NCLEX RN #32

1,3,4

A 2 year old is diagnosed with atopic dermatitis (eczema) . Which instructions should the nurse TEACH the parents? SELECT ALL THAT APPLY #70769904 (16) 1. Apply emollient immediately after a bath. 2. Dress child in wool pajamas 3. Give tepid baths with mild soaps. 4. Keep child's nails well-trimmed 5. Thoroughly rub the skin dry after baths.

4

A charge nurse is monitoring a newly licensed registered nurse. What ACTION by the new nurse would warrant INTERVENTION by the charge nurse? #70769904 (31) 1. Administer hydromorphone 1 mg to a client who rates pain at 7 on a 1 to 10 scale. 2. Notifies physician of occassional premature ventricular beats in a client with myocardial infarc-tion. 3. Positions a postoperative pneumonectomy client on the affected side. 4. Prepares to administer IVPB potassium chloride via gravity infusion for a client with hypokalemia.

1,2,5

A client comes to the clinic indicating that a home pregnancy test was positive. The client's last menstrual period was September 7. Today is December 7. Which are the statements for this client ? SELECT ALL THAT APPLY #70769904 (34) 1. According to Naegele's rule, the expected date of delivery is June 14. 2. Detection of the fetal heart rate via Doppler is possible. 3. Fundal height should be 24 cm above the symphysis pubis. 4. The client should be feeling fetal movement. 5. Urinary frequency is a common symptom

3

A client diagnosed with VAGINAL CANDIDIASIS is instructed on self-care management techniques and proper administration of the prescribed miconazole vaginal cream. Which statement by the client indicates that FURTHER TEACHING is needed? #70769904 (35) 1. "Each time I use the bathroom, I will wipe myself from the front to the back." 2. "I should choose loose-fitting cotton underwear instead of nylon undergarments." 3. "I will refrain from having sex until my partner is also tested and treated for the infection." 4. "Prior to going to bed at night, I will apply miconazole cream using the vaginal applicator."

4

A client is diagnosed with carpal tunnel syndrome (CTS) . Teaching for this client is primarily FOCUSED on which of the following? #70769904 (15) 1. No caffeine and smoking 2. Repetitive hand exercises 3. Use of elastic compression 4. Use of hand splint.

2

A client suffering from chronic kidney disease is scheduled to receive recombinant human erythro-poietin and iron sucrose. An assessment of labora-tory work shows hemoglobin of 9.7 g/dL and he-matocrit of 29% . What is the BEST nursing action? #70769904 (22) 1. Administer the erythropoietin in the client's abdominal area. 2. Check the client's blood pressure prior to administering the erythropoietin 3. Hold the client's next scheduled iron sucrose dose. 4. Hold the erythropoietin dose and inform the health care provider.

4

A client undergoes TRANSURETHRAL RESECTION of the prostate for benign prostatic hyperplassia. The client has a 29 Fr balloon 3 way Foley catheter with continuous bladder irrigation. Which assess-ment by the nurse is the BEST indication that the bladder irrigation is running at an adequate rate? #70769904 (32) 1. Blood pressure 120/80 mm Hg , pulse 80/min 2. Client has no bladderspasms 3. Intake 3,200 , ouput 3,000 mL 4. Output urine is light pink in color.

4

A client who was placed in restraints appears in the hallway an hour later and states."I'M Houdini... I can get out of anything. There could be trouble now." Which of the following is the BEST response to the client? #70769904 (12) 1. "How are you feeling now?" 2. "How did you manage to get out of the restraints?" 3. Say nothing but signal to other staff that assistance is needed. 4. "What kind of trouble are you thinking about?"

3

A client with end-stage renal disease, oxygen-dependent chronic obstructive pulmonary disease (COPD) and a Do Not Resuscitate (DNR) code status is admitted to the medical floor for COPD exacerbation. The nurse walks into the room and finds that the client is not breathing. What should the nurse do FIRST? #70769904 (28) 1. Activate the code system 2. Call the health care provider (HCP) stat. 3. Check the apical pulse 4. Check the blood pressure.

2

A client with peripheral arterial disease is visiting the health clinic. The nurse completes a health assessment. Which statement by the client indicates a PRIORITY need for follow-up teaching? #70769904 (11) 1. "I always take my simvastatin in the evening." 2. "I prop my legs up in the recliner and use a heating pad when my feet are cold." 3. "I've been walking on my treadmill at home for 15 minutes each day." 4. "I've noticed that I don't have much hair on my lower legs anymore."

3

A nurse is discontinuing patient controlled anal-gesia per the health care provider's prescription and notes that there is 10 mL of morphine sulfate left in the syringe. No other nurse is available to witness the waste of the medication. What is the BEST action by the nurse? #70769904 (30) 1. Ask the unlicensed assistive personnel on the unit to waste the medication. 2. Document that another nurse was not availa-ble to waste the medication. 3. Wait until another nurse is available to witness the waste. 4. Waste the medication and have another nurse sign off on it later.

