NCLEX RN#31

Herpes Zoster (Shingles)

can occur in clients with a history of chickenpox (varicella-zoster virus exposure). The vesicular rash has a characteristic, linear dermatomal distribution and can present with severe pain.Vaccination prevents _____ #70890112 (65)

3

A 59 year old client comes to the clinic due to a blistering, linear rash on the left chest. The client reports itching and pain around the rash.What is the PRIORITY question for the nurse to ask the client? #70890112 (65) 1. "Did the rash start after taking a new medication?" 2. "Have you been keeping the rash covered." 3. "Have you ever had chickenpox?" 4. "What have you tried to help the pain?"

compartment syndrome

After a new cast is placed, the nurse should elevate the client's above the heart for the first 48 hours to increase venous return and decrease edema in the affected extremity. However, the extremity should not be elevated if ___ develops #70890112 (75)

Hip dislocation

is prevented by using an abductor pillow to maintain the hip in a straight and neutral position. The nurse should also teach the client not to bend at the hip more than 90 degrees or cross the legs or ankles. #70890112 (75)

Abdominal paracentesis

is used to remove ascitic fluid from the peritoneal cavity in end stage liver disease (cirrhosis). The client should be positioned in high Fowler's or sat upright to facilitate the flow of fluid to the bottom of the peri-toneal cavity, where the needle will be inserted. The client should void prior to the procedure to decrease the risk of bladder puncture. #70890112 (66)

Metabolic syndrome

Individual with ________________________________(insulin resistance syndrome) have an increased risk of diabetes and coronary artery disease. The presence of abdominal obesity causes increased insulin production (hyperinsulinemia), this excess insulin leads to insulin resistance, the primary feature of #70890112 (61)

Buck traction

immobilizes hip and femur fractures. A boot or traction tape is applied to the affected extremity and a prescribed weight pulls the limb into trac-tion. The client is typically placed in Trendalenburg or supine position with the foot of the bed raised to maintain counteraction. #70890112 (75)

RYGB

procedure uses a small portion of the stomach to create a gastric pouch that is anastomosed to the Roux limb of the small intestine, by passing most of the stomach and a portion of the duodenum. Dumping syndrome, the rapid emptying of gastric contents into the small intestine, is a potential complication. #70769904 (02)

Severe hyperkalemia

requires urgent treatment because cardiac muscle can not tolerate very high potassium levels.It increases the risk for life threatening ventricular dysrhythmias (eg. ventricular tachycardia and fibri-llation, asystole) #70890112 (67)

1

A client is 1 day postoperative abdomi-noplasty and is discharged to go home with a Jackson-Pratt (JP) closed wound system drain in place. The nurse teaches the client how to care for the drain and empty the collection bulb. Which statement indicates that the client NEEDS FURTHER INSTRUC-TION ? #70769904 (04) 1. "I'll empty the JP bulb when it is totally full so that I don't have to unplug it so many times." 2. I'll pull the plug on the JP bulb pour the drainage into the measurable specimen cup." 3. I'll squeeze the JP bulb from side to side as I hold it in my hand. 4. "While the JP is totally compressed, I'll clean the spout with alcohol and replace the plug."

4

A client is admitted to the emergency room with right lower quadrant pain and suspected ACUTE APPENDICITIS. Which health care provider prescription should the nurse implement FIRST? #70890112 (59) 1. Administer 5-325 mg hydrocodone/ acetaminophen PO for pain. 2. Draw blood for complete blood count and electrolyte levels 3. Obtain urine specimen for urinalysis 4. Start intravenous (IV) line with normal saline 100 mL/hr.

3

A client returns to the unit after receiving hemodialysis for the first time. The client vomits once, reports headache, and appears restless and disoriented. What is the PRIORITY interven-tion ? #70890112 (60) 1. Administer antihypertensives that were held prior to dialysis. 2. Administer PRN ondansetron to relieve nausea 3. Contact the health care provider. 4. Place client in Trendelenburg position.

1

A client with advanced kidney disease has serum potassium of 7.1 mEq/L and creatinine of 4.5 mg/dL. What is the PRIORITY prescribed interven-tion ? #70890112 (67) 1. Administer IV 50% dextrose and regular insulin 2. Administer IV furosemide 3. Administer oral sodium polystyrene sulfonate. 4. Prepare the client for hemodialysis catheter placement.

