Hessy & Saunders NCLEX Questions (use multiple choice)

with breakfast to reduce likelihood of nocturia and nausea

When should hydrochlorothiazide be taken?

3

Which is the most appropriate catheter for a male client with severe urinary retention, a history of urinary tract infections, and a stage 4 decubitus on the coccyx? REFER TO CHART.

decrease in serum protein levels

Which lab test will the PN monitor to determine if the decreased hepatic blood glow is the cause of a patient's fluid volume deficit?

uric acid

Which lab value should the nurse monitor for an increase, during treatment with busulfan (Myleran)?

345

Which qualities are traits of an addictive personality? Select all that apply. 1. Confusion 2. Illogical thinking 3. Negative self-image 4. Feelings of insecurity 5. Low tolerance for stress

residual and disorganized

Which subtypes of schizophrenia have a (worst) poor prognosis?

Danozol

Which teratogen causes masculinization of the female fetus

It will pull fluid from the interstitial and intracellular spaces into the blood stream and cause fluid volume deficit due to it being hypertonic

Why is it a problem if a patient's labs has a serum sodium level of 135 and they're prescribed an infusion of 3% normal saline to infuse at 100 ml/hr?

anaphylactic reactions after vaccinations

Why would you not administer a vaccine?

decongestants, anticholinergics, and antidepressants.

With BPH, episodes of urinary retention can be triggered by which medications?

1 hour before meals

cystic fibrosis pt needs chest percussion when?

bed rest

A cervical radiation implant is placed in the client for treatment of cervical cancer. Which activity would the nurse most likely expect to note in the health care provider's prescriptions?

Ensure that small clamps are attached to the AV shunt dressing.

A client has an arteriovenous (AV) shunt in place for hemodialysis. The nurse should take what priority precaution, knowing that bleeding is a potential complication?

Side-lying with the legs pulled up and the head bent down onto the chest

A client is about to undergo a lumbar puncture (LP). The nurse tells the client that which position will be used during the procedure?

flat neck veins

A client is admitted with a diagnosis of pneumonia and dehydration. The nurse monitors the client for which symptom that correlates with this client's fluid imbalance?

Continue with the treatment because this is expected.

A client with a burn injury is applying mafenide acetate (Sulfamylon) to the wound. The client tells the nurse that the medication is uncomfortable and is causing a burning sensation.

going for a walk with staff

A mental health nurse caring for a client diagnosed with mania selects which activity for this client?

multi-lumen subclavian catheter

A patient is to get short term TPN treatment that will last 10 days, what access device will the HCP insert at the bedside?

The drainage will become thicker and appear more yellow or yellow-brown.

A patient with a new ileostomy asks if the dark green liquid stoma drainage is normal, what should the PN respond?

decreased cerebrospinal fluid production

A pt has a supratentorial lesion, the nurse monitors the client for effectiveness of Acetazolamide, knowing which is its primary action?

foul-smelling ribbon-like stools

An infant with Hirschprungs disease has what?

Administer insulin using a sliding-scale protocol

After a non diabtic patient has been receiving TPN solution of 50% dextrose at 60 mL/hour and the fingerstick glucose level 6 hours after the TPN started is at 215, what action should be taken by the PN?

risk for injury (thrombus formation)

After discovering a patient has phlebitis from an IV infusion, which problem does the PN identify as the most pertinent problem in this situation?

Kiwi Bananas Avocados

Foods that can trigger a latex allergy (esp for children with spinabifida)

rubber shod clamps

For a chest tube drainage system, what equipment should be available, in the event that the drainage system needs to be changed?

Diaphoresis and hyperpyrexia

For a pt receiving haloperidol may be developing neuroleptic malignant syndrome, what are signs?

body weight

For ongoing evaluation of a patients fluid volume status it is most important to obtain which data?

.5 mL intramuscularly within 12 hours of birth

Hep B vac for newborn w/ hep B positive mom is what and when?

straighten the joint above the site

If the IV pump alarm sounds, and indicates an obstruction, and there's no kinks in the tubing, what intervention will the PN take next?

2-3 weeks

Imipramine hydrochloride is an antidepressan takes how long to take effect?

abdominal guarding (may indicate perforation of the intestine)

Immediately after the sigmoidoscopy, it is important for the PN to monitor for which manifestation?

Tell me about your concerns right now.

Newly dx pt w/ multiple myeloma asks, "How long do you think I have to live?" Response?

"You should follow your diet as prescribed by the dietician." AND "You should perform regular exercise to maintain a normal health status."

Pt has DM, which statements made by the nurse are based on the second level of health promotion as per the U.S. Department of Public Health?

Making exaggerated use of old, familiar mechanisms.

Pt with vascular dementia probably what?

risk of pulmonary embolism

Reason for not putting weight on popliteal space after surgery?

Further teaching on skin care is necessary.

Patient is putting ice packs or heating pad on area of erythema caused by radiation therapy...

Prescription of corrective lenses

Treatment of refractive errors in both eyes?

Using products with lemon or alcohol

The nurse is administering mouth care to an unconscious client, what should the nurse avoid using to prevent drying and cracking?

300 units/L

The nurse is assigned to a hospitalized client with chronic pancreatitis. The nurse reviews the client's record and expects to note a serum amylase level that is most alike to which value?

Acute Resuscitative Rehabilitative

The nurse is caring for a client who is a victim of a major burn injury. Which are the names of the primary phases of burn care assessment?

blood pressure

The nurse is caring for a client who is receiving hydralazine (Apresoline). The nurse evaluates the effectiveness of the medication by monitoring which client parameters?

gown and gloves

The nurse prepares to give a bath and change the bed linens on a client with cutaneous Kaposi's sarcoma lesions. The lesions are open and draining a scant amount of serous fluid. What should the nurse done?

