NCLEX Review Study Guide 6

A nurse is caring for a client who is immobilized in skeletal traction after sustaining a leg fracture in a motor vehicle crash. The nurse notes that the client is restless, and the client complains of being bored. Which problem does the nurse identify on the basis of this information?

Lack of adequate diversional activity

Alprazolam (Xanax) is prescribed for a client to treat an anxiety disorder. Which side effect does the nurse warn the client of?

Lightheadedness

A nurse is assessing a client with hepatitis for signs of jaundice. Which area does the nurse check, knowing that it will provide the best data regarding the presence of jaundice?

Mucous membranes

A client with multiple sclerosis has been started on baclofen (Lioresal) for muscle spasms. The client calls the physician's office 1 week after beginning the medication and tells the nurse that she feels extremely drowsy. The nurse most appropriately tells the client:

That drowsiness usually diminishes with continued therapy

Disulfiram (Antabuse) is prescribed to a client with an alcohol abuse problem. The nurse provides information about the medication and tells the client:

That the medication cannot be started until at least 12 hours has elapsed since the client's last ingestion of alcohol

A client is scheduled to undergo an upper gastrointestinal (GI) series, and the nurse provides instructions to the client about the test. Which statement by the client indicates a need for further instruction?

"I need to drink citrate of magnesia the night before the test and give myself a Fleet enema on the morning of the test."

A client with type 1 diabetes mellitus is instructed by the physician to obtain glucagon hydrochloride (Glucagon) for emergency home use. The nurse provides information to the client's wife about the medication. Which statement by the client's wife indicates that she understands the information?

"I need to give this if he has signs of low blood sugar and goes into a coma."

Desmopressin (DDAVP) is prescribed to a client with diabetes insipidus. Which parameter does the nurse tell the client that it is important to monitor while she is taking the medication?

Intake and output

A Tensilon test is performed on a client with suspected myasthenia gravis. Which finding constitutes a positive result?

An increase in muscle strength

A nurse provides skin care instructions to a client with acne vulgaris. Which statement by the client indicates a need for further instruction?

"I should use oil-based cosmetics."

A client with post-traumatic stress disorder tells the nurse that he has stopped taking his prescribed medication because he didn't like how the medication was making him feel. Which of the following initial responses by the nurse is appropriate?

"Tell me more about how the medication was making you feel."

A client is admitted to the nursing unit with a diagnosis of avoidant personality disorder. Which of the following behaviors is a characteristic of the disorder?

Hypersensitivity to negative evaluation

A nurse is teaching a client with left-side weakness how to walk with the use of a quad-cane. The nurse ensures that:

30-degree flexion of the client's elbow is maintained when the client is holding the cane

A nurse notes documentation in the client's medical record indicating that the client has a stage II pressure ulcer. On the basis of this information, which of the following findings does the nurse expect to note?

A diagram of ulcers, stage II ulcer is characterized by nonintact skin. There is partial-thickness skin loss, and the wound may appear as an abrasion, a shallow crater, or a blister.

A nurse assisting with a delivery is monitoring the client for placental separation after the delivery of a viable newborn. Which of the following observations indicates to the nurse that placental separation has occurred?

A sudden gush of dark blood from the introitus

The mother of a newborn found to have a congenital diaphragmatic hernia asks the nurse to explain the diagnosis. The nurse tells the mother that in this condition:

Abdominal contents herniate through an opening of the diaphragm

A nurse is preparing to care for a client who was admitted to the antepartum unit at 34 weeks' gestation after an episode of vaginal bleeding resulting from total placenta previa. In report, the nurse is told that the client's vital signs are stable, that the fetal heart rate is 140 beats/min with a reassuring pattern, and that both the client and her husband are anxious about the condition of the fetus. On reviewing the client's plan of care, which client concern does the nurse identify as the priority at this time?

Anxiety

Testing of the plasma theophylline level in a client who is receiving a continuous intravenous infusion of theophylline reveals a level of 20 mcg/mL. The nurse interprets this result as:

At the top of the therapeutic range

A nurse is monitoring a client with pheochromocytoma who is receiving an intravenous (IV) infusion of phentolamine. Which vital sign does the nurse monitor most closely during the infusion?

Blood pressure

A nurse is providing dietary instructions to the mother of a child with celiac disease. The nurse tells the mother that it is acceptable to give the child:

Boiled rice

A nurse has assisted a physician in inserting a central venous access device into a client with a diagnosis of severe malnutrition who will be receiving parenteral nutrition (PN). After insertion of the catheter, the nurse immediately plans to:

Call the radiography department to obtain a chest x-ray

A client in labor experiences spontaneous rupture of the membranes. The nurse immediately counts the fetal heart rate (FHR) for 1 full minute and then checks the amniotic fluid. The nurse notes that the fluid is yellow and has a strong odor. Which of the following actions should be the nurse's priority?

Contacting the physician

A nurse caring for a client 24 hours after a radical neck dissection notes the presence of serosanguineous drainage in the portable wound suction device attached to the surgical site. On the basis of this finding, the nurse should:

Document the findings

A nurse is transcribing a physician's prescription for oral prednisone 5 mg/day that was written in the chart of a client with type 2 diabetes mellitus who is already taking an oral hypoglycemic medication. The nurse contacts the physician to ask about the prescription because:

Prednisone can increase the blood glucose level

A nurse discovers that a client receiving heparin sodium by way of continuous intravenous (IV) infusion has removed the IV tubing from the infusion pump to change his hospital gown. After assessing the client and placing the tubing back in the infusion pump, which medication does the nurse check for in the medication room in case a heparin overdose has occurred?

Protamine sulfate

A client is brought to the emergency department after sustaining smoke inhalation injury during a fire in the client's home. The nurse plans to first:

Provide the client with 100% oxygen by mask

A nurse in the postpartum unit is caring for a client who delivered a healthy newborn 12 hours ago. The nurse checks the client's temperature and notes that it is 100.4° F (38° C). On the basis of this finding, the nurse would:

Recheck the temperature in 4 hours

A nurse is reviewing the laboratory results of a client in the emergency department with diabetic ketoacidosis (DKA). Which laboratory result would the nurse expect to note?

Serum bicarbonate of 12 mEq/L

A nurse is caring for a client who has undergone transsphenoidal hypophysectomy to remove a microadenoma of the pituitary gland. Which of these findings would be of greatest concern to the nurse?

Urinary specific gravity is low

A nurse transcribing the prescriptions of a client admitted to the nursing unit notes that metformin (Glucophage) 850 mg/day has been prescribed. The nurse makes a note in the client's medication record that the medication should be administered:

With the morning meal