NCLX- PN - content
The nurse is reinforcing instructions to the client about the use of ceftriaxone, an antibiotic, for treating cervical gonorrhea. The nurse should determine a need for further teaching if the client makes which statement? 1. "I can expect to get this one shot." 2."I will take the pills for 20 full days " 3."I may experience some discomfort at the injection site." 4."If I have a penicillin allergy, I may be allergic to this medication too.
2."I will take the pills for 20 full days " Rationale: If the client indicates she will be taking pills for 20 days, further teaching is needed. Cervical gonorrhea is treated with one (125 mg) injection of ceftriaxone or one (400 mg) oral dose of cefixime. Allergies to penicillin may contraindicate giving ceftriaxone, and slight discomfort at the injection site is common.
The nurse is assisting a client who has just been given a hearing aid to wear for the first time. When reinforcing client teaching, the nurse should include which instruction? 1. "The hearing aid should not be worn if an ear infection is present." 2. "The ear mold should be washed with mild soap and water once a month." 3. "The hearing aid should be removed at the end of the day and then turned off after removal." 4. "The hearing aid contains a lifelong battery, so there is no need to be concerned about changing batteries."
1. "The hearing aid should not be worn if an ear infection is present." Rationale: The client should be instructed that the hearing aid should not be worn if an ear infection is present. The client should be instructed to turn off the hearing aid before removing it from the ear to prevent noisy feedback. The hearing aid should be turned off when not in use, and extra batteries should be kept on hand. The client should wash the ear mold frequently with mild soap and water, using a pipe cleaner to cleanse the cannula.
A client with a peripheral intravenous (IV) site calls the nurse to the room and tells the nurse, "The IV is not running right." Which findings would indicate an infiltrated IV? Select all that apply. 1. Cool to touch 2.Vein hard to touch 3.Redness at the site 4.Swelling at the site 5.May not have a blood return
1. Cool to touch 4.Swelling at the site 5.May not have a blood return Rationale: An infiltrated IV is one that has dislodged from the vein, and is lying in subcutaneous tissue. The pallor, coolness, and swelling are the result of IV fluid being deposited in the subcutaneous tissue. When the pressure in the tissues exceeds the pressure in the tubing, the flow of the IV solution will stop. The corrective action is to remove the catheter and start a new IV line. The other options indicate phlebitis.
The nurse has admitted a client to the clinical nursing unit following a right mastectomy. Which interventions should be included in the plan of care? Select all that apply. 1. Elevate the right arm on one or two pillows. 2.Do not check the radial pulse in the right arm. 3.Use small-gauge needles if the IV is initiated in the left arm. 4.Instruct the client to avoid bending the fingers of the right hand. 5.Ensure that no venipunctures or blood pressures (BPs) are done in the right arm.
1. Elevate the right arm on one or two pillows. 5.Ensure that no venipunctures or blood pressures (BPs) are done in the right arm. Rationale:The client, who has undergone a mastectomy (removal of the breast) procedure, is at risk for developing lymphedema due to disruption of the lymph circulation. The client's operative arm should be positioned so that it is elevated on one or two pillows and does not exceed shoulder elevation. This will facilitate the flow of fluids through the lymph and venous routes and prevent lymphedema (accumulation of lymph in soft tissue). Placing a sign stating no venipunctures or BPs in the operative arm will inform all health care workers of the precautions needed to prevent infection or blockage of lymph channels in the arm. Checking the radial pulse in the right arm will not block lymph circulation. The left arm needs no precautions because the lymph circulation is intact on that arm. The client may bend the fingers and not bending them will likely promote edema.
The nurse is monitoring a client who is receiving a unit of packed red blood cells. Within an hour after the initiation of a transfusion, the nurse finds the client to be restless, with reports of chills and back pain. The nurse notes that there is dark urine in the Foley catheter drainage bag. The nurse interprets that the client is experiencing which reaction? 1. Allergic 2.Hyperkalemic 3.Acute hemolytic 4.Delayed hemolytic
3. Acute hemolytic Rationale: The client is experiencing an acute hemolytic reaction to the transfusion. The nurse in this instance would immediately stop the infusion and notify the primary health care provider. A delayed hemolytic reaction typically occurs from 2 to 14 days after transfusion. A hyperkalemic reaction occurs when blood is transfused that has been stored for too long, resulting in red blood cell hemolysis. The client experiencing a hyperkalemic reaction would exhibit nausea, muscle weakness or paresthesias, apprehension, bradycardia, electrocardiogram (ECG) changes, and possibly cardiac arrest. An allergic reaction is characterized by flushing, nausea and vomiting, respiratory stridor, hypotension, and other signs of anaphylaxis.
