Saunder NCLEX-PN 2

The nurse initiates a prescription from the primary health care provider and restrains a client who has a chest tube connected to suction. The client is confused and continues to remove the dressing around the tube and pulls at the tube. Which information should the nurse document in the client's medical record regarding restraints? Select all that apply. 1. The reason the chest tube was inserted 2.The probable time the restraints will be discontinued 3.Adequacy of circulation in the body area that is restrained 4.Type of restraint and body area where the restraint was applied 5.Communication with client and family member about need for restraint 6.The alternative measures that were attempted before restraints were applied

3.Adequacy of circulation in the body area that is restrained 4.Type of restraint and body area where the restraint was applied 5.Communication with client and family member about need for restraint 6.The alternative measures that were attempted before restraints were applied

The nurse is preparing to care for a dying client and several family members are at the client's bedside. Which therapeutic techniques should the nurse use when communicating with the family? Select all that apply. 1. Discourage reminiscing. 2.Make the decisions for the family. 3.Encourage expression of feelings, concerns, and fears. 4.Explain everything that is happening to all family members. 5.Touch and hold the client's or family member's hand if appropriate. 6.Be honest and let the client and family know that they will not be abandoned by the nurse.

3.Encourage expression of feelings, concerns, and fears. 5.Touch and hold the client's or family member's hand if appropriate. 6.Be honest and let the client and family know that they will not be abandoned by the nurse.

The nurse is assisting in providing surgical instructions to a preoperative client who will have abdominal surgery. Which instructions would be appropriate to include in the preoperative plan of care? Select all that apply. 1.Wound care 2.Personal hygiene 3.Activity restrictions 4.Frequent assessment of vital signs 5.Coughing and deep breathing exercises 6.Pain monitoring and medications to relieve pain

4.Frequent assessment of vital signs 5.Coughing and deep breathing exercises 6.Pain monitoring and medications to relieve pain

A nurse is monitoring a pregnant client for the warning signs/symptoms of gestational hypertension. Which are signs/symptoms of this complication of pregnancy? Select all that apply. 1. Edema 2.Polyuria 3.Proteinuria 4.Thrombocytopenia 5.Irregular, painless contractions

1) Edema 2)Proteinuria 4)Thrombocytopenia

A client is admitted with a diagnosis of pneumonia and dehydration. The nurse monitors the client and determines which symptoms correlate with this client's fluid imbalance? Select all that apply. 1. Lung crackles 2.Flat neck veins 3.Weakly palpable peripheral pulses 4.Heart rate of 104 beats per minute 5.Blood pressure (BP) of 136/86 mmHg

2.Flat neck veins 3.Weakly palpable peripheral pulses 4.Heart rate of 104 beats per minute

A client is being seen at the primary care clinic for her annual gynecological examination. Which client statements are most likely associated with potential intimate partner abuse? Select all that apply. 1. "My husband always brings me flowers and apologizes after he hits me." 2."I have bruises all over my body. I am frequently clumsy and fall a lot." 3."My partner and I do almost everything together; we have the same hobbies." 4."My boyfriend yells and accuses me of having an affair if I am late after work." 5."My husband stays out all night drinking and then passes out on the couch."

1. "My husband always brings me flowers and apologizes after he hits me." 2."I have bruises all over my body. I am frequently clumsy and fall a lot." 4."My boyfriend yells and accuses me of having an affair if I am late after work."

A postoperative client has been placed on a clear liquid diet. Which items is the client allowed to consume? Select all that apply. 1. Broth 2.Coffee 3.Gelatin 4.Pudding 5.Ice cream 6.Vegetable juice

1. Broth 2.Coffee 3.Gelatin

A client who had abdominal surgery complains of feeling as though "something gave way" in the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel protruding through the incision. Which nursing interventions should the nurse take? Select all that apply. 1.Notify the registered nurse immediately. 2.Document the client's complaint with the exact times. 3.Place a sterile saline dressing and ice packs over the wound. 4.Prepare the client for wound closure by notifying surgery department. 5.Place the client in a supine position without a pillow under the head. 6.Instruct the client to remain quiet and reassure the situation is being taken care of.

