Saunders NCLEX RN Pretest review
Content: acetylsalicylic acid (aspirin) poisoning A 5 year old boy is brought by his mother to the emergency department after ingesting a bottle of acetylsalicylic acid. Which procedure should be initially instituted with this child? 1. Administer ipecac by mouth and monitor emesis. 2. Institute a gastric lavage and administer activated charcoal. 3. Administer a chelating agent such as edetate calcium disodium. 4. Institute a gastric lavage and administer the antidote acetylcysteine.
Answer: 2. Institute a gastric lavage and administer activated charcoal Rationale: A gastric lavage must be performed after ingestion of acetylsalicylic acid, and activated charcoal is administered to prevent further absorption of the substance. N-acetylcysteine is the antidote for acetaminophen. Administering ipecac or edetate calcium disodium is not a treatment measure for acetylsalicylic acid poisoning. Edetate calcium disodium may be prescribed for the treatment of lead poisoning. Ipecac causes vomiting, and this substance is used only in specific poisoning conditions; in this situation, vomiting can cause irritation of the esophagus.
The nurse analyzes the laboratory values of a child with leukemia who is receiving chemotherapy. The nurse notes that the platelet count is 19,500 mm3 (19.5 × 109/L). On the basis of this laboratory result, which intervention should the nurse include in the plan of care? 1. Initiate bleeding precautions. 2. Monitor closely for signs of infection. 3. Monitor the temperature every 4 hours. 4. Initiate protective isolation precautions.
answer: 1 Rationale: Leukemia is a malignant increase in the number of leukocytes, usually at an immature stage, in the bone marrow. It affects the bone marrow, causing anemia from decreased erythrocytes, infection from neutropenia, and bleeding from decreased platelet production (thrombocytopenia). If a child is severely thrombocytopenic and has a platelet count less than 20,000 mm3 (20.0 × 109/L), bleeding precautions need to be initiated because of the increased risk of bleeding or hemorrhage. Precautions include limiting activity that could result in head injury, using soft toothbrushes, checking urine and stools for blood, and administering stool softeners to prevent straining with constipation. In addition, suppositories, enemas, and rectal temperatures are avoided. Options 2, 3, and 4 are related to the prevention of infection rather than bleeding.
The nurse is monitoring a 3-year-old child for signs and symptoms of increased intracranial pressure (ICP) after a craniotomy. The nurse plans to monitor for which early sign or symptom of increased ICP? 1. Vomiting 2. Bulging anterior fontanel 3. Increasing head circumference 4. Complaints of a frontal headache
answer: 1 Rationale: The brain, although well protected by the solid bony cranium, is highly susceptible to pressure that may accumulate within the enclosure. Volume and pressure must remain constant within the brain. A change in the size of the brain, such as occurs with edema or increased volume of intracranial blood or cerebrospinal fluid without a compensatory change, leads to an increase in ICP, which may be life-threatening. Vomiting, an early sign of increased ICP, can become excessive as pressure builds up and stimulates the medulla in the brainstem, which houses the vomiting center. Children with open fontanels (posterior fontanel closes at 2 to 3 months; anterior fontanel closes at 12 to 18 months) compensate for ICP changes by skull expansion and subsequent bulging fontanels. When the fontanels have closed, nausea, excessive vomiting, diplopia, and headaches become pronounced, with headaches becoming more prevalent in older children.
What is the priority nursing action when admitting a client who has just attempted suicide? 1. Ensure constant observation of the client at all times. 2. Conduct a thorough mental health assessment of the client. 3. Determine whether the client has ever attempted suicide previously. 4. Remove all potentially dangerous articles from among the client's belongings.
answer: 1 Rationale: The plan of care for a client with a serious suicide attempt must reflect action that will promote the client's safety. Constant observation status (one-on-one by the nurse) and never being less than an arm's length away are the best interventions. While the remaining options are appropriate, none have the priority at the time of admission.
