NCLEX RN uworld 38

4

A 65 year old client has been hospitalized for 2 weeks with diabetic gastroparesis. While preparing to administer the daily dose of IV metoclopramide to this client, the nurse assesses for which symptom that may indicate a serious adverse effect of this medication? #70706961 (42) 1. Bradycardia 2. Diarrhea 3. Frequent burping 4. Unusual movements

3

A child with a high level of school absenteeism has been determined to have school phobia. The school nurse should counsel the child's parent/caregiver to take which action? #70706961 (63) 1. Allow the child to stay home when the child seems particularly anxious. 2. Encourage the parent/caregiver to sit in the classroom with the child. 3. Insist on school attendance immediately, starting with a few hours a day 4. Return the child to school when the cause of the school phobia has been identified.

3

A client admitted with acute myocardial infarction suddenly displays air hunger, dyspnea, and coughing with frothy, pink tinged sputum. What would the nurse anticipate when auscultating the breath sounds of this client? #70706961 (54) 1. Bronchial breath sounds at lung periphery 2. Clear vesicular breath sounds at lung bases 3. Diffuse bilateral crackles at lung bases 4. Stridor in upper airways.

3

A client calls the nurse to report exacerbation of chronic lower back pain after working in the yard all weekend. Knowing that this worsened back pain is probably due to acute inflammation, the nurse recommends which nonpharmacologic interven-tion? #70706961 (38) 1. Heating pad 2. Positioning for comfort 3. Rest from pain-aggravating activities 4. Stretching exercises.

1

A client has a follow-up check up in the UROLOGY clinic. Six months ago, the client started taking tolterodine. What data collected from the client should the nurse report to the health care pro-vider? #70706961 (48) 1. Client excitedly reports being able to go an entire work day without having to urinate. 2. Client is using an over the counter artificial saliva product for dry mouth. 3. Client reports occasional dizziness in the morning and when changing positions 4. Client reports symptoms of constipation.

4,5,6

A client is admitted to the hospital for evaluation of suspected pulmonary tuberculosis (TB) .The nurse assesses for which characteristic presenting signs and symptoms associated with TB disease? SELECT ALL THAT APPLY #70706961 (53) 1. Dysuria 2. Jaundice 3. Low back pain 4. Night sweats 5. Purulent or blood tinged sputum 6. Weight loss

3

A highly intoxicated client is brought to the emer-gency department after found lying on the side-walk. On admission, the client is awake with a pulse of 70/min and blood pressure of 160/80 mm Hg. An hour late, the client is lethargic, pulse is 48/min, and blood pressure is 200/80 mm Hg. Which action does the nurse anticipate taking NEXT? #70706961 (47) 1. Administer atropine for bradycardia 2. Administer nifedipine for hypertension 3. Have CT scan performed to rule out an intracranial bleed 4. Perform hourly neurologic checks with Glasgow coma scale.

4

A long term care nurse is caring for a client newly diagnosed with MACULAR DEGENERATION . Which client statement would support this diagnosis? #70706961 (44) 1. "I have been seeing small flashes of light 2. "I have trouble threading my sewing needle, I have to hold it at arm's length. 3. "I notice that my peripheral vision is becoming worse." 4. "I see a blurry spot in the middle of the page when I read."

3

A nurse finds a client on the floor in the client's room. Based on the documentation shown in the exhibit, the nurse made an INCORRECT entry in the client's medical record at what time? CLICK ON THE EXHIBIT BUTTON FOR ADDITIONAL INFORMATION #70706961 (40) 1700 Found client lying on floor next to bed. Client states., "I fell out of bed while reaching for my eyeglasses and hit my head on the bedside table" Client is alert and oriented to time, place, person, and situation. Denies pain, dizziness, or nausea,. No visible injuries. Assisted back to bed. Neurological vital signs within normal limits ( see assessment flow sheet) Client instructed to use call bell for assistance. Will continue to monitor ___________________RN 1710 Health care provider (HCP) notified of fall. Prescribed CT of head STAT __________ 1740 No change in neurologic status. Client to CT via gurney. Report filed per policy ________________RN 1810 Client returned from CT. No change in neurologic status. Reinforced use of call bell, and client demonstrated understanding. Will continue to monitor_________________________RN1. 1. 1700 2. 1710 3. 1740 4. 1810

3

A nurse is admitting a child who has LEUKEMIA. Several rooms are available on the pediatric unit. Which client should share a room with this child? #70706961 (56) 1. A client recovering from a ruptured appendix. 2. A client with cystic fibrosis 3. A client with minimal change nephrotic syndrome 4. A client with rheumatic fever.

