Study for NCLEX
A nurse is participating in a heath fair for older adult clients. What immunization should the nurse recommend for this age group?
Herpes zoster
Normal creatinine values?
0.5-1.5 mg/dl
Normal calcium values?
8.5-10.5
What is the normal PT value?
9.5-12 seconds
A nurse is caring fro a client who has bacterial meningitis.. Upon monitoring the client, what findings should the nurse expect?
Red macular rash
Amount of blood ejected by the heart in any one contraction is called?
Stroke volume
A mother brings her child to the clinic because the child has developed a rash on the trunk and scalp. The child is diagnosed with varicella. What will the nurse tell the mother about the infectious period?
"The infectious period is 1 to 2 days before the onset of the rash to 5 days after the onset of lesions and the crusting of lesions."
Meds most often used to treat status epilepticus?
-Diazepam (Valium) -Phenytoin (Dilantin) -Phenobarbitol (Luminol)
The nurse is assessing a client with bipolar disorder who is taking lithium carbonate and who has a lithium level of 1.7 mEq/L. The nurse would expect to find what sign/symptoms of lithium toxicity associated with this level?
-Incoordiantaion -Mental confusion -Muscle hyper irritability
The nurse is evaluating the data results of a client with sepsis and acute kidney injury with related azotemia and oliguria. What are the primary features of azotemia and oliguria?
-Increase in serum creatinine -Increase in blood urea nitrogen (BUN) -Urine output less than 0.5 mL/kg/hour
Dietary considerations for Cushings?
-Increase protein and potassium -Decrease sodium and calories
Dietary considerations for Celiac disease?
-No gluten -Increase calories -Increase protein
A morbidly obese client, 3 days postoperative gastric bypass surgery, comes to the clinic complaining of pain. The nurse suspects that the client has an anastomotic leak requiring hospitalization. What findings validate this suspicion?
-Oliguria -Restlessness -Abdominal pain -Unexplained tachycardia
The metabolic panel of a client reveals a calcium level of 6.5 mg/dL. Based on this laboratory finding, what additional data specific to this calcium level should the nurse collect?
-Presence of Chvostek's sign -Presence of electrocardiogram abnormality -Presence of tingling in the fingertips and around the mouth -Presence of carpal spasm when blood pressure cuff is inflated above systolic blood pressure for a few minutes
Normal magnesium values?
1.5-2.5
Normal sodium values?
135-145
Nagele's rule?
1st day of last menstrual cycle, minus 3 months, plus 7 days= estimated date of delivery
How many arteries and veins are in the umbilical cord?
2 arteries, 1 vein
What is the normal PTT value?
20-45 seconds
Normal potassium levels?
3.5-5.0
Normal PaCO2 value?
35-45
Normal WBC values?
5,000-10,000
Normal BUN values?
7-18 8-20 over 60 years
Normal blood pH?
7.35-7.45
A nurse is monitoring a client who is taking acarbse. What finding should the nurse identify as an adverse effect of the medication?
Abdominal cramps
Heparin sodium is prescribed for the client. What laboratory result indicates that the heparin is prescribed at a therapeutic level?
Activated partial thromboplastin time (aPTT) of 55 seconds
A nurse is caring for a client who had an acute ischemic stroke 1 day ago. What action should the nurse take to reduce the risk for aspiration?
Allow 30 minutes of rest before meals
A client with a history of hypertension has been prescribed triamterene (Dyrenium). The nurse determines that the client understands the effect of this medication on the diet if the client states to avoid what fruit?
Bananas
What is the normal heart and blood flow in the correct order?
Blood enters, Right atrium, Tricuspid valve, right ventricle, pulmonic valve, left atrium, mitral valve, left ventricle, aortic valve, and out to the body
A nurse is collecting data from a client who has chronic kidney disease with hyperkalemia. What findings should the nurse expect related to hyperkalemia?
Bradycardia
Ill health, malnutrition, and wasting as a result of chronic disease are all associated with?
Cachexia
Administered to asymptomatic human immunodeficiency virus (HIV)-infected children who are at increased risk for developing TB?
Calmette-Guerin Vaccine (BCG)
The nurse checks a closed chest tube drainage system on a client who had a lobectomy of the left lung 24 hours ago. The nurse notes that there has been no chest tube drainage for the past hour. What should the nurse do first?
Check for kinks in the chest drainage system.
How to mix insulin?