3

A nurse is caring for a client with an exacerbation of chronic obstructive pulmonary disease (COPD) and a history of type 2 diabetes mellitus requiring insulin. The client has been prescribed prednisone. The nurse anticipates which need? #70890112 (70) 1. Close monitoring for hypotension 2. Gradually increasing the prednisone dose 3. Increasing the insulin dose 4. Monitoring and recording intake and output

4

A nurse is caring for a postpartum client who has chosen to exclusively formula feed her newborn for medical reasons and is experiencing breast engorgement. What should the nurse teach regarding relief of breast engorgement. #70769904 (07) 1. Apply heat frequently to both breasts for 15-20 minutes 2. Manually express milk several times a day. 3. Massage breasts from the base to the nipple 3 or 4 times a day. 4. Used chilled, fresh cabbage leaves on breast throughout the day .

2

A nurse is talking with the parent of a 6 year old regarding sleep and rest. Which information should be included? #70769904 (09) 1. Active play before bedtime promotes restful sleep. 2.. Bedtime hours should be established. 3. Rest need are related to the high rate of growth in this age group. 4. Seven to 8 hours of sleep are required.

1

A primigravid client in early labor is admitted and reports intense back pain with contractions. The fetal position is determined to be right occiput posterior. Which ACTION by the nurse would be MOST helpful for alleviating the client's back pain during early labor? #70769904 (05) 1. Applying counter pressure to the client's sacrum during contractions 2. Encouraging the client to remain in bed during early labor. 3. Positioning the client on the left side with pillows for support. 4. Requesting that the nurse anesthetist administer epidural anesthesia.

1

A registered nurse is precepting a new graduate nurse on the orthopedic unit. Which action by the graduate nurse requires the registered nurse to INTERVENE #70890112 (75) 1. Elevating a client's residual limb on a pillow 1 day after above the knee amputation. 2. Placing an abductor pillow between a client's legs after total hip replacement. 3. Positioning a client with buck traction supine with the foot of the bed raised. 4. Using pillows to raise a client's extremity following cast placement.

2

An elderly client has a 17 mm induration after a tuberculin skin test (TST). Based on this result, which statement is MOST accurate? #70890112 (73) 1. The client has a false-positive reaction due to advanced age. 2. The client has a tuberculosis (TB) infection 3. The client has active TB disease 4. The client must be isolated immediately.

3

An elderly client is admitted with chronic obstruc-tive pulmonary disease (COPD) exacerbation. Pulse oximetry is 84% on room air. The client is restless, has expiratory wheezing and a productive cough, and is using his accessory muscles to breathe. Which prescription should the nurse QUESTION? #70890112 (71) 1. Albuterol 2.5 mg by nebulizer 2. Intravenous (IV) methylprednisone 125 mg now and every 6 hours 3. IV morphine 2 mg now and may repeat every 2 hours. 4. Oxygen at 2L/min by nasal cannula.

3

An elderly client with osteoporosis falls onto an out stretched hand and injures the wrist. The client has severe wrist edema, deformity, and pain rated a 10 on a pain scale of 0-10. What should the nurse's FIRST action? #70769904 (03) 1. Administer analgesia 2. Apply an ice pack to the wrist 3. Assess capillary refill and sensation 4. Elevate the wrist above heart level

2

An emergency department nurse is assigned in triage. Which client should the nurse assess FIRST? #70890112 (62) 1. Five year old with a superficial leg lacera-tion. 2. Lethargic 3 month old with diarrhea for the past 12 hours. 3. Seven year old with a elevated temperature of 101 F (38.3C) and hematuria 4. Seventeen year old with severe, acute abdominal pain.

2

The charge nurse evaluates the care provided by a new registered nurse (RN) for a client re-ceiving mechanical ventilation (MV). Which action by the new RN indicates the NEED FOR FURTHER EDUCATION? #70890112 (63) 1. Administers morphine to relieve anxiety and restlessness 2. Applies suction when inserting the catheter into the airway. 3. Increases the oxygen concentration on the MV before suctioning 4. Suctions when MV high-pressure alarm continues to sound and rhonchi are present.

