wound edges, usually accompanied by a gush of pink-tinged fluid. Although peristalsis may be decreased because of surgery, this decrease will not account for the client's clinical manifestations.
A client who has had a cesarean birth has been having difficulty breastfeeding for 2 days and now asks the nurse to bring her a bottle of formula. Which would be the nurse's initial action? 1) Obtaining the request formula 2) Administering the prescribed pain medication 3) Assessing the client's breastfeeding technique 4) Notifying the health care practitioner of the client's request to switch feeding methods
3 The nurse would assess the client to determine why the client is having difficulty breast-feeding. She may be uncomfortable or in need of assistance with her breast-feeding technique. The nurse would also explore the client's feelings about breast-feeding. Immediately providing the formula without assessing the situation does not meet the client's needs at this time. Pain may be a factor in the client's frustration with breast-feeding; however, this should be determined through the assessment process. Notifying the health care practitioner of the client's request to switch feeding methods is premature. It is the nurse's responsibility to assess the situation and arrive at a solution in collaboration with the client.
Which assessment finding would the nurse observe in a client who has been found to have an antisocial personality disorder? 1) Pays great attention to detail and demonstrates a high level of anxiety 2) Has scars from self-mutilation and a history of many negative relationships 3) Displays charm, has an above-average intelligence, and tends to manipulate others 4) Demonstrates suspiciousness, avoids eye contact, and engages in limited conversation
3 The nurse would observe charm, above-average intelligence, and manipulation of others. A client with an antisocial personality disorder is charming on first contact, but this charm is a manipulative ploy. These clients usually are bright and use their intelligence for self-gain. Paying great attention to detail and demonstrating a high level of anxiety are traits of an individual with an obsessive-compulsive personality disorder. The client with a borderline personality disorder self-mutilates when under stress; there is a fear of abandonment, so any relationship is better than no relationship. Demonstrating suspiciousness, avoiding eye contact, and engaging in limited conversation resembles the behavior of an individual with a paranoid personality, which includes suspiciousness and lack of trust.
Soon after a vaginal examination revealing cervical dilation of 8 cm, bloody show increases and the client becomes nauseated and irritable. Which phase of labor would the nurse conclude the client is entering? 1) Latent 2) Active 3) Transition 4) Early active
3 The transition phase is the most difficult phase of labor. Characterized by restlessness, irritability, nausea, and increased blood show, it continues from 8 to 10 cm of dilation. The latent phase is early labor (1-4 cm of dilation). It is relatively easy to tolerate, and the client generally is in control and not too uncomfortable. The active phase lasts from about 4 to 6 cm of dilation. It is difficult but is not accompanied by nausea, irritability, or an increase in bloody show. The early active phase lasts from about 4 to 6 of cm dilation. It is difficult but is not accompanied by nausea, irritability, or an increase in bloody show.
An adolescent is severely injured in a motor vehicle collision. There are multiple fractures, contusions, and muscle spasms, causing the teenager to refuse to move. How can the nurse best support the adolescent in movement? 1) Allowing friends to visit daily 2) Explaining that some pain is inevitable 3) Encouraging decision-making regarding care 4) Setting specific limits regarding this behavior
3 Decision-making fosters and supports independence, a developmental need of the adolescent. It also increases a sense of self-worth and control. Allowing friends to visit daily promotes social interaction, not movement. Although it may be true that pain is inevitable, explaining this is not a motivating intervention. Setting specific limits is confrontational; limit-setting meets the security needs of young children.
Which content would the nurse emphasize in a prepared childbirth class? 1) Birth as a family experience 2) Labor without the use of analgesics 3) The course of labor and coping techniques 4) Hydration, relaxation, and pain control during labor
3) The course of labor and coping techniques The objective of childbirth classes is to adequately educate parents about the process of labor and birth, the options open to them, and techniques of coping. Birth as a family experience is only part of the class content. Labor without the use of analgesics is not the preference of all women. A fair and balanced presentation of both natural childbirth and the use of analgesia and anesthesia should be covered. Hydration, relaxation, and pain control during labor is only part of the class content.