4

After a prolonged surgical procedure, the client reports unilateral leg pain. Which client assessment finding is MOST con-cerning? #70706961 (57) 1. Client rates leg pain as "7" 2. Negative Homan's sign 3. Prominent varicose veins bilaterally 4. Right calf is 4 cm larger than left calf.

2

The emergency department nurse assesses a client involved in a motor vehicle accident who sustained a coup-contrecoup head injury. Which assessment finding is consistent with injury to the occipital lobe? #70706961 (51) 1. Decreased rate and depth of respirations 2. Deficits in visual perception 3. Expressive aphasia 4. Inability to recognize touch.

3

The nurse employed in a woman's health care clinic would be MOST CONCERNED about which client statement? #70706961 (60) 1. "I recently noticed a small, round, painless, mobile lump in my left breast while showering." 2. "Last night while breastfeeding, my nipples were cracked and my breast were painful." 3. "My right breast is red and warm with little tiny indented areas on the surface of the skin." 4 "Sometimes during my cycle, I noticed breast nodules that are movable and feel soft to the touch."

2

The nurse has just determined a dose of 0.5 mg atropine to a client with a heart rate of 48/min and blood pressure of 90/62 mm Hg . Which rhythm strip would indicate that the medication achieved the desired outcome? #70706961 (64) 1. 1 2. 2 3. 3 4 4

2

The nurse is caring for a client after a lumbar puncture (spinal tap) . Which client assessment is MOST concerning and requires a nursing response? #70706961 (39) 1. Consumes 600 mL liquid over 4 hours. 2. Insertion site dressing saturated with clear fluid. 3. Observed lying in the right sided Sim's position. 4. Reports a headache rated 6/10

1

The nurse is caring for a client on a mechanical ventilator. The settings on the ventilator have just been changed. and the standing prescription is to draw arterial blood gases 30 minutes after a venti-lator change. In anticipation of this blood draw. what intervention should the nurse implement. #70706961 (41) 1. Avoid suctioning the client. 2. Pre-oxygenate the client 3. Raise the head of the bed. 4. Reduce the amount of sedation medication.

2

The nurse is conducting a follow up interview with a client who is being treated for depression and suicidal ideation. Which factor BEST indicates the client is not currently at risk for suicide? #70706961 (45) 1. Client claims to have more energy and vigor since starting therapy. 2. Client has clear future plans involving personal goals and family milestones 3. Client has signed a contract promising not to commit suicide. 4. Client reports losing amitriptyline and request a refill.

3

The nurse is documenting assessments of pregnant clients in the antepartum unit. Which client assessment findings are MOST important to report to the health care provider? #70706961 (62) 1. Client at 28 weeks gestation with an asymptomatic systolic murmur. 2. Client at 34 weeks gestation with 1+edema of bilateral lower extremities. 3. Client at 35 weeks gestation with painful genital lesions 4. Client at 39 weeks gestation with brownish, mucoid vaginal discharge.

3

The nurse is triaging clients in the emergency de-partment. Which client needs to be seen FIRST? #70706961 (58) 1. 18 year old female with fever, suprapubic pain, and dysuria. 2. 21 year old male with diffuse abdominal pain and a rigid abdomen 3. 64 year old male with a pulsatile mass in the periumbilical area and back pain 4. 75 year old with nausea, fever, and left lower quadrant pain.

3

The nurse provides care for a client diagnosed with POLYCYTHEMIA VERA. Which statement by the client would require IMMEDIATE follow up? #70706961 (59) 1. "I am trying to find makeup to cover my unattractive and ruddy facial complexion." 2. "I take a baby aspirin to relieve my occasional headaches." 3. "My leg has been sore, I suppose I need to elevate it more often when I am sitting." 4. "My skin itches so severely that no lotion or cream seems to help.

1

The nurse receives report on 4 clients. Which client should be seen FIRST? #70706961 (43) 1. Client with amyotrophic lateral sclerosis expe-riencing increased dysarthria. 2. Client with chronic obstructive pulmonary di-sease reporting increasing leg edema. 3. Client with strep throat and fever of 102 F (38.9 C) on antibiotics for 12 hours. 4. Client with urolithiasis reporting wavelike flank pain and nausea.