1.Notify the registered nurse immediately. 2.Document the client's complaint with the exact times. 4.Prepare the client for wound closure by notifying surgery department. 6.Instruct the client to remain quiet and reassure the situation is being taken care of.

The nurse is caring for a client who has been prescribed cold pack applications to the right lower extremity. The nurse plans to collect which data specifically associated with this therapy before the initiation of therapy? Select all that apply. 1.Pedal pulses 2.Capillary refill 3.Color of the extremity 4.Temperature of the skin 5.Condition of the toenails 6.Presence of numbness

1.Pedal pulses 2.Capillary refill 3.Color of the extremity 4.Temperature of the skin 6.Presence of numbness

The nurse is assigned to assist the primary health care provider (PHCP) with the removal of a chest tube. Which interventions should the nurse anticipate performing during this process? Select all that apply. 1. Reinforce instructions to breathe deeply while the tube is removed. 2.Cover the site with an occlusive dressing after the tube is removed. 3.Clamp the chest tube near the insertion site just before the removal. 4.Raise the drainage system to the level of the chest tube insertion site. 5.Have the client perform the Valsalva maneuver as the chest tube is pulled out.

2) Cover the site with an occlusive dressing after the tube is removed. 5)Have the client perform the Valsalva maneuver as the chest tube is pulled out.

Which signs/symptoms are observed in the clonic phase of a seizure? Select all that apply. 1. Body stiffening 2.Muscular relaxation 3.Sudden loss of consciousness 4.Brief flexion of the extremities 5.Extension spasms of the body 6.Contortion of the face with eye rolling

2.Muscular relaxation 5.Extension spasms of the body 6.Contortion of the face with eye rolling

The nurse has given dietary instructions to a client to minimize the risk of osteoporosis. The nurse determines that the client understands the recommended changes if the client verbalizes the intention to increase intake of which foods? Select all that apply. 1. Fish 2.Yogurt 3.Potatoes 4.Chicken 5.White bread 6.Cottage cheese

2.Yogurt 6.Cottage cheese

A licensed practical nurse (LPN) is assisting in the care of a client who is receiving oxytocin to induce labor. The LPN plans to notify the registered nurse immediately if which signs and symptoms are noted? Select all that apply. 1. Contractions increasing in intensity 2.Contractions increasing in frequency 3.Decreased blood pressure, increased pulse 4.Contractions greater than 1 minute in duration 5.Early decelerations on the fetal heart rate monitor

3)Decreased blood pressure, increased pulse 4)Contractions greater than 1 minute in duration

The nurse is reviewing the postoperative primary health care provider's (PHCP'S) prescriptions for a 3-week-old infant with Hirschsprung's disease admitted to the hospital for surgery. Which prescriptions documented in the child's record should the nurse question? Select all that apply. 1. Measure abdominal girth daily. 2.Monitor strict intake and output. 3.Take temperature measurements rectally. 4.Start clear liquid diet after 8 hours postoperative. 5.Maintain IV fluids until the child tolerates oral intake. 6.Monitor the surgical site for redness, swelling, and drainage.

3)Take temperature measurements rectally. 4)Start clear liquid diet after 8 hours postoperative.

The licensed practical nurse is assisting the registered nurse (RN) in the care of a child who is receiving a blood transfusion and notifies the RN if the child displays which signs/symptoms of fluid overload? Select all that apply. 1. Chills 2.Itching 3.Back pain 4.Dry cough 5.Distended neck veins

4)Dry cough 5)Distended neck veins

When examining the umbilical cord immediately after birth, which blood vessels are present in a normal umbilical cord? Select all that apply. 1. One vein 2.Two veins 3.One artery 4.Two arteries 5.One capillary 6.Two capillaries

1. One vein 4. Two arteries

A licensed practical nurse has decided to purchase disciplinary defense insurance and is aware that this type of insurance would provide which type of benefits? Select all that apply. 1. Representation by a qualified attorney 2.Payment to an individual for negligent care 3.Reimbursement for travel to the state board of nursing 4.Payment of all legal fees for defense of negligent care 5.Payment of all legal fees for defense of a nursing license