4

An adult client is admitted with back pain and found to have a metastatic tumor on the spine. The health care provider (HCP) explains that the client has few months to live and is likely to become totally paralyzed below the waist soon. The next day the clients tells the nurse of wanting to be dis-charged despite the HCP's recommendation that the client stay a few more days. Which is the most appropriate INITIAL response by the nurse? #70769904 (13) 1. "I understand you desire to leave, but it would very risky." 2. "I will ask the palliative nurse to talk with you to help clarify your care goals." 3. "I will let the HCP know that you want to be discharged and do everything I can to make it happen." 4. "Tell me more about your need to leave the hospital."

4

At 8AM , medication are prescribed for assigned clients. Which medication should the nurse admi-nister FIRST? #70769904 (27) 1. Acetysalicytic acid for a client with a history of coronary artery disease and ischemic stroke. 2. Metformin for a client with serum glucose of 285 mg/dL who is scheduled for a CT scan with contrast. 3. Morphine sulfate for a client with terminal lung cancer who has chronic bone pain. 4. Pyridostigmine for a client with myasthenia gravis exacerbation who reports difficulty swallow-ing .

2

The clinic nurse supervises a graduate nurse who is teaching the parents of a 2 year old with ACUTE DIARRHEA about home management. The nurse would NEED TO INTERVENE when the graduate nurse provides which instruction? #70769904 (24) 1. "Do not administer antidiarrheal medications to your child." 2. "Follow the bananas, rice, applesauce , and toast diet for the next few days." 3. "Record the number of wet diapers and return to the clinic if you notice a decrease" 4. "Use a skin barrier cream such as zinc oxide in the diaper area until diarrhea subsides."

3

The nurse assesses 4 infants. Which assessment finding would require FOLLOW-UP by the health care provider? #70769904 (18) 1. 3 week old whose anterior fontanelle bulges with crying. 2. 4 week old whose posterior fontanelle is soft 3. 6 month old with birth weight of 7 lb 3 oz (3.3kg) who now weighs 12 lb (5.4 kg) 4. 12 month old with birth weight of 6 lb 4 oz (2.8 kg) who now weighs 20 lb (9.1 kg)

1

The nurse is caring for a 2 year old who is receiving a saline enema for treatment of intussusception. Reporting which client finding to the health care provider (HCP) is MOST IMPOR-TANT ? #70769904 (17) 1. Passed a normal brown stool 2. Passed a stool mixed with blood 3. Stopped crying 4. Vomited a third time.

2,3,5

The nurse is discharging a client who has been prescribed warfarin for chronic atrial fibrillation. The nurse should instruct the client to avoid excess or inconsistent intake of which foods? SELECT ALL THAT APPLY #70769904 (29) 1. Bananas 2. Brocoli 3. Grapefruit juice 4. Red meat 5. Spinach

2

The nurse is reinforcing education to a client newly prescribed LEVETIRACETAM for seizures. Which state-ment made by the client indicates a need for FUR-THER INSTRUCTION? #70769904 (20) 1. "Drowsiness is a common side effect of this medication and will improve over time" 2. "I can begin driving again after I have been on this medication for a few weeks." 3. "I need to immediately report any new or in-creased anxiety when on this medication." 4. "I need to immediately report any new rash when on this medication. "

4

The nurse is working in a busy emergency department and is assigned 4 clients. Which client should the nurse see FIRST? #70769904 (10) 1. Client receiving cyclophosphamide reporting bloody urine. 2. Client who reports severe nausea and vomiting after chemotherapy 3. Client with an elbow abrasion and a lip laceration possibly requiring sutures. 4. Homeless client who appears drowsy with a temperature of 95F (35 C)

1,3,5,6

The nurse observes an ambulating client begin to experience a tonic-clonic seizure. Which nursing ACTIONS should be IM-PLEMENTED immediately? SELECT ALL THAT APPLY #70769904 (37) 1. Guide the client to the floor and gently cradle the head. 2. Insert a tongue blade to prevent the client from swallowing the tongue. 3. Move objects that may cause injury away from the client. 4. Physically restrain the client to prevent injury. 5. Place the client in left lateral position. 6. Remain with the client, observe and record the seizure activity.

3

The nurse plans to start an IV line on a female client hospitalized with pneumonia. the nurse reviews the electronic medical record for relevant information and learns that the client is right-handed and has a history of a left-sided mastectomy with lymph node removal. Which site is BEST for the nurse to select for the client's IV line? #70769904 (23) 1. Basilic vein of the left forearm 2. Cephalic vein in the right antecubital space 3. Median vein of the right forearm 4. Radial vein of the left wrist.