Which parental statement related to fine motor skill development in a 24-month-old child indicates the need for more education? 1) "My child should be able to turn a doorknob." 2) "My child should be able to align two or three cubes like a train." 3) "My child should imitate vertical strokes when drawing." 4) "My child should turn more than one page of a book at a time."
4 A 24-month-old child should be able to turn one page of a book at a time. This parental statement indicates the need for further education regarding fine motor skills. The parental statements related to turning a door knob, aligning two or three cubes like a train, and imitating vertical strokes when drawing all indicate correct understanding of fine motor skills at 24 months of age.
Which would the nurse instruct the parents to do to enhance their toddler's need for autonomy? 1) Help the child learn society's roles 2) Teach the child to share with others 3) Help the child develop internal controls 4) Teach the child to accept external limits
4 Appropriate limit setting and discipline are necessary for children to develop self-control while learning the boundaries of their abilities. Role within society are learned by the school-aged child. Learning to share develops during the preschool years. Internal controls begin to develop in the preschool years
Which nursing intervention is the priority for a client in the acute-care setting with urine output of 250 mL in 24 hours, blood osmolality of 310 mOsm per kilogram, and a systolic blood pressure of 90 mm Hg? 1) Consider it as a normal finding 2) Advise the client to drink 2 to 3 L of water daily 3) Assess the creatinine and blood urea nitrogen (BUN) levels 4) Request an increase in the intravenous fluid rate from the health care provider
4 Normal urine output is in the range of 600 to 2500 mL per 24 hours and normal blood osmolality is in the range of 275 to 295 mOsm per kilogram. The normal systolic pressure is 120 mm Hg. The client's medical record indicates an abnormal urine output of 250 mL in the past 24 hours, blood osmolality of 310 mOsm per kilogram, and systolic blood pressure of 90 mm Hg, which indicate severe volume depletion. The priority nursing intervention is requesting an increase in the intravenous fluid rate from the health care provider to prevent permanent kidney damage. A healthy individual is advised to drink 2 to 3 L of water daily. The client's creatinine and BUN level are assessed to detect kidney function, but only after the client is made stable.
When checking the cervical dilation of a client in labor, the nurse notes that the umbilical cord has prolapsed. Which action would the nurse take in response to this finding? 1) Check the fetal heart rate 2) Turn the client on her side 3) Cover the cord with a sterile saline-soaked cloth 4) Assist the client into the Trendelenburg position
4 Placing the client in the Trendelenburg position may prevent further prolapse and should relieve pressure on the umbilical cord. The fetal heart rate will be taken later; the priority is relieving pressure on the umbilical cord. Turning the client on her side will not relieve pressure on the umbilical cord, although it will promote placental perfusion. Covering the cord with a sterile saline-soaked cloth will not relieve pressure on the umbilical cord.
A child who is recently admitted to school is introverted and prefers being alone at the school. Which temperament is the child exhibiting, according to Stella Chess and Alexander Thomas's longitudinal study? 1) The easy child 2) The difficult child 3) The hyperactive child 4) The slow to warm up child
4 The child will be categorized as a slow-to-warm-up child. These children are uneasy or cautious in new situations or with unfamiliar people. They react negatively with mild intensity to new stimuli. An easy child is open and adaptable to change and displays a mild-to-moderately intense mood that is typically positive. A difficult child adapts slowly to new routines, people, or situations. This type of child has intense mood expressions with negative behavior. A hyperactive child usually has problems concentrating and paying attention
Which long-term outcome would the nurse use for a child who has conduct disoder? 1) Avoids verbally aggressive behavior for 4 months 2) Verbalizes 10 alternative methods to address anger 3) Is sent to the principal's office 5 times in 5 weeks 4) Has no physically aggressive episodes for 3 months
4 A long-term outcome for a child with conduct disorder would be having no physical aggressive episodes for 3 months. A child with a conduct disorder is physically aggressive; the physical aggression differentiates it from oppositional defiant disorder. An absence of physical aggression over the span of 3 months demonstrates that treatment is successful. Controlling verbal aggression alone is not appropriate for this child; this outcome more correctly addresses the problems of a child with oppositional defiant disorder. Verbalizing 10 alternative methods of addressing anger is an appropriate short-term, not long-term, outcome for this child. Being sent to the principal's office 5 times in 5 weeks is a negative outcome for this child.