The nurse in the preoperative holding unit administers a dose of scopolamine to a client. The nurse monitors the client for which common side effect of the medication? 1 . Dry mouth 2.Diaphoresis 3.Excessive urination 4.Pupillary constriction
1 . Dry mouth Rationale: Scopolamine is an anticholinergic medication that causes the frequent side effects of dry mouth, urinary retention, decreased sweating, and pupil dilation. Each of the incorrect options is the opposite of a side effect of this medication.
The nurse is planning to administer hydrochlorothiazide to a client. Which are concerns related to the administration of this medication? 1. Hypouricemia, hyperkalemia 2. Hypokalemia, hyperglycemia, sulfa allergy 3. Hypokalemia, increased risk of osteoporosis 4. Hyperkalemia, hypoglycemia, penicillin allergy
2. Hypokalemia, hyperglycemia, sulfa allergy Rationale:Thiazide diuretics such as hydrochlorothiazide are sulfa-based medications, and a client with a sulfa allergy is at risk for an allergic reaction. Also, clients are at risk for hypokalemia, hyperglycemia, hypercalcemia, hyperlipidemia, and hyperuricemia. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Pharmacology: Cardiovascular Medications Integrated Process: Nursing Process/Data Collection Priority Concepts: Cellular Regulation, Fluids and Electrolytes Strategy(ies): Subject
A client who had previously undergone cataract surgery tells the nurse that she has begun seeing flashing lights and floaters in the eye. Based on the client's history, the nurse interprets that the client is at risk for which? 1. Glaucoma 2.Papilledema 3.Detached retina 4.Recurrent cataract
3. Detached retina Rationale: Clients with a history of cataract surgery, myopia, trauma, or a family history of retinal conditions are at greater risk for developing a detached retina. Signs and symptoms include sudden onset of flashing lights or floaters. The client may also have loss of peripheral vision or a sudden shadow in the field of vision. Clients with these risk factors should be taught the signs and symptoms of a detached retina and should report them promptly. Options 1, 2, and 4 are not associated risks.
The nurse is reviewing the health records of assigned clients. The nurse should plan care knowing that which client is at the least likely risk for the development of third-spacing? 1. The client with sepsis 2.The client with cirrhosis 3.The client with kidney failure 4.The client with diabetes mellitus
4.The client with diabetes mellitus Rationale: Fluid that shifts into the interstitial space and remains there is referred to as third-space fluid. Common sites for third-spacing include the abdomen, pleural cavity, peritoneal cavity, and pericardial sac. Third-space fluid is physiologically useless because it does not circulate to provide nutrients for the cells. Risk factors include liver or kidney disease, major trauma, burns, sepsis, wound healing, major surgery, malignancy, malabsorption syndrome, malnutrition, alcoholism, and older age.
A client has a nasogastric tube in place that is attached to suction. The client is at risk for developing which electrolyte imbalances with prolonged suction? Select all that apply. 1. Hypokalemia 2.Hyperkalemia 3.Hyponatremia 4.Hypernatremia 5.Hypomagnesemia 6.Hypermagnesemia
Hypokalemia, Hyponatremia, Hypomagnesemia Rationale: Prolonged gastric suction can result in electrolyte imbalances. There can be deficits of potassium, sodium, or magnesium blood levels.
A postoperative client has a prescription to receive an intravenous (IV) infusion of 1000 mL normal saline solution over a period of 10 hours. The drop (gtt) factor for the IV infusion set is 15 gtts/mL. The nurse sets the flow rate at how many drops per minute? Fill in the blank.