3

The nurse prepares to administer the prescribed 8 AM medications to 4 clients. The nurse should ad-minister medication to which client FIRST? #70769904 (39) 1. Client 2 days postoperative abdominal surgery who is to receive enoxaparin for venous thrombo-embolism prophylaxis. 2. Client with hypertension who has a blood pressure of 196/98 mm Hg and is to receive IV Hydralazine. 3. Client with suspected sepsis who has a tem-perature of 102.3 F (39.1 C)and is to receive an initial dose of IV ceftazidime 4. Client with type 2 diabetes mellitus and blood sugar of 500 mg/dL who is to receive subcutaneous regular insulin glargine.

4

The nurse provides post-procedure teaching for a female client who had a CYSTOSCOPY as an out patient. Which client statement indicates the NEED FOR ADDITIONAL INSTRUCTION? #70769904 (38) 1. "I can expect pink-tinged urine for at least 24 hours." 2. "I can take a warm bath and acetaminophen if I have discomfort or bladder spasms." 3. "I should expect frequency and burning when I urinate." 4. "I should expect to see blood clots in my urine for up to 24 hours.

3

The nurse reinforces education with a client start-ing ISOTRETINOIN for acne. Which statement indicates that the clients needs FURTHER INSTRUCTION? #70769904 (33) 1. "I should not donate blood when taking the medication." 2. "I will stop taking my tetracycline prior to taking this medication. 3 "I will take vitamin A supplements 4. "I will use condoms and birth control pills.

2,3,4

The registered nurse (RN) is providing discharge instructions to a client who has had coronary artery bypass grafting (CABG). Which teaching is correct? SELECT ALL THAT APPLY #70769904 (26) 1. No sexual activity for at least 6 weeks postoperatively 2. Notify health care provider (HCP) of redness, swelling, or drainage at the incision site. 3. Refrain from lifting objects weighing >5lb (2.26 kg) until approved by the HCP. 4. Take a shower daily without soaking chest and leg incisions. 5. Use lotion on incision sites with dressing changes if the area is dry.

3

The risk management nurse is reviewing client records. Which nursing INTERVENTION could have contributed to a sentinel event? #70769904 (19) 1. Administered flumazeril to a client who overdosed on lorazepam 2. Administered insulin/dextrose to a client with potassium level of 7.2 mEq/L 3. Administered warfarin to a client with international Normalized Ratio of 6 4. Initiated nitroprusside infusion in a client with blood pressure of 210/112 mm Hg.

1,2,3,4

The school nurse is teaching a class of 10 year old children about prevention of dental caries. Which recommendation would be part of the nurse's TEACHING plan? SELECT ALL THAT APPLY #70769904 (25) 1. Chewing sugar free gum 2. Including milk, yogurt and cheese in the diet 3. Minimizing intake of sweet, sticky foods 4. Rinsing the mouth with water after meals when brushing is not possible. 5. Substituting fruit juices and drinks for sugary, carbonated beverages.

1,3,5

The unit is staffed with an experienced registered nurse, an experienced licensed practical nurse and unlicensed assistive personnel (UAP). Which task can the charge nurse APPROPRIATELY delegate to UAP , SELECT ALL THAT APPLY #70769904 (21) 1. Apply protective skin ointment after perineal cleansing 2. Determine if a client has adequate relief after administration of an analgesic. 3. Document daily weight for a client with congestive heart failure. 4. Feed a client who had a stroke 24 hours after admission. 5. Perform passive range-of-motion exercises for a client on a ventilator.

4

What is an appropriate nursing intervention after the birth of a newborn with anencephaly? #70769904 (14) 1. Instruct the parents that visitors should be restricted. 2. Provide information to the parents about genetic counseling. 3. Refer the parents to a perinatal loss support group. 4. Wrap the newborn in warm blankets for the parents to hold.

3

Which health history information would be MOST important for the nurse to obtain when assessing a client with suspected bladder cancer who reports painless hematuria? #70769904 (36) 1. Family risk factors 2. Industrial chemical exposure 3. Tobacco use 4. Usual diet.

Atopic dermatitis (eczema)

is a chronic skin disorder manifested by pruritus, erythema and very dry skin. The goal of manage-ments is to reduce scratching with key measures such as giving tepid baths, moisturizing skin with emollients, wearing soft cotton clothing and keeping nails trimmed short. #70769904 (16)

Sepsis

is a serious condition involving an INFECTION IN THE BLOODSTREAM that can lead to organ dysfunction and death. IV antibiotics should be administered to a client with sepsis as soon as possible after ob-taining blood and other cultures to help prevent progression to septic shock and multiorgan dysfunction syndrome #70769904 (39)

Anencephaly

is a severe neural tube defect resulting in little to no brain tissue or skull formation in utero. The newborn may be stillborn or born alive, although death occurs shortly thereafter. Nurses should facilitate a therapeutic environment for grieving parents and provide newborn comfort care such as warmth and oxygen. #70769904 (14)

Isotretinoin

is a vitamin A derivative prescribed to treat severe and/ or cystic acne. #70769904 (33)

Carpal tunnel syndrome

is caused by compression of a median nerve at the wrist. Nightime wrist splinting is most beneficial #70769904 (15) .