Saunder NCLEX-PN 3

The nurse is collecting data from a pregnant client with a history of cardiac disease and is checking the client for venous congestion. The nurse inspects which body areas, knowing that venous congestion is commonly noted in which areas? Select all that apply. 1.Legs 2.Vulva 3.Fingers 4.Around the eyes 5.Around the abdomen

1,2

A client is admitted to the emergency department with carbon monoxide poisoning. Which signs and symptoms indicate carbon monoxide poisoning? Select all that apply. 1.Mental changes 2.Cardiac irregularities 3.Cherry-red skin color 4.Abnormal arterial blood gas results 5.Negative carboxyhemoglobin levels

1,2,3

The nurse is teaching the client with angina pectoris about disease management and lifestyle changes that are necessary in order to control disease progression. Which statements by the client indicate a need for further teaching? Select all that apply. 1."I will avoid using table salt with meals." 2."I am going to switch to electronic cigarettes." 3."It is best to exercise once a week for an hour." 4."I will take nitroglycerin whenever chest discomfort begins." 5."I will use muscle relaxation to cope with stressful situations."

2,3

The nurse is reviewing the record of a pregnant client and notes that the primary health care provider has documented the presence of Chadwick's sign. The prenatal client asks the nurse to explain Chadwick's sign. Which information provided by the nurse is accurate? Select all that apply. 1.Chadwick's sign relates to fundal height. 2.Chadwick's sign is a probable sign of pregnancy. 3.Chadwick's sign may be present as early as 6 weeks' gestation. 4.Chadwick's sign is a bluish discoloration of the vagina and cervix. 5.Chadwick's sign occurs when the pregnant client experiences fetal movement.

2,3,4

Which statements made by a nursing student indicate that the student has an appropriate knowledge base regarding the pregnancy hormone human chorionic gonadotropin (hCG)? Select all that apply. 1."Maximum level of human chorionic gonadotropin is reached at term." 2."Human chorionic gonadotropin is the hormone responsible for a positive pregnancy test." 3."Human chorionic gonadotropin may be present as early as 8 to 10 days following conception." 4."Human chorionic gonadotropin is produced by the trophoblastic cells that surround the developing embryo." 5."Human chorionic gonadotropin preserves the function of the ovarian corpus luteum so that estrogen and progesterone are produced before placental functioning."

2,3,4,5

The nurse is preparing to administer an intermittent tube feeding to a client. The nurse aspirates 90 mL of residual from the tube. What should the nurse do? Select all that apply. 1.Hold the feeding. 2.Document the amount of residual. 3.Place it into a container for laboratory analysis. 4.Reinstill the residual and administer the feeding. 5.Deduct the amount of the residual from the new feeding before administering.

2,4

Potassium iodide is prescribed for a client. The nurse reinforces instructions to the client that the primary health care provider should be notified if the client experiences which symptom? Select all that apply. 1.Gastric upset 2.A burning in the mouth 3.A bitter taste in the mouth 4.A brassy taste in the mouth 5.Soreness of the gums and teeth

2,4,5

The nurse is caring for a client who just been prescribed alendronate. Which conditions contraindicate this medication being given to the client? Select all that apply. 1.Liver failure 2.Hypocalcemia 3.Cardiac disease 4.Poor renal function 5.Irritable bowel syndrome (IBS) 6.Gastroesophageal reflux disease (GERD)

2,4,6

A client is at risk for developing hypocalcemia. The nurse determines which signs are associated with this electrolyte disturbance? Select all that apply. 1.Increased heart rate 2.Increased blood pressure 3.Positive Trousseau's sign 4.Hypoactive bowel sounds 5.Fine tremors noted in hands

3,5

The 16-year-old client presents to the dermatology clinic with a diagnosis of acne vulgaris. The client says to the nurse, "I don't know what else to do! I wash my face twice a day. I wear noncomedogenic makeup. I shower after I work out. I guess I'm just going to have acne on my face forever." Which responses by the nurse would be appropriate? Select all that apply. 1."You need to try witch hazel." 2."I understand. When I was your age, I had acne problems, too." 3."You feel like there's nothing else you can do to cure your acne." 4."Your acne really isn't that bad! Our last client's acne was much worse." 5."You seem frustrated by your acne. Please tell me what it is about your acne that is frustrating."

3,5

The nurse should implement which interventions for a child older than 2 years with type 1 diabetes mellitus who has a blood glucose level of 60 mg/dL (3.4 mmol/L)? Select all that apply. 1.Administer regular insulin. 2.Encourage the child to ambulate. 3.Give the child a teaspoon of honey. 4.Provide electrolyte replacement therapy intravenously. 5.Wait 30 minutes and confirm the blood glucose reading. 6.Prepare to administer glucagon subcutaneously if unconsciousness occurs.

3,6

The nurse is collecting initial data on a newborn in the delivery room. Which observations should the nurse expect to note in a healthy newborn? Select all that apply. 1.Sunken anterior fontanel 2.Appearance of facial jaundice 3.Heart rate of 80 beats per minute 4.Respiratory rate of 40 breaths/minute 5.Three umbilical cord vessel, two arteries and one vein

4,5

A 39-year-old man learned today that his 36-year-old wife has an incurable cancer and is expected to live not more than a few weeks. The nurse identifies which responses by the husband as indicative of effective individual coping? Select all that apply. 1.He states that he will not allow his wife to come home to die. 2.He refuses to visit his wife in the hospital or to discuss her illness. 3.He immediately arranges for their three teenage children to live with relatives in another state. 4.He expresses his anger at God and the primary health care providers for allowing this to happen. 5.He tells the nurse he has prayed that God will allow his wife to live long enough to watch their children's high school graduation. 6.He has asked his wife and children to assist him in making funeral arrangements, such as casket selection and cemetery burial sites.