The nurse has inserted a nasogastric (NG) tube to the level of the oropharynx and has repositioned the client's head in a flexed-forward position. The client has been asked to begin swallowing. The nurse starts to slowly advance the NG tube with each swallow. The client begins to cough, gag, and choke. Which actions should the nurse take that will result in proper tube insertion and promote client relaxation? Select all that apply. 1. Pull the tube back slightly. 2. Instruct the client to breathe slowly. 3. Assist the client to take sips of water. 4. Continue to slowly advance the tube to the desired distance. 5. Check the back of the pharynx using a tongue blade and flashlight.
answer: 1, 2, 3, 5 Rationale: As the NG tube is passed through the oropharynx, the gag reflex is stimulated, which may cause coughing, gagging, or choking. Instead of passing through to the esophagus, the nasogastric tube may coil around itself in the oropharynx, or it may enter the larynx and obstruct the airway. Because the tube may enter the larynx and obstruct the airway, pulling the tube back slightly will remove it from the larynx; advancing the tube might position it in the trachea. Swallowing closes the epiglottis over the trachea and helps move the tube into the esophagus. Slow breathing helps the client relax, which reduces the gag response. The nurse should check the back of the client's throat to note whether the tube has coiled. The tube may be advanced after the client relaxes.
A woman infected with the human immunodeficiency virus (HIV) has given birth to an infant who appears normal, and the nurse provides instructions about newborn infant care. Which statement by the mother indicates an understanding of the instructions? Select all that apply. I am going to need to bottle-feed my baby." 2. "I need to wash my hands before and after bathroom use." 3. "I can transmit the infection to my baby when I breast-feed." 4. "My baby won't need any medication to prevent the virus because my baby appears normal." 5. "I am going to contact some support groups to help me cope and learn ways to deal with things when I get home."
answer: 1, 2, 3, 5 Rationale: Perinatal transmission of HIV to the fetus or neonate of an HIV-positive woman can occur during the antenatal, intrapartal, or postpartum period. HIV transmission can occur during breast-feeding; therefore, HIV-positive clients should be encouraged to bottle-feed their neonates. Note that in the United States HIV infection is considered a contraindication for breastfeeding. However, this may not be the practice in other countries. In developing countries where HIV is prevalent, the benefits of breast feeding for infants outweigh the risk of contracting HIV from infected mothers. Frequent hand washing is encouraged. It is recommended that newborn infants of HIV-positive clients receive antiviral medications for the first 6 weeks of life. Support groups and community agencies can be identified to assist the parents with the newborn's home care, the impact of the diagnosis of HIV infection, and available financial resources.
The nurse is reviewing the urinalysis results for a client with glomerulonephritis. Which findings should the nurse expect to note? Select all that apply. 1. Proteinuria 2. Hematuria 3. Positive ketones 4. A low specific gravity 5. A dark and smoky appearance of the urine
answer: 1, 2, 5 Rationale: In the client with glomerulonephritis, characteristic findings in the urinalysis report are gross proteinuria and hematuria. The specific gravity is elevated, and the urine may appear dark and smoky. Positive ketones are not associated with this condition but may indicate a secondary problem.
Acarbose is prescribed to treat a client with type 2 diabetes mellitus. Which instruction should the nurse provide when teaching the client about this medication? 1. Take the medication at bedtime. 2. Take the medication with the first bite of each regular meal. 3. The medication will be used to treat symptoms of hypoglycemia. 4. Headache and dizziness are the most common side effects of this medication.
answer: 2 Acarbose is an α-glucosidase inhibitor. Taken with the first bite of each major meal, acarbose delays absorption of ingested carbohydrates, decreasing postprandial hyperglycemia. It is not taken at bedtime. Abdominal pain and flatulence (not headache and dizziness) are the most common side effects of this medication.
The client with a traumatic brain injury (TBI) has begun excreting copious amounts of dilute urine through the Foley catheter. The client's urine output for the previous shift was 3000 mL. The nurse expects that the health care provider will prescribe which medication? 1. Mannitol 2. Desmopressin 3. Ethacrynic acid 4. Dexamethasone
answer: 2 Rationale: A complication of TBI is diabetes insipidus, which can occur with insult to the hypothalamus, the antidiuretic hormone storage vesicles, or the posterior pituitary gland. Urine output that exceeds 9 L per day generally requires treatment with desmopressin. Dexamethasone is usually given to control cerebral edema secondary to brain tumors. Ethacrynic acid and mannitol are diuretics, which would be contraindicated.
The mother of a 3-year-old is concerned because her child still is insisting on a bottle at nap time and at bedtime. Which is the most appropriate suggestion to the mother? 1. Allow the bottle if it contains juice. 2. Allow the bottle if it contains water. 3. Do not allow the child to have the bottle. 4. Allow the bottle during naps but not at bedtime.
answer: 2 Rationale: A toddler should never be allowed to fall asleep with a bottle containing milk, juice, soda pop, sweetened water, or any other sweet liquid because of the risk of nursing (bottle-mouth) caries. If a bottle is allowed at nap time or bedtime, it should contain only water.