25 gtts/minute Formula: Total volume × gtt factor------------------------- = gtt/ minute Time in minutes
A comatose client with an admitting diagnosis of diabetic ketoacidosis (DKA) has a blood glucose value of 368 mg/dL, arterial pH of 7.2, arterial bicarbonate of 14 mEq/L, and is positive for serum ketones. The diagnosis is supported by which noted data? Select all that apply. 1. Shakiness 2.Hypertension 3.Fruity breath odor 4.Rapid, deep breathing 5.Dry mucous membranes
3.Fruity breath odor 4.Rapid, deep breathing 5.Dry mucous membranes Rationale: Diabetic ketoacidotic coma is usually identified with a fruity breath odor; dry, cracked mucous membranes; hypotension; and rapid, deep breathing. Hypoglycemia is identified by cool, clammy skin; shakiness; and hunger.
When caring for a client diagnosed with pheochromocytoma, which signs and symptoms should the nurse note? Select all that apply. 1. Bradycardia 2.Flushed face 3.Severe headache 4.Profuse diaphoresis 5.Severe hypertension
3.Severe headache 4.Profuse diaphoresis 5.Severe hypertension Rationale:Pheochromocytoma is a catecholamine-producing tumor of the adrenal gland and causes secretion of excessive amounts of epinephrine and norepinephrine. Signs and symptoms of pheochromocytoma are related to excess catecholamine release. These include tachycardia and severe hypertension (as high as 250/150 mm Hg) that can be intermittent or persistent. Profuse diaphoresis, severe headache, palpitations, nausea, weakness, and pallor may also be present.
A client received 20 units of NPH insulin subcutaneously at 8:00 am. The nurse should check the client for a potential hypoglycemic reaction at which time? 1. 9:00 am 2. 12:00 Noon 3. 1:00 pm 4. 5:00 pm
4. 5:00 pm NPH insulin is intermediate-acting insulin. Its onset of action is 60 to 120 minutes, it peaks in 6 to 14 hours, and its duration of action is 16 to 24 hours. Hypoglycemic reactions most likely occur during peak time.
A client has been examined in the clinic and has been diagnosed with pelvic inflammatory disease. The client asks the nurse to describe this condition. Which description of pelvic inflammatory disease by the nurse is accurate? 1. "Pelvic inflammatory disease is pain that occurs during ovulation." 2."Pelvic inflammatory disease is also known as primary dysmenorrhea." 3."Pelvic inflammatory disease is the cause of cessation of menstruation." 4."Pelvic inflammatory disease is an infectious process that involves the uterine, tubes and uterus."
4."Pelvic inflammatory disease is an infectious process that involves the uterine, tubes and uterus." Rationale: Pelvic inflammatory disease (PID) is an infectious process that most commonly involves the uterine (fallopian) tubes (salpingitis), and uterus. Multiple organisms have been found to cause PID, and most cases are associated with more than one organism. Mittelschmerz refers to pelvic pain that occurs midway between menstrual periods. Primary dysmenorrhea refers to menstrual pain without identified pathology. Amenorrhea is the cessation of menstruation for a period of at least 3 cycles or 6 months in a woman who has established a pattern of menstruation and can be due to a variety of causes.
A client with epilepsy is taking the prescribed dose of phenytoin to control seizures. A phenytoin blood level is drawn, and the results reveal a level of 35 mcg/mL. Which symptom would be expected as a result of this laboratory result? 1. Nystagmus 2.Tachycardia 3.Slurred speech 4.No symptoms, because this is a normal therapeutic level
3.Slurred speech Rationale: The therapeutic phenytoin level is 10 to 20 mcg/mL. At a level higher than 20 mcg/mL, involuntary movements of the eyeballs (nystagmus) appear. At a level higher than 30 mcg/mL, ataxia and slurred speech occur. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Pharmacology: Neurological Medications Integrated Process: Nursing Process/Data Collection Priority Concepts: Clinical Judgment, Intracranial Regulation Strategy(ies): Subject, Therapeutic Communication Techniques
The nurse is providing instructions to a client with a diagnosis of scabies regarding the administration of crotamiton. Which statement by the client indicates an understanding regarding the application of this medication? 1. "I should apply the medication to my entire body, washing it off after 2 hours." 2. "I will apply the application to my entire body and leave it on for 24 hours, followed by a cleansing bath." 3. "I should apply the medication to my entire body, avoiding the skin folds and creases and wash it off in 12 hours." 4. "I will massage the medication into the skin from my chin downward and apply a second application in 24 hours, followed by a cleansing bath 48 hours after the second application."
