Unit 3 Nclex

The mother of a toddler tells the nurse that she has a difficult time getting the child to go to bed at night. The nurse should suggest which to the mother?

Inform the child of bedtime a few minutes before it is time for bed."

The nurse should use which best method to open the victim's airway if the victim sustained a neck injury?

Jaw thrust maneuver

A client presents to the emergency department with lethargy; deep, regular respirations; and a fruity odor to the breath. The client's arterial blood gas (ABG) results are pH of 7.25, Pco2 of 34 mm Hg, Po2 of 86 mm Hg, and HCO3- of 14 mEq/L. The nurse interprets that the client has which acid-base disturbance?

Metabolic acidosis

A client with a tentative diagnosis of gastroesophageal reflux is going to undergo ambulatory pH monitoring. The nurse assists in the procedure and should bring which item to the bedside?

Nasogastric (NG) tube

The nurse is reinforcing instructions to a client following mastectomy who will be discharged with an axillary drain in place. The client will be receiving home care visits from a nurse to monitor drainage and perform dressing changes. Which statement by the client indicates a need for further teaching?

"I need to begin full range-of-motion (ROM) exercises to my upper arm as soon as I get home."

The nurse is reviewing the serum magnesium results for a group of clients. Which results warrant a call to the health care provider by the nurse? Select all that apply.

1.2 mg/dL, 3.0 mg/dL, 4.2 mg/dL

The nurse is obtaining the intershift report for a group of assigned clients. The nurse plans to monitor which client for signs of hyperkalemia because of the physiology associated with the health problem?

A client with a new burn injury

The nurse is caring for a client with a diagnosis of myocardial infarction (MI). The client reports chest pain. When the administration of a sublingual nitroglycerin tablet as prescribed does not relieve the chest pain, which is the next nursing action?

Check the blood pressure and administer another nitroglycerin tablet.

A child with leukemia is experiencing nausea related to medication therapy. The nurse, concerned about the child's nutritional status, should offer which during an episode of nausea?

Cool, clear liquids

The nurse is collecting data on a client who sustained circumferential burns of both legs. The nurse should check which first?

Peripheral pulses

A client has returned to the nursing unit following abdominal hysterectomy. To most effectively gather data on the client's postoperative bleeding, the nurse would implement which intervention?

Rolling the client to one side to view bedding

Which finding in the prenatal client supports the medical diagnosis of placental abruption?

Tender, rigid abdomen

The nurse is completing the laboratory requisition that will accompany an arterial blood gas (ABG) specimen sent to the laboratory for analysis. The nurse understands that which data will be needed by the laboratory for adequate evaluation of the specimen? Select all that apply.

The client's temperature The date the specimen was drawn The time the specimen was drawn Any supplemental oxygen the client is receiving

The nurse is administering intramuscular iron to an assigned client. The nurse should take which action to avoid skin staining around the injection site?

Use a Z-track method for administration.

A pregnant woman has a positive history of genital herpes, but she has not had lesions during her pregnancy. The nurse plans to provide which information to the client?

You will be evaluated at the time of delivery for herpetic genital tract lesions. If they are present, a cesarean delivery will be needed."

Which arterial blood gas (ABG) result should the nurse anticipate in the client with profuse vomiting for 2 days?

pH 7.49; Pco2 45; HCO3- 30

The client is to receive a Fleet enema. Which is the best position for administering an enema? Refer to figure.

side lying

The nurse is caring for a client with a suspected diagnosis of hypercalcemia. Which sign/symptom is an indication of this electrolyte imbalance?

Generalized muscle weakness

A client has been placed on neutropenic precautions. Which information is appropriate when explaining what this means? Select all that apply.

Get plenty of sleep and rest. Take all medications as prescribed. wash your hands frequently with antibacterial soap

The nurse is inserting an indwelling urinary catheter into the urethra of a client. As the nurse inflates the balloon, the client complains of discomfort. Which is the appropriate nursing action?

Aspirate the fluid, advance the catheter further, and reinflate the balloon.