1. Representation by a qualified attorney 3.Reimbursement for travel to the state board of nursing 5.Payment of all legal fees for defense of a nursing license

The nurse is assisting in the care of a client who has a serum sodium level of 128 mEq/L (128 mmol/L). The nurse relates which of the client's signs and symptoms to this electrolyte imbalance? Select all that apply. 1. Dry flaky skin 2.Bleeding from the gums 3.Weakness in all extremities 4.Confusion with garbled speech 5.Diarrhea with abdominal cramping

3.Weakness in all extremities 4.Confusion with garbled speech 5.Diarrhea with abdominal cramping

The nurse is checking a child for dehydration and documents that the child is moderately dehydrated. Which symptoms should be noted in determining this finding? Select all that apply. 1. Oliguria 2.Slight thirst 3.Pale skin color 4.Slightly sunken fontanels 5.Very dry, mucous membranes

1. Oliguria 4.Slightly sunken fontanels 5.Very dry, mucous membranes

Which interventions are appropriate for the care of an infant? Select all that apply. 1. Provide swaddling. 2.Talk in a loud voice. 3.Provide the infant with a bottle of juice at naptime. 4.Hang mobiles with black-and-white contrast designs. 5.Caress the infant while bathing or during diaper changes. 6.Allow the infant to cry for at least 10 minutes before responding.

1. Provide swaddling. 4.Hang mobiles with black-and-white contrast designs. 5.Caress the infant while bathing or during diaper changes.

The client has a three-way closed continuous bladder irrigation system. Which information should be included in the documentation for this client? Select all that apply. 1.Character of drainage 2.Presence of blood clots 3.Amount of drainage emptied 4.Client complaint of pain/spasms 5.Type and amount of irrigation fluid used 6.Frequency of emptying the drainage bag

1.Character of drainage 2.Presence of blood clots 3.Amount of drainage emptied 4.Client complaint of pain/spasms 5.Type and amount of irrigation fluid used

The nurse is reviewing a plan of care for a client with Addison's disease. The nurse notes that the client is at risk for dehydration and suggests nursing interventions that will prevent this occurrence. Which nursing interventions are appropriate components of the plan of care? Select all that apply. 1.Monitoring intake and output 2.Maintaining a low-sodium diet 3.Monitoring for changes in mental status 4.Encouraging an intake of low-protein foods 5.Encouraging fluid intake of at least 3000 mL/day

1.Monitoring intake and output 3.Monitoring for changes in mental status 5.Encouraging fluid intake of at least 3000 mL/day

The nurse provides information to a client following a gastrectomy who is now diagnosed with pernicious anemia. Which instructions about pernicious anemia should the nurse reinforce to the client? Select all that apply. 1. Provide meticulous and frequent oral hygiene. 2.Use additional lightweight blankets as needed. 3.Encourage a diet of foods with high iron content. 4.Check blood serum vitamin B12 levels every 1 to 2 years. 5.Administer replacement vitamin B12 monthly for the next 5 years.

1. Provide meticulous and frequent oral hygiene. 2.Use additional lightweight blankets as needed. 4.Check blood serum vitamin B12 levels every 1 to 2 years.

The nurse is caring for an older adult and knows that an ethical dilemma is most likely to occur in this population because of which issues? Select all that apply. 1. Limited vision 2.Chronic illness 3.Increased hearing 4.Improved memory 5.Lack of assertiveness

1. Limited vision 2.Chronic illness 5.Lack of assertiveness

The nurse in a prenatal clinic is teaching a group of pregnant clients about physiological adaptations during pregnancy. Which are increased during the first trimester of pregnancy? Select all that apply. 1. Pulse 2.Blood volume 3.Cardiac output 4.Blood pressure 5.Red blood cell mass 6.White blood cell count

1. Pulse 2.Blood volume 3.Cardiac output 5.Red blood cell mass