4. "I will massage the medication into the skin from my chin downward and apply a second application in 24 hours, followed by a cleansing bath 48 hours after the second application." Rationale: The client is instructed to massage the medication into the skin of the entire body, starting with the chin and working downward. The head and face are treated only if needed. Special attention should be given to skin folds and creases. Contact with eyes, mucous membranes, and any region of inflammation should be avoided. A second application is made 24 hours after the first. A cleansing bath should be taken 48 hours after the second application, and, if needed, treatment can be repeated in 7 days.
A client who suffered a crush injury to the leg has a highly positive urine myoglobin level. The nurse plans to monitor this particular client carefully for signs of which complication? 1. Respiratory failure 2. Brain attack (stroke) 3. Myocardial infarction 4. Acute tubular necrosis
4. Acute tubular necrosis Rationale: The normal urine myoglobin level is negative. After extensive muscle destruction or damage, myoglobin is released into the bloodstream where it is cleared from the body by the kidneys. When a large amount of myoglobin is being cleared from the body, the renal tubules may become clogged with myoglobin, which causes acute tubular necrosis. This is one form of acute kidney injury.
After weeks of witnessing a hospice client's deterioration and subsequent death from liver failure, his family disagrees about performing an autopsy. Which criterion does the nurse use to determine if the autopsy can proceed? 1. Specifics in the client's will 2. Decision by the client's sister 3. Ruling from medical examiner 4. Determination by the client's son
4. Determination by the client's son Rationale: The nurse works with the client's son to determine if an autopsy can be performed (option 4) because the only powers that supersede an offspring's decision are the client's written statement, a durable power of attorney, or a surviving spouse. In order, a parent, brother, or sister can make the decision if the client has no children. A client's will involves bequeathing property and does not contain information about medical care (option 1). The client's sibling is consulted after an offspring (option 2). The client's death is unlikely to be a medical examiner's case or a suspicious death, so a medical examiner's ruling is not indicated.
The nurse is reinforcing instructions to a client newly diagnosed with diabetes mellitus regarding insulin administration. The primary health care provider has prescribed a mixture of NPH and regular insulin. The nurse should stress that which is the first step?
Inject air equal to the amount of NPH insulin prescribed into the vial of NPH insulin. Rationale: The initial step in preparing an injection of insulin that is a mixture of NPH and regular is to inject air into the NPH bottle equal to the amount of insulin prescribed. The client is instructed to next inject an amount of air equal to the amount of prescribed insulin into the regular insulin bottle. The regular insulin should then be withdrawn followed by the NPH insulin. Contamination of regular insulin with NPH insulin will convert part of the regular insulin into a longer-acting form.
The nurse is providing a list of instructions to a client who is scheduled to have an electroencephalogram (EEG). Which instructions should the nurse place on the list? Select all that apply. 1. Cola is acceptable to drink on the day of the test. 2.Tea and coffee are restricted on the day of the test. 3.The test will take between 45 minutes and 2 hours. 4.The hair should be washed the evening before the test. 5.All medications need to be withheld on the day of the test. 6.A nothing-by-mouth (NPO) status is required on the day of the test.
2.Tea and coffee are restricted on the day of the test. 3.The test will take between 45 minutes and 2 hours. 4.The hair should be washed the evening before the test. Rationale: Preprocedure instructions include informing the client that the procedure is painless. The procedure requires no dietary restrictions other than avoidance of cola, tea, and coffee on the morning of the test. These products have a stimulating effect and should be avoided. The hair should be washed the evening before the test, and gels, hairsprays, and lotion should be avoided. Any hair decorations should be removed. The client is informed that the test will take 45 minutes to 2 hours and that medications are usually not withheld before the test.
