RN questions NCLEX review

The homecare nurse is providing family teaching on safety issues for a client diagnosed with Parkinson's disease. What adaptions should the nurse instruct the family to initiate? - Install grab bars on tub walls - Place nightlights in hallways - Add bran and fiber to daily diet - Remove scatter rugs or loose cords - Keep bedroom dark, cool, and quiet - Put tennis balls on legs of walker.

- Install grab bars on tub walls - Place nightlights in hallways - Add bran and fiber to daily diet - Remove scatter rugs or loose cords - Keep bedroom dark, cool, and quiet.

A nurse is caring for a client diagnosed with pneumonia. What nursing interventions should the nurse implement for the client's night sweats and fever? Select all that apply - Keep water by the bedside - Place a plastic cover over the pillow - Administer an antipyretic every 4 hours - Keep a change of linen in the room - Position the client in a semi-Fowler's position

- Keep water by the bedside - Place a plastic cover over the pillows - Keep a change of linen in the room Antipyretics should be administered as needed, not every 4 hours; placing the client in different positions will not help their fever

A homecare nurse is attempting to visit clients isolated during the pandemic. Upon arriving at one small rural home, the nurse discovers the client is almost out of food, has no wood for heating and has a broken water faucet. The client is alert, oriented and refuses to leave the home. There is no family to help the client. How could the nurse best assist the client to remain home at this time? Select all that apply - Call local ambulance crew to transport client to the hospital - Ask the healthcare provider to order emergency placement - Request immediate evaluation by senior protective services - Run to the local store to obtain food and water for the client - Develop a plan of care with client, based on present needs.

- Request immediate evaluation by senior protective services - Develop a plan of care with client, based on present needs

What developmental milestone does the nurse expect to see in an 18 month old toddler? Select all that apply - Says and shakes head "no" - Points to one body part - Drinks from a cup - Points to show someone what they want - Kicks a ball - Walks up and down stairs holding on

- Says and shakes head "no" - Points to one body part' - Drinks from a cup - Points to show someone what they want.

The emergency room nurse is assessing a client with an eye injury that occurred while chopping wood. The client states the chain saw caused a log to splinter, sending slivers of wood into the right eye. While waiting for the eye specialist, the nurse discusses future safety precautions for such an activity. What safety precautions are most important for the nurse to include in client teaching? Select all that apply. - Wear heavy gloves - Stand with feet together - Use steel-toed boots - Wear unbreakable goggles - Use ear covers and plugs - Wear loose-fitting clothing.

- Wear heavy gloves - Wear unbreakable goggles - Use ear covers and plugs.

The homecare nurse is visiting a newly diagnosed diabetic being treated for a small left foot wound. What is the nurse's priority assessment on this first home visit? - Determine stage and drainage of foot wound - Assess the client's ability to prepare and administer insulin - Check home environment for potential hazards - Assess client's knowledge of signs of hypoglycemia

Check home environment for potential hazards

A client who is of the Jehovah's Witness faith presents to the emergency department following a traffic accident. The primary healthcare provider orders a type and cross-match for this client. It is determined that the client will benefit form two units of blood. What should the nurse do? - Prepare the client for the administration of blood - Explain to the healthcare provider that the client's faith prohibits blood transfusions - Explain to the client that the blood transfusions are needed for return to health - Try to convince the client to accept the transfusions

Explain to the primary healthcare provider that the client's faith prohibits blood transfusions

In the office for a yearly physical examination, a 30-year-old client reports that the client and husband used to be very happy before the children were born. Now the client is struggling with the current situation. What should the nurse understand about this situation? - The client is probably having an extramarital affair - The developmental task at this stage is adjusting to the needs of more than two family members - A relative or close friend should be consulted for help so the client can pursue activities outside the home - The client should be referred to a psychotherapist for evaluation and care

The developmental task at this stage is adjusting to the needs of more than two family members.