4,5,6

The nurse is observing a client who is independently performing the application of an ostomy appliance for the first time. Which actions observed demonstrate the need for further teaching? Select all that apply. 1.Assess the stoma and skin. 2.Remove the used pouch and barrier. 3.Perform hand hygiene and don gloves. 4.Lightly scrub the stoma with soap and water. 5.Press the adhesive backing of the pouch against the skin. 6.Cut the opening on the appliance ½ inch larger than stoma.

4,6

A client with hyperlipidemia is seen in the clinic for a follow-up visit. Which dietary modifications should the nurse include to lower the risk of coronary heart disease? Select all that apply. 1.Use liquid vegetable oil. 2.Increase intake of fruits. 3.Choose whole grain foods. 4.Remove skin from poultry. 5.Select whole milk products.

1,2,3,4

In caring for a preterm newborn, what knowledge related to skin care should the nurse consider when providing nursing care? Select all that apply. 1.Skin of the preterm baby is thinner than that of the full-term infant. 2.A preterm baby has less subcutaneous fat than the full-term infant. 3.The posture of the preterm infant will expose more skin to potential heat loss. 4.The preterm infant has a high body surface area in relation to their body weight. 5.The preterm infant has larger amounts of brown fat, which promotes thermoregulation.

1,2,3,4

The nurse is discussing prenatal testing with a woman who is approximately 6 weeks pregnant. The nurse shares which tests are expected to be conducted during the first trimester? Select all that apply. 1.Urinalysis 2.Rubella titer 3.Blood glucose 4.Complete blood count 5.Serum alpha-fetoprotein

1,2,4

The nurse is preparing to reposition a dependent client who weighs more than 250 lbs. Which interventions should the nurse use to move this client? Select all that apply. 1.Use a friction-reducing slide sheet. 2.Use a mechanical lift to move the client. 3.Place the client in Trendelenburg's position. 4.Keep elbows close and work close to the body. 5.Administer oral pain medication 5 minutes before moving the client. 6.Obtain assistance of a second caregiver to assist with mechanical aids.

1,2,4,6

A client with end-stage kidney disease (ESKD) undergoes a surgical procedure to create an arteriovenous fistula for hemodialysis in the upper extremity. The nurse should take which actions when the client returns from surgery? Select all that apply. 1.Monitor pain and administer analgesics. 2.Monitor bleeding and swelling at the site. 3.Monitor for circulation above the fistula site. 4.Measure the blood pressure in the arm every hour. 5.Check for audible bruit and palpable thrill at the fistula site.

1,2,5

The nurse is reviewing the complete blood count (CBC) laboratory results of a female adult client suspected of having iron deficiency anemia. The nurse reviews the results and determines that which results are consistent with this diagnosis? Select all that apply. 1.Hemoglobin (Hgb) 8.8 g/dL 2.Hematocrit (Hct) 30% 3.Platelet count 300,000 mm3 4.White blood count (WBC) 7500 mm3 5.Decreased mean corpuscular volume (MCV) 66 fL

1,2,5

The nurse is caring for a client who begins to experience seizure activity while in bed. Which actions by the nurse would be contraindicated? Select all that apply. 1.Restrain the client's limbs. 2.Loosen restrictive clothing. 3.Consider insertion of a padded tongue blade. 4.Remove the pillow and raise the padded side rails. 5.Position the client to the side, if possible, with head flexed forward.

1,3

The nurse is developing a teaching plan for a client following a radical mastectomy and includes measures that will assist in preventing lymphedema of the affected arm. The nurse should include which interventions when reviewing instructions with the client to prevent this complication? Select all that apply. 1.Elevate the affected arm on a pillow higher than the heart. 2.Place a cool compress or ice bag on the affected arm at bedtime. 3.Instruct the client to perform simple arm exercises in the affected arm daily. 4.Inspect the arm daily and notify the primary health care provider of redness or swelling. 5.Make sure that clothing fits snugly around the arm and wrap the arm with an ace wrap at bedtime.

1,3,4

The nurse is applying a topical corticosteroid to a client with eczema. The nurse should apply the medication to which body area? Select all that apply. 1.Back 2.Axilla 3.Eyelids 4.Soles of the feet 5.Palms of the hands

1,4,5

The nurse instructs a client at risk for hypokalemia from thiazide diuretic therapy about foods that are high in potassium. The nurse determines that there is a need for further teaching if the client states that which foods are high in potassium and should be included in the diet plan? Select all that apply. 1.Eggs 2.Beef 3.Pork 4.Raisins 5.White bread with butter

1,5

The nurse is reviewing the laboratory results of a client hospitalized with a diagnosis of Crohn's disease. The client has a magnesium level of 1.0 mEq/L (0.5 mmol/L). Which nursing interventions should the nurse initiate? Select all that apply. 1.Monitor the client for dysrhythmias. 2.Instruct the client to consume low-calcium foods. 3.Instruct the client to include a banana in the daily diet. 4.Instruct the client to consume foods low in magnesium. 5.Notify the primary health care provider (PHCP) of the laboratory results.

1,5