Which expected surgical outcome would the nurse include in the preoperative teaching for a client scheduled for a labyrinthectomy to treat Meniere syndrome? 1) Absence of pain 2) Decreased cerumen 3) Loss of sense of smell 4) Permanent irreversible deafness
4) The labyrinth is the inner ear and consists of the vestibule, cochlea, semicircular canals, and other structures. A labyrinthectomy alleviates the symptoms of Meniere syndrome but results in deafness on the affected side because the organ of Corti and cochlear nerve are located in the inner ear. There is no pain associated with Meniere syndrome. Meniere syndrome does not affect the production of cerumen. The scheduled surgical procedure does not affect the sense of smell (anosmia).
Which occurs immediately after birth that increases the risk for cardiac decompensation in a client with a compromised cardiac system? 1) Increased pressure is placed on the veins 2) Intra-abdominal pressure is significantly increased 3) The blow flow to the heart is decreased considerably 4) Extravascular fluid is remobilized into the vascular compartment
4) Extravascular fluid is remobilized into the vascular compartment During the immediate period after birth the extravascular fluid is remobilized into the vascular compartment, increasing the client's risk for cardiac decompensation. At the moment of birth, the pressure on the veins is removed, the intra-abdominal pressure decreases dramatically, and the blood flow to the heart is significantly increased.
Which findings in a client may indicate potential thyrotoxic crisis? 1) Elevated serum calcium 2) Sudden drop in pulse rate 3) Hypothermia and dry skin 4) Rapid heartbeat and tremors
4) Rapid heartbeat and tremors Thyrotoxic crisis (thyroid storm) refers to a sudden and excessive release of thyroid hormones, which causes pyrexia, tachycardia, and exaggerated symptoms of thyrotoxicosis; surgery, infection, and ablation therapy can precipitate this life-threatening condition. Hypercalcemia is not related to thyrotoxic crisis; hypocalcemia results from accidental removal of the parathyroid glands after a thyroidectomy. Tachycardia is an increased, not decreased, heart rate, which occurs with thyrotoxic crisis because of the sudden release of thyroid hormones; thyroid hormones increase the basal metabolic rate. Fever, not hypothermia, and diaphoresis, not dry skin, occur with thyrotoxic crisis because of the sudden release of thyroid hormones, which increase the basal metabolic rate.
A client is diagnosed with hyperthyroidism and is treated with I-131. Before discharge, the nurse teaches the client to observe for signs and symptoms of therapy-induced hypothyroidism. Which signs and symptoms would be included in the teaching? SATA A) Fatigue B) Dry skin C) Insomnia D) Intolerance to heat E) Progressive weight gain
A, B, E Fatigue is caused by a decreased metabolic rate associated w/ hypothyroidism. Dry skin most likely is caused by decreased glandular function r/t hypothyroidism. Progressive weight gain is associated with hypothyroidism in response to a decrease in the metabolic rate because of insufficient thyroid hormone. Insomnia is associated with hyperthyroidism, not hypothyroidism, in response to an increase in the metabolic rate because of excessive thyroid hormone. Intolerance to heat is associated with hyperthyroidism, not hypothyroidism, in response to an increase in the metabolic rate because of excessive thyroid hormone.