A new mother asks the clinic nurse why her baby should receive recommended vaccinations. What is the best response by the nurse concerning vaccinations? - Vaccinations give antibodies to your baby to protect them from disease - Vaccinations will help your baby produce antibodies against disease causing organisms - Federal law requires that your baby receive recommended vaccinations - There is no reason not to vaccinate your baby since only mild, uncomfortable reactions can occur.

Vaccinations will help your baby produce antibodies against disease causing organisms.

The nurse is caring for a client who has been receiving treatment for systolic heart failure. What assessment findings would indicate to the nurse that further treatment is necessary? Select all that apply - 3+ pedal edema - CVP of 6 mm HG - One day weight loss of 2 pounds - Purse-lip breathing - Pale nail beds - Urine output at 50 ml/hr

- 3+ pedal edema - Purse-lip breathing - Pale nail beds - 3+ pedal edema and purse-lip breathing is seen when client is short of breath. Pale conjuctiva, nail beds, buccal mucosa are signs of impaired gas exchange - Normal CVP is 2-6 mm Hg - weight loss indicates that fluid is being removed - output of 50 mL/hr means that renal perfusion is adequate

Which signs and symptoms does the nurse expect to see in a client admitted to the medical unit with Parkinson's disease? Select all that apply - Blank affect - Decrease ability to swing arms - Waddling gait - Walking on toes - Pill-rolling tremor - Stiff muscles

- Blank affect - Decreased ability to swing arms - Pill-rolling tremor - Stiff muscles Waddling gait and walking on the toes is a sign of Duchenne Muscular Dystrophy. The client with Parkinson's disease has a shuffling gait.

The nurse is talking with a group of teenagers who have expressed an interest in getting a tattoo. What information about tattoos should the nurse provide? - Apply a moisturizer to the tattooed skin daily - Carefully consider the tattoo location as weigh gain can distort the image - Bloodborne risks of tattooing include Hepatitis and HIV - Tattoo dyes can cause allergic skin reactions - Tattoos can be inexpensively removed with little discomfort - Make sure the tattoo artist removes the needles and tubes from sealed packages

- Carefully consider the tattoo location as weight gain can distort the image - Bloodborne risks include Hepatitis and HIV - Tattoo dyes can cause allergic skin reactions - Make sure the tattoo artist removes the needle and tubes from sealed packages

An elderly widower has been admitted to a psychiatric crisis unit with a diagnosis of major depression with agitation. What behaviors would the nurse expect to observe during an initial assessment? Select all that apply - Memory loss - Difficulty focusing - Excessive sleepiness - Short-tempered - Hand-wringing.

- Difficulty focusing - Short-tempered - Hand-wringing

Which sighs/symptoms does the nurse expect to see in a client diagnosed with Bell's Palsy? Select all that apply. - Drooping of one side of the face - Inability to wrinkly forehead - Excessive tearing - Decreased sensitivity to sound - Inability to taste - Numbness of affected side

- Drooping of one side of the face - Inability to wrinkle forehead= - Excessive tearing - Inability to taste - Numbness of affected side of face - Symptoms of Bell's Palsy include sudden weakness or paralysis on one side of the face that causes it to droop, drooling, eye problems such as excessive tearing or a dry eye, loss of ability to taste, pain in or behind the ear, numbness in the affected side of the face, increased sensitivity to sound. There would be an increased sensitivity to sound with Bell's Palsy.

The nurse has been teaching the parents of a child taking methylphenidate for the treatment of attention deficit hyperactivity disorder (ADHA). Which comments by the parents indicate adequate understanding of the important considerations for methylphenidate? Select all that apply. - I know that I need to monitor weight - I am supposed to call if my child has decreased attentiveness - This medication may cause increased drowsiness - I know that I need to monitor my child's height - If my child can't sleep, the dosage may need to be increased.

- I know that I need to monitor weight - I am supposed to call if my child has decreased attentiveness - I know that I need to monitor my child's height.

