NCLEX STUDY REVIEW

The nurse is caring for an older adult client who states the need to use the restroom. Which safety intervention must the nurse perform first?

Assess the need for assistance with ambulation.

A client who is bedridden and dependent has been ordered to resume an oral diet. When feeding the client, the nurse should perform what action?

Assist the client into a high-Fowler's position.

A nurse is caring for a client with fecal impaction. Which factors cause fecal impaction? Select all that apply.

weak abdominal muscles severe dehydration unrelieved constipation

The nurse is caring for a client who is postoperative 3 days from coronary artery bypass graft. The client has a prescription to ambulate. What is the best action by the nurse?

Discuss with the client the need for assistance during ambulation.

A nurse is caring for a postoperative client. What intervention(s) will help prevent thrombophlebitis? Select all that apply.

Leg range of motion exercises Sequential compression devices (SCDs) and antiembolic stockings Early ambulation as tolerated Frequent turning and positioning

The physician has ordered that the client should ambulate 3 times a day. The nurse enters the room to ambulate the client and the client reports pain. What is the nurse's most appropriate action?

Medicate the client and wait to ambulate later.

A nurse is collecting a routine urinalysis on a client presenting to the emergency room with abdominal pain. What nursing action is important in the collection of this specimen?

Obtain a nonsterile specimen and send it to the lab.

The emergency room nurse is caring for a client who will need a lumbar puncture. The health care provider prescribes lidocaine 2.5% and prilocaine 2.5% cream (EMLA) to decrease the pain associated with the procedure. When should the nurse administer the cream?

One hour prior to the procedure

The nurse has measured from the tip of the client's nose to the earlobe and then down to the xiphoid process before inserting a nasogastric (NG) tube and attaching it to low suction. Which components of the nursing process has the nurse demonstrated?

Planning; implementing

A client's primary care provider has informed the nurse that the client will require thoracentesis. The nurse should suspect that the client has developed which disorder of lung function?

Pleural effusion

The client is preparing to obtain a clean-catch midstream urine specimen. List in order the steps needed to complete the diagnostic test.

Provide instruction to the client. Clean the area surrounding the urinary meatus with the provided cloth. Void a small amount into stool. Void into the provided collection device. Secure the lid on the specimen container. Submit collected specimen to the health care professional.

A nurse has just inserted a nasogastric tube in a client. Which method is most reliable for verifying the correct placement of the tube?

Radiographic confirmation of position

An indwelling urinary catheter has been ordered for a client experiencing urinary retention after surgery. When the nurse enters the room to place the catheter, the client reports voiding in the bathroom. Which is the nurse's most appropriate action?

Reassess whether the client still needs the urinary catheter.

The nurse needs to collect a stool specimen for culture from a client. The client passed stool into the toilet instead of using the collection container. What is the next step for the nurse?

Reinstruct the client on use of collection container for next bowel movement.

A nurse is providing oral care to an unconscious client. When planning this intervention, the nurse should prioritize which nursing diagnosis?

Risk for Aspiration

The nurse is engaged in collecting a urine specimen for a routine urinalysis from a client with an indwelling catheter. What nursing action has the greatest impact on the accuracy of the testing results?

Selecting this particular specimen port site

The nurse is preparing a client to receive a hypertonic enema solution. Into which position will the nurse place the client?

Sims

A client has just had abdominal surgery, and the nurse is consulting with him about his diet now that he is allowed to eat. Which nutrient is most important for wound healing?

protein

A nurse is developing a plan of care for a client who is at high risk for developing pressure injuries. Which intervention should the nurse include in the plan to prevent the development of pressure injuries? Select all that apply.

provide incontinent care every 2 hours and as needed. turn the client every 2 hours when the client is in bed. encourage the client to take fluids every 2 hours.

The nurse is caring for a client with an ankle sprain. Which client statement regarding an ice pack indicates that nursing teaching has been effective?

"I will put a layer of cloth between my skin and the ice pack."

The health care provider has prescribed an indwelling catheter for a 48-year-old male client who is in traction with leg fractures. Which information will the nurse give the client when he states not wanting the indwelling catheter?

"Let me talk to your health care provider about a condom catheter."

An older adult client is transferring from a supine position to a sitting position in a chair. The client reports dizziness when transferring. Which teaching by the nurse is most appropriate?

"Move slowly and sit on the edge of the bed before transferring to the chair."

A client is scheduled for thoracentesis. The nurse assesses that the client appears anxious about the procedure and needs honest support and reassurance. What is the most appropriate response by the nurse to this client?

"The needle causes discomfort or pain when it goes in, but I will be by your side throughout and will help you hold your position."

The nurse has admitted a client on airborne precautions onto the medical-surgical unit. When the client asks, "When will these airborne precautions be removed?" what is the appropriate nursing response?

"When your sputum culture is negative."

A healthy client eats a regular, balanced diet and drinks 3,000 mL of liquids during a 24-hour period. In evaluating this client's urine output for the same 24-hour period, the nurse realizes that it should total approximately how many mL?

3,000

Which client would be a candidate for total parenteral nutrition?

A client with colitis and bloody diarrhea

The nurse observes a client independently move all the joints through their normal motions. Which range of motion has the client demonstrated?