4

The health care provider prescribes SIMVASTATIN for a client with hyperlipedemia. The nurse instructs the client to take this medication in which manner? #70769904 (06) 1. At noon with a meal 2. In the morning on an empty stomach 3. In the morning with breakfast 4. With the evening meal

4

The home health nurse reviews the laboratory results for 4 clients. Which laboratory value is MOST IMPORTANT for the nurse to report to the health care provider? #70890112 (68) 1. Client with Clostridium difficile infection receiving metronidazole has a white blood cell count of 15,000/mm 2. Client with liver cirrhosis has an international Normalized Ratio of 1.5 3. Client with mild asthma exacerbation recei-ving prednisone has a blood glucose of 250 mg/dL 4. Client with rheumatoid arthritis taking adalimumab has a white blood cell count of 14,000/mm

2,3,4

The nurse INITIATES prescribed intravenous (IV) therapy on an 86 year old hospitalized client. Which life span concepts(s) should be considered when initiating IV therapy and caring for an older adult receiving IV therapy? SELECT ALL THAT APPLY #70769904 (01) 1. Avoid infusion devices in confused clients as alarms can be disruptive. 2. Cardiac and renal changes may put the client at risk for hypervolemia 3. Older adults may have more fragile veins, increasing the risk of infiltration. 4. Skin protectants and nonprous tape are helpful in reducing skin tears on fragile skin 5. Use a 30-45 degree angle on insertion because older adult veins that roll.

2,3,5

The nurse is assessing a group of clients in the community health clinic for METABOLIC SYNDROME. Which clients exhibit features of the syndrome? SELECT ALL THAT APPLY #70890112 (61) 1. Female with a low-density lipoprotein (LDL) level of 96 mg/dL 2. Female with a waist circumference of 38 inches. 3. Female with blood pressure of 148/90 mm Hg 4. Male with a fasting blood glucose of 99 mg/dL 5. Male with a triglyceride level of 201 mg/dL

3,4,5

The nurse is drawing a blood specimen from a client's central line. Identify the steps necessary to prevent TRANSMISSION OF INFECTION while performing this procedure. SELECT ALL THAT APPLY #70890112 (69) 1. Discard the first 6-10 ml of blood drawn from the line. 2. Flush the line with sterile normal saline before and after collection. 3. Perform hand hygiene 4. Place the specimen in a biohazard bag 5. Scrub the catheter hub with antiseptic prior to use.

1

The nurse is preparing a client who had a Roux-en-Y gastric bypass (RYGB) for discharge from the hospital. What information should the nurse plan to include related to the prevention of dumping syndrome? #70769904 (02) 1. Meals should be small and low in carbohy-drate content. 2. Fluid should be encouraged with each meal. 3. Take a multivitamin with iron and calcium supplements daily. 4. You will need to take your cobalamin injection monthly.

2

The nurse is reviewing the history of several female clients. The nurse will recommend Papanicolaou (Pap) cervical cancer screening for which individual? #70890112 (74) 1. 18 year old who reports being sexually active for the last 3 years 2. 32 year old whose last Pap screening at age 29 was negative. 3. 51 year old who had a total hysterectomy with cervix removal. 4. 67 year old whose Pap tests were negative at age 61 and 64

2

The nurse is teaching a client, gravida 1 para 0, at 8 weeks gestation about expected weight gain in pregnancy. The client's prepregnancy BMI is 21 kg/m2. Which statement made by the client INDICATES an understanding about weight gain? #70890112 (64) 1. "I should gain 10-15 lb during the first trimester" 2. "I should gain a total of about 30 lb during my pregnancy." 3. "I should gain no more than 0.5 lb per week during the third trimester." 4. "If I gain <20 lb during pregnancy, it will be easier to lose weight postpartum."

3

The nurse on the mental health unit receives about a client diagnosed with schizophrenia who is expe-riencing a DELUSION of reference. Which client statement supports this symptom? #70890112 (72) 1. "I need for you to get rid of these bugs that are crawling under my skin." 2. "Hear that? She told me to kill my father." 3 "That song is a message sent to me in secret code." 4. "Those Martians are trying to poison me with the tap water."

2

The precepting nurse is supervising a new obstetric nurse performing a labor admission assessment on a client with suspected sponta-neous rupture of membranes. Which ACTION by the new nurse would cause the precepting nurse to INTERVENE? #70769904 (08) 1. Documenting a positive nitrazine test result when the test strip-turns blue 2. Donning nonsterile gloves and using soluble gel for vaginal examination. 3. Palpating the client's abdomen before applying external fetal monitors. 4. Providing the client with a variety of clear liquids to drink.

1,4,5

Which of these are correct nursing actions related to client positioning? SELECT ALL THAT APPLY. #70890112 (66) 1. Position client in high Fowler's for a paracen-tesis related to end-stage cirrhosis. 2. Position client on left side after liver biopsy. 3. Position client on side with head, back, and knees flexed after lumbar puncture. 4. Position client trendelenburg on left side if air embolism is suspected. 5. Position client with arm raised above head for chest tube placement.

Corticosteroids

commonly cause hyperglycemia and worsen hypertension. When taken in combination with NSAIDs, they can increase the risk of peptic ulcer disease. #70890112 (70)