The nurse is caring for a client who is to receive an antibiotic in 50 mL of D5W over 30 minutes using an infusion pump. The nurse will set the infusion pump to deliver how many mL per hour? Round answer to the nearest whole number.

50 mL : 30 min = x mL : 60 min 30x = 3000 x = 100

What is the first intervention the emergency department nurse should implement when caring for a lethargic toddler with a diagnosis of near-drowning? - Torso warming - Start intravenous infusion - Apply oxygen - Prepare for nasogastric intubation

Administer oxygen

Which action should the nurse recommend to parents so that their home will be safer for a toddler? - Place the child in the center of an adult-sized bed when napping - Buckle the child into the high chair if parents leave the room during a meal - Anchor top-heavy furniture or fish tanks so that they cannot be pulled over - Allow the toddler to explore stairs in the home if supervised.

Anchor top-heavy or fish tanks so that they cannot be pulled over

A home health care nurse is educating a female client about home care considerations for intermittent catheterization. Which statement by the client would let the nurse know that the client understands what has been taught? - After insertion, I will tape the tubing to my lower abdomen - I will wash the rubber catheter thoroughly with soap and water after use - It is important that I keep the drainage bag below the level of my bladder - Catheterization should be done hourly

I will wash the rubber catheter thoroughly with soap and water after use

The nurse is developing a teaching plan for a female client who is taking one of the thiazolidinediones for the treatment of type 2 diabetes. What instruction should be included in the teaching plan? - Make sure that you use effective contraception while taking this drug - The drug may lead to weight loss - Therapeutic effect is reached within one to two weeks - Therapeutic effect is reached within one month

Make sure that you use effective contraception while taking this drug

A client with recurrent angina and hypertension has been started on new medications. When reviewing the admission forms, the nurse should immediately question which prescription? - 2 gm sodium diet - Metoprolol 25 m PO once daily - Potassium 10 meq PO once daily - Diltiazem 120 mg PO once daily Exhibit: Primary Healthcare Provider Prescription - Spironolactone 50 mg PO once daily - Metoprolol 25 mg PO once daily - Diltiazem 120 mg PO once daily - Potassium 10 meq PO once daily - 2 gm sodium diet

Potassium. Spironolactone is a potassium sparing diuretic; therefore, the client should not be taking a daily dose of potassium

A preeclampsia client is being treated with magnesium sulfate. The nursing assessment shows a respiratory rate of 10 with deep tendon reflexes of 0. What is the nurse's priority action? - Place client in Trendelenburg position and apply oxygen - Stop magnesium and prepare to give calcium gluconate - Ask another nurse to verify the deep tendon reflexes - Prepare the client for an emergency cesarean section

Stop magnesium and prepare to give calcium gluconate

The parents of a 1 month old report that their baby wakes up startled and stretches out the arms throughout the night. What suggestion should the nurse provide to the parents to decrease this reflex? - Rock to sleep - Place in a baby swing - Provide a pacifier - Swaddle the baby

Swaddle the baby

The nursing unit manager is reviewing cardiopulmonary resuscitation protocols with a group of new nurses. When the unit manager asks for an indication of effective CPR on an adult, what new nurse response would be most accurate? - Chest wall visibly rises with rescue breathing - Skin color and temperature becomes pink and warm - There is a palpable femoral pulse with a compression - A sinus beat appears on monitor during compression.

There is a palpable femoral pulse with a compression

A client states, "I really do not want to go through open heart surgery. I have told my children this, but they still want me to go through with the surgery. I don't know what to do." What is the best response for the nurse as client advocate? - Your children are correct. The open heart surgery is the best thing for your health. - You feel as if your children are not addressing your concerns. You and your family will need to resolve this before you go to surgery - I can contact your primary healthcare provider so that you can discuss your concerns regarding open heart surgery. - You have some genuine concerns about the open heart surgery, and you feel as if your children are not addressing your concerns.

You have some genuine concerns about the open heart surgery, and you feel as if your children are not addressing your conerns.