Fundamentals - NCLEX

What would be alarming in a post op colostomy patient? a. Purple Stoma b. Protrusion of Stoma c. Mucosa of the stoma bleeds slightly when touched d. Red peistomal skin under the adhesive

A. The stoma should appear red and moist. Stoma's dark in color show impaired circulation.

A nurse finds a client on the floor upon entering the room. The roommate reports that the client was trying to get out of bed and fell over the bedrail onto the floor. Which of the following is the correct documentation of this incident? a. Incident report completed b. client climbed over the bedrails c. client found lying on floor d. client was trying to get out of bed

C. document must be what nurse actually observes.

A nurse is preparing to perform nasopharyngeal suctioning for a client who is unable to cough up excessive secretions. Which of the following actions is appropriate? a. use the clean technique throughout the procedure b. Insert the catheter as the client exhales c. Apply suction for up to 20 seconds d. Perform suctioning while removing the catheter

D. Nasopharyngeal suctioning= sterile technique. Insert when client takes a deep breath. Do not suction more than 10-15 seconds at a time. Use intermittent suction as she rotates the catheter and withdraws it form the airway.

A nurse is preparing to administer 750 mL of 0.9% sodium chloride IV to infuse over 7 hr. The nurse should set the infusion pump to deliver how many mL/hr?

Volume needed/total infusion time= x mL/hr 750 mL/7 hr = 107.14 107=X

A nurse is caring for a young child who is prescribed a blood transfusion. The parents have refused the treatment due to religious beliefs. Which of the following actions should the nurse take? a. examine personal values about the issue b. tell the parents that this is a necessary procedure c. inform the parents that their con sent is not required d. contact the chaplain to explain the importance of the procedure

A. It is not appropriate to contact the chaplain without the parent's consent

A nurse is caring for a client who is receiving medication intramuscularly. The nurse should recognize that this route a. increases infection rates b. is the safest option c. has the slowest absorption rate d. decreases the client's risk for reactions

A. Because the IM route breaks skin integrity, the risk for infection is increased. -the oral route is the safest - muscles are highly vascular= medications absorbed quickly - IM increases risk for medication reactions because of rapid absorption rate

A nurse is admitting a client who is having an exacerbation of heart failure. In planning this client's care, when should the nurse initiate discharge planning? a. during the admission process b. as soon as the client's condition is stable c. during the initial team conference d. after consulting with the client's family

A. discharge planning should begin as soon as the client undergoes admission. The nurse should begin to assess the client's needs and plan for care during and after hospitalization. The initiation of discharge planning does not depend on the client's physiologic stability.

A nurse is reviewing a client's fluid and electrolyte status. Which of the following findings should the nurse report to the provider? a. Bun 15 mg/dL b. Creatinine 0.8 mg/dL c. Sodium 143 mEq/L d. Potassium 5.4 mEq/L

D

A nurse is monitoring an older adult client who is receiving IV fluid therapy. Which of the following assessment findings should the nurse recognize as an adverse effect of excess fluid therapy? (select all that apply) a. Edema b. Crackles in lungs c. oliguria d. elevated blood pressure e. Jugular venous distention

Edema, crackles in lungs, elevated blood pressure, JVD

A nurse is caring for a client who is combative in the emergency department. The provider orders wrist restraints after the client attempts to assault the admitting nurse. Which of the following actions is appropriate for the nurse to take? a. tie the restraints to the lower edge of the side rail b. remove each restraint one at a time every 2 hours c. ensure 3 finger-widths of space between the restraint and the client's wrist d. use a square knot to securely tie the restraints to the bed

Remove each restraint one at a time every 2 hours!! The nurse should ensure there are only two finger-widths of space between the restraint and wrist. Use a quick-release tie

A nurse is planning to teach a preschool child how to properly use a metered dose inhaler. Which of the following methods is appropriate for this child? a. hold the child in the lap while giving explanations b. help the child identify her feelings about using an inhaler c. encourage independent learning d. use role play and imitation when explaining

a. for a toddler b. for an adolescent d. for a preschooler Preschoolers learn best by role play and imitation.

A nurse is caring for a client who has recently started using a hearing aid worn behind the ear. Which of the following client statements indicates to the nurse that he understands the use of this assistive device? a. I expect to hear a whistling sound when I first insert the hearing aid b. I will be sure to remove my hearing aid before taking a shower

B. The client should remove any hearing device before showering because exposure to water can damage the hearing aid. Whistling during insertion is a sign that the hearing aid does not fit properly. Also, a buildup of cerumen or fluid in the ear can cause this sound.

A nurse is preparing to administer oral medications to a client who has dysphagia. Which of the following is an appropriate action by the nurse? a. have the client drink water from a straw after taking the medication b. instruct the client to lift his chin upward when swallowing medications c. offer each medication one at a time d. place the medication in the client's mouth

C.- give one at a time The nurse should instruct the client to avoid using straws, this increases risk of aspiration. Place chin in downward position when swallowing to prevent aspiration. The nurse should encourage the client to self-administer medications.

A client who is nonambulatory notifies the nurse to tell her that his trash can is on fire. After confirming the fire, which of the following actions should the nurse take next? a. call emergency fire code b. extinguish the fire c. confine the fire d. evacuate the client

D. According to the Race mnemonic, the first action in response to a fire is to rescue the client, moving to a safe area.

A nurse is teaching a client and his family how to care for the client's tracheostomy at home. Which of the following instructions is appropriate for the client and family? a. remove the outer cannula cautiously for routine cleaning b. uses tracheostomy covers when outdoors c. use sterile technique when performing tracheostomy care at home d. cleanse irritated skin with full-strength hydrogen peroxide

B. the client should never remove the outer cannula In the home environment clean technique is appropriate hydrogen peroxide can irritate the skin; therefore, 0.9% sodium chloride is recommended to cleanse the site to prevent further irritation.

A nurse is planning care for a client who has had a stroke resulting in aphasia and dysphagia. Which of the following tasks should the nurse assign to an AP? a. assist the client with a partial bed bath b. measure the client's BP after the nurse administers an antihypertensive medication c. test the client's swallowing ability by providing thickened liquids d. use a communication board to ask what the client wants for lunch e. irrigate the client's indwelling urinary catheter

a. within AP scope of practice b. within AP scope of practice c. NOT within scope of practice d. within AP scope of practice e. NOT within scope of practice