A client is admitted to the psychiatric unit with a diagnosis of bipolar affective disorder and mania. The nurse should prioritize which assessment finding as requiring immediate intervention? 1. Grandiose delusions of being a czar of Russia 2. Constant physical activity and poor oral intake 3. Constant, incessant talking, with sexual innuendoes 4. Outlandish behaviors and wearing odd, eccentric clothing
answer: 2 Rationale: Mania is a period when the mood is predominantly elevated, expansive, or irritable. The client's mood may be characterized by excitement, euphoria, hyperactivity, excessive energy, decreased need for sleep, and impaired ability to concentrate or complete a single train of thought. Each of the options is reflective of possible symptoms. The need for adequate food and rest is the priority.
A client is experiencing blockage of the eustachian tubes. The nurse educates the client on how the client may forcibly open the eustachian tube. Which statement by the client indicates that the teaching has been effective? 1. I should tap the side of the head lightly." 2. "I should perform the Valsalva maneuver." 3. "I should use cotton-tipped applicators in the ears." 4. "I should chew food using exaggerated mouth movements."
answer: 2 Rationale: Performing the Valsalva maneuver increases pressure in the nasopharynx and may help open a blocked eustachian tube. The actions described in the other options will not accomplish this.
A client admitted with hypertensive crisis has an intravenous (IV) infusion of 1000 mL of normal saline with 20 mEq of potassium chloride added. A prescription is written to administer sodium nitroprusside by continuous IV infusion. The nurse should plan to do which to administer this medication? 1. Monitor the blood pressure every 15 minutes during administration. 2. Protect the sodium nitroprusside from light with an opaque material. 3. Check the solution for a faint brown coloration and discard it if this is noticed. 4. Piggyback the sodium nitroprusside into the IV line containing the potassium chloride.
answer: 2 Rationale: Sodium nitroprusside can be degraded by light and should be protected with an opaque material. It is dispensed in powdered form and must be dissolved and diluted for the IV solution. A fresh solution may have a faint brown coloration, but solutions that are deeply colored, such as blue-green or dark red, should be discarded. No other medication should be mixed with the infusion solution. During the infusion, the blood pressure should be monitored continuously either through an arterial line or with an electronic monitoring device.
The ambulatory care nurse is seeing a client for a follow-up visit after treatment for toxic shock syndrome (TSS). To assess the client's recovery from TSS, the nurse should ask whether which signs and symptoms have resolved? 1. Low-grade fever, nausea, and vaginal bleeding 2. High fever, abdominal pain, vomiting, and diarrhea 3. Low-grade fever, vomiting, and greenish vaginal discharge 4. High fever, purulent vaginal discharge, and abdominal pain
answer: 2 Rationale: The classic symptoms of TSS are high fever (temperature of 101°F [38.3°C] or higher), vomiting, and severe diarrhea. Other typical symptoms include headache, myalgia, chills, abdominal pain, dizziness, lethargy, possible confusion, and agitation. Vaginal bleeding or discharge is not part of the clinical picture. TSS typically is caused by Staphylococcus aureus infection associated with tampon use during menses.
A client has just been given a prescription for diphenoxylate with atropine. The nurse determines that the client understands important information about this medication if the client makes what statement? 1. "It's best to take this medication with a laxative." 2. "This medication contains a habit-forming ingredient." 3. "I might drool frequently from taking this medication." 4. "I will probably become irritable from taking this medication."
answer: 2 Rationale: The client should understand that an adverse effect of this medication is that it may be habit forming, so careful adherence to proper dose is important. The medication is an antidiarrheal and therefore should not be taken with a laxative. Side effects of the medication include dry mouth and drowsiness. Drooling and irritability are not associated with the use of this medication.
A maternity unit nurse is creating a plan of care for a client with severe preeclampsia who will be admitted to the nursing unit. The nurse should include which nursing intervention in the plan? 1. Restrict food and fluids. 2. Reduce external stimuli. 3. Monitor blood glucose levels. 4. Maintain the client in a supine position.
answer: 2 Rationale: The client with severe preeclampsia is kept on bed rest in a quiet environment. External stimuli such as lights, noise, and visitors that may precipitate a seizure should be kept to a minimum. Food and fluid are not restricted unless specifically prescribed by the health care provider. The client is instructed to rest in a left lateral position to decrease pressure on the vena cava, thereby increasing cardiac perfusion of vital organs.