The nurse is told in report that a client has a positive Chvostek's sign. Which other data should the nurse expect to find on data collection? Select all that apply. 1. Coma 2.Tetany 3.Diarrhea 4.Possible seizure activity 5.Hypoactive bowel sounds 6.Positive Trousseau's sign
2.Tetany 3.Diarrhea 4.Possible seizure activity 6.Positive Trousseau's sign Rationale: Focus on the subject, a positive Chvostek's sign, which is indicative of hypocalcemia. Other signs and symptoms include tachycardia, hypotension, paresthesias, twitching, cramps, tetany, seizures, positive Trousseau's sign, diarrhea, hyperactive bowel sounds, and a prolonged QT interval. Client Needs: Physiological Integrity Cognitive Ability: Analyzing Content Area: Adult Health: Neurological Integrated Process: Nursing Process/Data Collection Priority Concepts: Fluids and Electrolytes, Intracranial Regulation Strategy(ies): Subject
The nurse is preparing to care for a client with acquired immunodeficiency syndrome (AIDS) who has Pneumocystis jiroveci pneumonia. In planning infection control for this client, which should be the appropriate form of isolation to use to prevent the spread of infection to others? 1. Droplet precautions isolation 2.Enteric precautions 3.Contact precautions 4.Standard precautions
4. Standard precautions Rationale: The acquired immunodeficiency syndrome (AIDS) virus is transmitted through anal, vaginal, or oral sexual contact with infected semen or vaginal secretions; contact with infected blood or blood products; from mother to fetus during childbirth; or during breastfeeding. P. jiroveci pneumonia is an opportunistic infection seen in clients with compromised immune function. Standard precautions include blood and body fluid precautions and are used for contact with all clients including those who are HIV-positive. Pneumocystis jiroveci is normally not pathogenic for persons with a healthy immune system so no extra precautions are necessary for the nurse to follow. Droplet, enteric, and contact precautions are not indicated for the client in the question. If the client would develop another disease, some precautions may be needed.
The nurse is collecting data from a client who is suspected of having mittelschmerz. Which statement supports this probable diagnosis? 1. "My monthly cycle is very heavy." 2. "I experience pain that occurs during intercourse." 3. "I have incapacitating pain for the first few days of my menstrual cycle." 4. "I experience a sharp pain located on my low right side midway through my cycle."
4. "I experience a sharp pain located on my low right side midway through my cycle." Rationale: Some women will experience slight vaginal bleeding at the time they experience mittelschmerz. Mittelschmerz (middle pain) refers to pelvic pain that occurs midway between menstrual periods or at the time of ovulation. The pain is caused by growth of the dominant follicle within the ovary, or rupture of the follicle and subsequent spillage of follicular fluid and blood into the peritoneal space. The pain is fairly sharp and is felt on the right or left side of the pelvis. It generally lasts a few hours to 2 days. Mittelschmerz is not related to menstrual flow, pain during intercourse, or pain associated with menstruation.
The client arrives at the emergency department after a burn injury that occurred in their home basement and an inhalation injury is suspected. Which should the nurse anticipate as being prescribed for the client? 1. Oxygen via nasal cannula at 10 L 2. Oxygen via nasal cannula at 15 L 3. 100% oxygen via an aerosol mask 4. 100% oxygen via a tight-fitting, nonrebreather face mask
4. 100% oxygen via a tight-fitting, nonrebreather face mask Rationale: If an inhalation injury is suspected, the administration of 100% oxygen via a tight-fitting, nonrebreather face mask is prescribed until the carboxyhemoglobin level falls below 15%. With inhalation injuries, the oropharynx is inspected for evidence of erythema, blisters, or ulcerations. The need for endotracheal intubation is also determined. Options 1, 2, and 3 are incorrect.
A nursing instructor asks a nursing student to define a critical path. Which statement made by the student indicates a need for further teaching regarding critical paths? 1. "They are developed based on appropriate standards of care." 2."They are nursing care plans and use the steps of the nursing process. 3."They are developed through the collaborative efforts of all members of the health care team." 4."They provide an effective way to monitor care and for reducing or controlling the length of hospital stay for the client."
2."They are nursing care plans and use the steps of the nursing process. Rationale: Critical paths are not specifically nursing care plans; however, they can take the place of a nursing care plan and actually map out the desired clinical progress of a client during acute care admission. Options 1, 3, and 4 appropriately describe the use of a critical path.