Active range of motion

The nursing student learns in Fundamentals that the primary purpose for using proper body mechanics is for which reason?

Acts to prevent injury to the client and/or nurse

Which is true regarding the normal urination?

Catheterized clients should drain a minimum of 30 mL of urine per hour.

The physician tells the nurse that the elderly client has presbycusis. Which of the following interventions will the nurse place in the client's care plan?

Decrease background noises, as much as possible, before speaking.

A client has had a stroke and will require long-term tube feeding. Which type of feeding tubes would be most appropriate for this client's needs?

Gastrostomy tube

The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who expresses concerns about the ability to breathe easier. The nurse will suggest which position to help alleviate the client's dyspnea?

High Fowler's position

the nurse is caring for Mr. Cantrell, a 69-year-old client. He has gradually lost much of the ability to hear in both ears due to working with loud machinery all of his working life. Which interventions will the nurse add to Mr. Cantrell's care plan in order to make him more comfortable with his hearing loss? Choose all that apply.

Face the client; use meaningful gestures. Be aware of nonverbal communication. Decrease background noise if possible. Do not chew gum or food when speaking.

The nurse is transferring the client from the bed to a wheelchair when the client reports dizziness. What is the next step for the nurse?

Firmly grasp the gait belt and gently lower the client into bed.

A nurse is teaching a student nurse how to manage unexpected events during the removal of a nasogastric tube. Which action should the nurse recommend?

If within 2 hours after NG tube removal, the client's abdomen is showing signs of distention, notify the health care provider.

While administering a cleansing enema, the client displays lightheadedness, nausea, and has clammy skin. The nurse would implement which priority action?

Stop the procedure, monitor heart rate and blood pressure.

A new unlicensed assistive personnel (UAP) is preparing to ambulate an obese client. The registered nurse (RN) is concerned about the UAP's ability to safely ambulate the client. Which would be the nurse's most appropriate action?

Tell the UAP that the RN will assist the UAP with the client's ambulation.

The nurse is slowly advancing a nasogastric (NG) tube when the client begins to gasp and is unable to vocalize. Which scenario has likely occurred?

The NG tube is in the client's airway.

A nurse is assisting a client with the use of a bedpan. The nurse understands that which statement about bedpans is true?

The largest part of a regular bedpan should be placed under the client's buttocks.

The charge nurse is observing a new nurse care for a client who is receiving a continuous feeding through a nasogastric feeding tube. Which action by the new nurse would require intervention by the charge nurse?

The new nurse places the client in the left lateral recumbent position.

Which nursing interventions reflect the accurate use of heat or cold during wound care? Select all that apply.

The nurse makes more frequent checks of the skin of an older adult using a heating pad. The nurse fills an ice bag with small pieces of ice to about two-thirds full. The nurse covers a cold pack with a cotton sleeve to keep it in place on an arm.

A nurse is assisting client from a bed to a wheelchair. Which nursing action is appropriate?

The nurse uses assistive devices when lifting more than 35 lb (16 kg) of client weight.

A physician orders nutritional therapy administered via a central vein for a client who cannot take foods orally. What is the term for this type of nutrition?

Total parenteral nutrition (TPN)

The nurse teaches proper body mechanics for a group of unlicensed assistive personnel (UAP). Which statement by a class participant indicates the need for additional education?

When I lift and carry a heavy box of supplies I will keep it at arm's length from my body.

In which client would the nurse assess for a depressed respiratory system?

a client taking opioids for cancer pain

When providing oral care, what does the nurse recognize as the most important component of the oral care process?

a thorough, mechanical cleaning

The nurse is caring for a client with tuberculosis. Which precautions will the nurse select for this client?

airborne

When teaching a client, which laboratory tests will the nurse identify that assess cardiac and vascular disease risk? Select all that apply.

cholesterol level lipoprotein level triglyceride level

A client scheduled for a colonoscopy is scheduled to receive a hypertonic enema prior to the procedure. A hypertonic enema is classified as which type of enema?

cleansing enema

The nurse is caring for an older adult with a recurrent wound infection. Which precautions will the nurse begin?

contact

The nurse is caring for a pediatric client with whooping cough. Which precautions will the nurse begin?

droplet

The nurse is caring for an older adult with influenza. Which precautions will the nurse begin?

droplet

Which health problem is most clearly suggestive of a history of inadequate dental care?

periodontitis

The nurse is performing digital removal of a fecal impaction. Which nursing actions follow guidelines for this procedure? Select all that apply.

place the client in a side-lying position. Use nonsterile gloves for the procedure because the intestinal tract is not sterile. Provide a sitz bath or tub bath after the procedure to soothe the perianal area

A urinalysis has been ordered for a client. When is the best time for the client to provide a urine sample?

first thing in the morning

A client's last bowel movement was 4 days ago and oral laxatives and dietary changes have failed to prompt a bowel movement. How should the nurse position the client in anticipation of administering a cleansing enema?

left side-lying

A nurse is filling out an incident report after an older adult client fell while attempting to transfer from her bed to a commode. Which health problem should the nurse consider when client falls occur?

orthostatic hypotension