The nurse is observing a caregiver minimize misbehavior when a child is playing with an excessively noisy toy. The nurse recognizes that further instruction is needed about the appropriate way to do this if the caregiver takes which action? 1. Tells the child, "Put that toy down." 2. Instructs the child, "Don't touch that toy." 3. Interacts with the child in a quiet, calm voice. 4. Offers the child a quiet toy in exchange for the noisy one.
answer: 2 Rationale: Minimizing misbehavior includes teaching desirable behavior through example, such as using a quiet, calm voice rather than screaming. Requests for appropriate behavior should be phrased positively, such as "Put that toy down" rather than "Don't touch that toy." Alternatives, such as offering a quiet toy in exchange for one that is excessively noisy, should be offered in response to annoying actions.
When teaching the client with adrenal insufficiency about cortisone, the nurse should include which items? Select all that apply. 1. Increase intake of sodium. 2. Take the medication with food. 3. Increase intake of potassium-rich foods. 4. Stay away from people with active infections. 5. Discontinue the medication when symptoms subside. 6. Notify the health care provider if illness occurs or surgery is anticipated.
answer: 2, 3, 4, 6 Rationale: Glucocorticoids should not be abruptly discontinued because acute adrenal insufficiency could occur. Because glucocorticoids cause sodium and water to be retained while causing loss of potassium, the client should limit sodium intake and increase potassium intake. These medications can increase the risk of infection; therefore, the client should avoid contact with clients who are ill. Taking the medication with food helps prevent stomach upset. Individuals may need an increase in dosage during illness or times of stress (surgery).
The community health nurse is creating a poster for an educational session for a group of women and will be discussing the risk factors associated with breast cancer. Which risk factors for breast cancer should the nurse list on the poster? Select all that apply. 1. Multiparity 2. Early menarche 3. Early menopause 4. Family history of breast cancer 5. High-dose radiation exposure to chest 6. Previous cancer of the breast, uterus, or ovaries
answer: 2, 4, 5, 6 Rationale: Risk factors for breast cancer include nulliparity or first child born after age 30 years; early menarche; late menopause; family history of breast cancer; high-dose radiation exposure to the chest; and previous cancer of the breast, uterus, or ovaries. In addition, specific inherited mutations in BReast CAncer (BRCA)1 and BRCA2 increase the risk of female breast cancer; these mutations are also associated with an increased risk for ovarian cancer.
The nurse is caring for a client with a respiratory disorder who is attempting to stop smoking. The health care provider has recommended nicotine gum. When reviewing this treatment with the client, the nurse should provide which instruction? Drink water while chewing the gum. 2. Only chew the gum for a maximum of 10 minutes. 3. Hold the gum between the cheek and teeth periodically. 4. Eat a light snack immediately before chewing the gum.
answer: 3 Rationale: Nicotine gum should be chewed for 30-minute intervals with periods of holding the gum between the cheek and teeth; food and drink should be avoided 15 minutes before or during use.
The nurse is creating a plan of care for a client scheduled for surgery. The nurse should include which activity in the nursing care plan for the client on the day of surgery? 1. Avoid oral hygiene and rinsing with mouthwash. 2. Verify that the client has not eaten for the last 24 hours. 3. Have the client void immediately before going into surgery. 4. Report immediately any slight increase in blood pressure or pulse.
answer: 3 Rationale: The nurse would assist the client to void immediately before surgery so that the bladder will be empty. Oral hygiene is allowed, but the client should not swallow any water. The client usually has a restriction of food and fluids for 6 to 8 hours (or longer as prescribed) before surgery instead of 24 hours. A slight increase in blood pressure and pulse is common during the preoperative period and is usually the result of anxiety.
The nurse provides teaching on how to relieve discomfort to a client in her second trimester of pregnancy who is having frequent low back pain and ankle edema at the end of the day. Which statement made by the client indicates an understanding of the teaching? 1. When I get home I should lie on my left side, with my feet in a dorsiflexed position." 2. "I should soak in a tub bath of hot water when I get home and then perform pelvic tilt exercises." 3. "When I get home I should lie on my right side, with my feet elevated on a pillow, and put a heating pad on my back." 4. "When I get home I should lie on the floor, with my legs elevated on a couch, and turn my hips and knees at right angles."
answer: 4 Rationale: Lying on the floor with the legs elevated on a couch with the hips and knees at right angles will produce a posture of pelvic tilt while countering gravity, which is the force that leads to edema of the lower extremities. Lying on the left side with the feet dorsiflexed may help with the reduction of hemorrhoids. Remember that heat needs to be prescribed by a health care provider (HCP).