Clear before Cloudy (NPH)
A nurse is caring for a client who has a hx of breast cancer. The client asks the nurse about birth control. What method of birth control is contraindicated for this client?
Combination oral contraceptives
A nurse is reinforcing discharge teaching with a client who has cirrhosis. What instructions should the nurse include?
Consume foods low in sodium
What test is used to check Rh status?
Coombs test
What cranial nerve is optic?
Cranial nerve 2
A nurse is contributing to the plan of care for a client who has chronic obstructive pulmonary disease (COPD) and is dyspneic. What intervention should the nurse include in the plan?
Encourage abdominal breathing
A nurse is contributing to the plan of care for a client who has peripheral arterial disease (PAD) of the lower extremities. What interventions should the nurse include?
Dangle the extremities off the side of the bed.
A nurse is caring for a client who has a prescription for phenazopyridine. What finding should the nurse identify as a therapeutic effect of the medication?
Decreases pain during urination
Do Mydriatic drops constrict or dilate the pupils?
Dilate (myDriatic...D for dilate)
What is ptosis?
Drooping
A nurse is collecting data from a client who has hypokalemia. What finding should the nurse identify as a priority?
Dysrhythmia
Primary belief of psychiatric mental health nursing is?
Every person is worthy of dignity and respect
What sign is the softening of the cervix?
Goodell's
Broccoli, oranges, dark greens, and dark yellow vegetables can be eaten to?
Help improve body defenses
A nurse is reviewing the lab results of a client who has a chronic kidney failure and is receiving epotein alfa. The nurse should identify what lab value indicates the treatment is effective?
Hgb 11g/dL
A nurse is collecting data from a 55 year old female client who reports of vaginal dryness and hot flashes. The client is interest in trying hormone replacement therapy (HRT). What should the nurse recognize as a contraindication to HRT?
History of treatment for blood clots.
What nursing diagnoses might be appropriate as Parkinson disease progresses and complications develop?
Impaired physical mobility
A nurse is reinforcing teaching about management of constipation with a client who has hypothyroidism. What should the nurse include in teaching?
Increase intake of fiber rich foods
The nurse notes redness, warmth, and a yellowish drainage at the insertion site of a central venous catheter in a client receiving parenteral nutrition. These findings indicate what potential complication?
Infection of a central catheter site can lead to septicemia
The nurse is doing a routine assessment of a client's peripheral intravenous (IV) site. The nurse notes that the site is cool, pale, and swollen and that the IV has stopped running. The nurse determines that what has probably occurred?
Infiltration
Supine with legs straight and elevated at the hips and head is slightly raised (increases blood flow to heart and brain)
Modified Trendelenburg -Called the "Shock" position
A nurse is caring for a client who has acute pancreatitis. While providing care, the nurse observes ecchymosis around the umbilicus. The nurse should identify that this is a manifestation of what?
Intra-abdominal bleeding
A nurse is reinforcing teaching with a client who is on a low-sodium diet and asks how to improve the taste of bland food. What should the nurse recommend?
Lemon juice
A teenage client is admitted to the hospital because of tylenol overdose. Overdose of tylenol can precipitate life-threatening abnormalities in what organ?
Liver
The nurse is caring for a client who was admitted to the hospital with a fractured right femur sustained from a fall 5 hours ago. The client's plan of care includes interventions related to monitoring for signs of fat embolism. The nurse provides appropriate care by performing what action?
Monitoring for signs of dyspnea
Antidote for acetaminophen?
Mucomyst (Nacetylcysteine)
Normal value for Digoxin?
Normal is less than 2 ng/mL Toxic is greater than 2 ng/mL
What is the normal Lithium value?
Normal= less than 1.5 mEq/L Toxic= greater than 2 mEq/L
What is the constant and involuntary movement of the eyeball?
Nystagmus
The nurse is caring for a client with anorexia nervosa. The nurse is monitoring the behavior of the client and understands that the client with anorexia nervosa manages anxiety by what action?
Observing rigid rules and regulations
A nurse is reinforcing teaching with a client who has heart failure and a new prescription for hydrochlorothiazide. What finding should the nurse instruct the client to report to the provider?
Onset of nausea
Prolonged arching of the back with the head and heels bent backward?
Opisthotonos
The click that is heard or felt when the infant is supine and knees are flexed and hips are abducted (hip dyslpasia) is called?
Ortilani's sign
A nurse is monitoring an older adult client who has a history of an enlarged prostate and is experiencing suprapubic discomfort. What action should the nurse take first?