1

The nurse working in the ambulatory clinic is teaching a client measures to prevent chlamydia transmission and recurrence. Which statement by the client indicates a need for FURTHER TEACH-ING ? #70706961 (49) 1. "I can resume sexual intercourse a few days after starting treatment." 2. "I may still transmit the infection even if I do not have symptoms." 3. "I will make sure my partner gets treated as well." 4. "I will use a condom during all future sexual encounters."

3

The pediatric clinic nurse reinforces culturally competent care at an in-service. Which finding would be INAPPROPRIATE to include as a common dermatologic effect of alternative medicine therapies ? #70706961 (46) 1. Blisters with a garlic scent near the wrists. 2. Circular bruised blemishes on the back 3. Markings appearing to be human bites on the arms 4. Well-like linear lesions on the back.

2

The registered nurse (RN) is supervising a graduate nurse (GN) providing postoperative teaching for a male client after an inguinal hernia repair. Which statement by the GN would cause the RN to INTERVENE? #70706961 (52) 1. "Elevate your scrotum and apply an ice bag to reduce swelling." 2. "Practice coughing to clear secretion and prevent pneumonia." 3. "Standup to use the urinal if you have difficulty voiding." 4. "Turn in bed and perform deep breathing every 2 hours. "

4

The unlicensed assistive personnel (UAP) reports findings a reddened area on a client's sacrum du-ring a bath. What is the nurse's PRIORITY action? #70706961 (55) 1. Direct the UAP to apply a protective foam dressing. 2. Document results of the Braden Scale in the electronic record. 3. Notify the health care provider (HCP) 4. Perform an assessment on the client's skin

3,5

When assessing a client with cholelithiasis and acute cholecystitis, which findings might the nurse note during the health history and physical exami-nation? SELECT ALL THAT APPLY #70706961 (50) 1. Flank pain radiating to the groin 2. High protein food ingestion before the onset of pain. 3. Low grade fever with chills 4. Pain at the umbilicus 5. Right upper quadrant (RUQ) pain radiating to the right shoulder.

2

When assessing the client's pain level, what will the nurse determine is the MOST reliable indicator of the pain? #70706961 (61) 1. Client"s ethnic background 2. Client's report of symptoms 3. Client's vital signs 4. Extent of client's injury

Painful vaginal lesions

can be indicative of an outbreak of GENITAL HERPES SIMPLEX VIRUS (HSV) and are priority assessment finding to report to the health care provider. #70706961 (62)

Amyotrophic lateral sclerosis

causes PROGRESSIVE LOSS OF MOTOR NEURONS, resulting in muscle weakness and spasticity. Muscles involved in respiration and swallowing are affected, leading to aspiration and ultimately respiratory failure. Treatment focuses on maintaining respiratory function, adequate nutrition and quality of life. #70706961 (43)

Deep venous thrombosis (DVT)

is a major concern in clients with unilateral leg pain after prolonged immobilization (eg. air travel, surgery) or those with obesity, pregnancy, or other hypercoagulable states (eg. cancer) Eighty percent of DVTs start in the veins of the calf and move into the poplitial and femoral veins. Classic symptoms include UNILATERAL LEG EDEMA, local warmth,erythema and low grade fever. therefore, the swelling in one leg is highly concerning. #70706961 (57)

Appendicitis

is a result of viral or infectious processes and lead to rupture of the appendix, #70706961 (56)

Metoclopramide

is an antiemetic and/or prokinetic agent that promotes gastrointestinal motility and gastric emptying . It is commonly used to treat nausea/vomiting and gastroparesis. This medication can cause TARDIVE DYSKINESIA, a condition characterized by unusual uncontrollable movements of the arms, legs, head, face or entire body. #70706961 (42)

Coining

is believed by some cultures (eg. Chinese, Vietna-mese ) to remove illness from the body. A rounded surface (eg. coin, spoon) is firmly stroked on the lubricated skin of the back and can produce wetlike linear lesions. This is appropriate to include in a culturally competent care in-service. #70706961 (46)

Cupping

is used by many cultures to remove illness from the body. The mouth of a steam-filled cup in placed on the skin, causing dermatitis and burns on the wrists. This is appropriate to include in a culturally com-petent care in-service. #70706961 (46)

coup-contrecoup head injury

occurs when the head strikes an object and the brain receives an injury under the area of impact (coup) , after which it rebounds to the opposite side of the skull and sustains injury on that side as well (contrecoup). This type of injury is common in motor vehicle accidents and shaken baby syn-drome. Visual processing occurs in the occipital lobe #70706961 (51)