The nursing student is caring for a client with a diagnosis of presbycusis. The nursing instructor determines that the student understands presbycusis when which statement is made? 1. "It's a loss of vision associated with aging." 2. "A loss of balance occurs with presbycusis." 3. "Presbycusis is a conductive hearing loss that occurs with aging." 4. "It's a sensorineural hearing loss that occurs with the aging process."
answer: 4 Rationale: Presbycusis is a type of hearing loss that occurs with aging. It is a gradual sensorineural loss caused by nerve degeneration in the inner ear or auditory nerve. The statements in the remaining options are incorrect statements about this condition.
The nurse is caring for a client who is brought to the hospital emergency department with a spinal cord injury. The nurse minimizes the risk of compounding the injury by performing which action? 1. Keeping the client on a stretcher 2. Logrolling the client onto a soft mattress 3. Logrolling the client onto a firm mattress 4. Placing the client on a bed that provides spinal immobilization
answer: 4 Rationale: Spinal immobilization is necessary after spinal cord injury to prevent further damage and insult to the spinal cord. Whenever possible, the client is placed on a special bed, such as a Stryker frame, which allows the nurse to turn the client to prevent complications of immobility while maintaining alignment of the spine. If a Stryker frame is not available, a firm mattress with a bed board under it should be used. The remaining options are incorrect and potentially harmful interventions.
Which client is at risk for the development of a potassium level of 5.5 mEq/L (5.5 mmol/L)? 1. The client with colitis 2. The client with Cushing's syndrome 3. The client who has been overusing laxatives 4. The client who has sustained a traumatic burn
answer: 4 Rationale: The normal potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A serum potassium level higher than 5.0 mEq/L (5.0 mmol/L) indicates hyperkalemia. Clients who experience cellular shifting of potassium in the early stages of massive cell destruction, such as with trauma, burns, sepsis, or metabolic or respiratory acidosis, are at risk for hyperkalemia. The client with Cushing's syndrome or colitis and the client who has been overusing laxatives are at risk for hypokalemia. MASSIVE CELL DESTRUCTION CAUSES HYPERKALEMIA
The nurse has provided instructions to a client with a diagnosis of rheumatoid arthritis about measures to protect the joints. Which statement by the client indicates a need for further instruction? 1. "I should slide objects rather than lifting them." 2. "I should try not to remain in the same position for a long period of time." 3. "I should use large joints instead of small joints when performing activities." 4. "Pain or fatigue is expected, and I should try to continue with the activity if this occurs."
answer: 4 Rationale: The client should be instructed to use pain or fatigue as an indicator and guide to increase, maintain, or decrease an activity level. If pain or fatigue is experienced, the client should rest. The client should learn to slide objects rather than lifting them and not remain in the same position for a long time. Whenever possible, the client should use large joints instead of small joints for activities and should use the joints in their most natural position.
Nitrofurantoin is prescribed for a client with a urinary tract infection. The client contacts the nurse and reports a cough, chills, fever, and difficulty breathing. The nurse should make which interpretation about the client's complaints? 1. The client may have contracted the flu. 2. The client is experiencing anaphylaxis. 3. The client is experiencing expected effects of the medication. 4. The client is experiencing a pulmonary reaction requiring cessation of the medication.
answer: 4 Rationale: Nitrofurantoin can induce 2 kinds of pulmonary reactions: acute and subacute. Acute reactions, which are most common, manifest with dyspnea, chest pain, chills, fever, cough, and alveolar infiltrates. These symptoms resolve 2 to 4 days after discontinuing the medication. Acute pulmonary responses are thought to be hypersensitivity reactions. Subacute reactions are rare and occur during prolonged treatment. Symptoms (e.g., dyspnea, cough, malaise) usually regress over weeks to months following nitrofurantoin withdrawal. However, in some clients, permanent lung damage may occur. The remaining options are incorrect interpretations. STUDY ADVERSE EFFECTS OF NITROFURANTOIN