Palpate the abdomen
The nurse is assigned to care for a client who has a chest tube. The nurse is told to monitor the client for crepitus (subcutaneous emphysema). What method should be used to monitor the client for crepitus?
Palpating for the leakage of air into the subcutaneous tissues
The nurse is reviewing the history and physical examination of a client who will be receiving asparaginase (Elspar), an antineoplastic agent. The nurse consults with the registered nurse regarding the administration of the medication if what is documented in the client's history?
Pancreatitis
A client with a stroke (brain attack) is experiencing residual dysphagia. The nurse should remove what food items that arrived on the client's meal tray from the dietary department?
Peas
A nurse is caring for a client who has a compound fracture of the femur and was placed in balanced suspension skeletal traction 4 days ago. What action should the nurse take?
Perform pin site care daily
Painless vaginal bleeding is a possible sign of?
Placenta previa
A client with lung cancer is receiving a high dose of methotrexate (Rheumatrex). Leucovorin (citrovorum factor, folic acid) is also prescribed. The nurse who is assisting in planning care for the client understands that administering the leucovorin is for what purpose?
Preserve normal cells.
After a tonsillectomy, a child is brought to the pediatric unit. The nurse places the child in what appropriate position?
Prone
Antidote for heparin?
Protamine sulfate
Enoxaparin sodium (Lovenox) is prescribed for the client following hip replacement surgery. The nurse prepares to have what available in the event that an overdose of the medication occurs?
Protamine sulfate
The nurse assists to prepare a teaching plan regarding the administration of eardrops for the parents of a 2-year-old child. What should be included in the plan?
Pull the earlobe down and back before instilling the ear drops.
A nurse is caring for a client who is 1 day postoperative following a hip arthroplasty. The client is exhibiting hypotension, tachycardia, and tachypnea. The nurse should recognize that these findings indicate what complication?
Pulmonary embolism
The nurse notes documentation that a client is exhibiting Cheyne-Stokes respirations. On data collection of the client, the nurse expects to note what finding?
Rhythmic respirations with periods of apnea
Peripheral edema, bounding pulses, juglar vein distention, decreased/absent urinary output are signs of right or left sided heart failure?
Right-sided heart failure
"The disease is transmitted by contact with nasal or oral fluids, so any items contaminated with these types of fluids, such as a drinking cup, should not be used by your other children."
Roseola infantum
Teaching the client with gonorrhea how to prevent reinfection and further spread is an example of?
Secondary prevention
A nurse in a long term care facility is collecting data from a client who reports fullness in the rectum and abdominal cramping. What finding should indicate to the nurse that the client might have a fecal impaction?
Small liquid stools
The major electrolytes in the extracellular fluid are?
Sodium and Chloride
What is a continuous seizure that must be interrupted by emergency measures?
Status epilepticus
The nurse is caring for a neonate born to a mother who is addicted to drugs. The nurse expects to make what observation while caring for the neonate?
The neonate cries incessantly.
A nurse is performing an ECG on a client who is scheduled for surgery the following morning. What location should the nurse place the V1 electrode?
The nurse should identify that the V1 electrode should be placed in the 4th intercostal space just right of the sternum.
In caring for a preterm newborn's skin, what special characteristics should the nurse expect to note?
Thin and gelatinous skin with decreased amounts of subcutaneous fat and an open posture
What is the HEELP Syndrome?
This is pre-eclampsia with liver involvement
A nurse is examining a client's IV site and notes a red line up his arm. The client reports a throbbing, burning pain at the IV site. The nurse should identify that the client's manifestations indicate what complication of IV therapy?
Thrombophlebitis
Cycloserine (Seromycin) is added to the medication regimen for a client with tuberculosis. What instruction should the nurse reinforce in the client-teaching plan regarding this medication?
To return to the clinic weekly for serum drug-level testing
A client with ascites is scheduled for a paracentesis. The nurse is assisting the health care provider in performing the procedure. What position should the nurse assist the client into for this procedure?
Upright
What fetal heart monitoring pattern can indicate cord compression?
Variable deceleration
An adult client with a history of ear infections reports a right earache accompanied by a sensation of fullness. The client also reports nausea and has a temperature of 100.6° F. The nurse questions the client about which aspect of the client's history?
Whether the client has had a recent upper respiratory infection (URI)
Cyanosis, increased respiratory rate, decreased blood pressure, pulmonary crackles are signs or right or left sided heart failure?
left-sided heart failure