2

The nurse should plan to fill which chamber of the chest drainage unit to prevent atmospheric air from re-entering the pleural space? Refer to figure.

cranberries

Urinary tract infection is beginning medication therapy with nitrofurantoin (Macrodantin), avoid what food to maintain and acidic urine?

heart failure

What do you monitor a child with Kawasaki disease?

active transport

What involves trapping of bacterial cells through phagocytosis and requires energy expenditure?

hypokalemia

What might Hydrocholothiazide, a potassium-wasting diuretic, cause?

decreased hepatic blood flow

What problem often occurs in the elderly that may contrubute to a fluid volume deficit?

Pheochromocytoma

a benign tumor of the adrenal medulla that causes the gland to produce excess epinephrine (Congestion heard on auscultation of the lungs is a potential complication)

Brings objects from the hand to mouth

a motor function at 3 months

talk to nurse several times a day

activity for bipolar pt 1st week at unit?

Teleology

associated with the understanding that all actions are directed toward some ends, sometimes stated as "the ends justify the means."

coronary artery disease

baclofen (Lioresal) is contraindicated for patients with what?

self

basic therapeutic tool used to foster a client's psychological coping?

veracity

being truthful

uric acid

busulfan (Myleran) can cause an increase in what? (which can cause renal stones, and acute kidney injury)

350 mg orally 3 or 4 times daily

carisoprodol (Soma) the normal adult dosage for carisoprodol?

chemical irritation

client's IV site is warm, red, and tender, most-likely why?

systemic effects

coal tar can cause what?

bloody diarrhea and anal bleeding

common symptoms of ulcerative cholitis

fetal head compression

early decelerations of the fetal heart rate with a return to the baseline at the end of each contraction means what?

Peripheral neuritis

inflammation of the nerves of the PNS, numbness, paresthesias, and tingling in the extremities, an adverse effect of isoniazid, also

Brudzinski's sign

is observed if the client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column (used when patients have meningeal irritation)

pernicious anemia

lack of mature erythrocytes caused by inability to absorb vitamin B12 into the bloodstream (patients with a hemigastrectomy commonly have this)

amitriptyline

may cause glaucoma, causes dilation of the pupil (mydriasis), and IOP

Akathisia

motor restlessness

wheezes

musical whistling noises on inspiration and expiration scattered throughout the right lung fields

darkened urine

nurse suspects fluid volume deficiency on pt w/ weight loss, if?

Dependent personality disorder

personality disorder characterized by anxious and fearful behavior?

blood in urine

pt call doctor immediately taking coumadin if?

abdominal distention

sign of hypokalemia?

6 hours

spermacide cervical cap left in how long?

Kernig's sign

tests for meningeal irritation and pt flexes legs at hip and knee and complains of pain along vertebral column when leg extended

grief

therapy is most beneficial after an immediate event has passed?

Wooden puzzle with large pieces

toy for 2 year old?

Alzheimer disease

"It is a slow, relentless deterioration of the mind."

lactose intolerence

"It is the inability to tolerate sugar found in dairy products."

6 am, 2 pm, 10 pm

"Take three times a day." Means what?

1 fingerbreadth below the symphysis pubis

"What does it mean that the baby is at minus one?"

Decrease medication resistance and reduce medication toxicity.

A client with bladder cancer is receiving cisplatin and vincristine (Oncovin). The nurse plans care, knowing that which is the purpose of administering both of these medications?

a round or oval darkened area on the eardrum

A perforated eardrum is suspected in a client who was hit in the ear with a basketball. Which otoscopic examination finding supports this suspicion?

Less anxious and more aware of reality and ready to learn.

Most effective time to teach clients after sudden, traumatic, major loss is during the acceptance or adaptation coping stage, why?

IV push (but should be diluted in IV solution and administered over several hours)

What should potassium chloride NEVER be?

Spread the client's feet away from each other.

What should the nurse do to widen the client's base of support during the transfer?

carbidopa-levodopa (Sinemet)

What statement indicates a need for further teaching for a patient taking carbidopa-levodopa (Sinemet) for parkinsons disease?

Monitoring and evaluating the client's condition

What task is the role of the registered nurse, not an LPN delegatee?

pectin-based solid skin barrier

What type of product should the PN review with a patient with a new ileostomy for protection around the stoma?

Analyze the data to determine if characteristics occur that define a problem. A problem is then stated, a goal is established and interventions are planned and then implemented.

When a patient has phlebitis from IV infusion, and the PN plans to remove the IV and restart it in a new location, what step of the nursing process does the PN use after observing the IV site?

X-ray is used to visualize the large intestine after the barium enema is instilled.

When a patient is scheduled for a sigmoidoscopy, what explanation should the PN provide?

splenic rupture

When a patient with Epstein-Barr virus (mononucleosis) feels pain in the abdomen or shoulder pain what does this indicate?

auscultate breath sounds because fluid can collect in the lungs and impair oxygen exchange resulting in hypoxemia

When a patients intake is showing greater than her output, and in danger of developing fluid volume excess, what assessment is important for the PN to perform?

corticosteroid

When a pt is diagnosed with systemic lupus erythematosus (SLE). Which medication does the nurse expect to be prescribed?

6 hours before bed

When should pts take central nervous system (CNS) stimulant to avoid sleep disturbances?

To prevent from measuring ambient temperature.

Why do you put the temporal thermometer flush to the skin?

oral

With an Acetaminophen (Tylenol) overdose, Acetylcysteine is prescribed to be administered to the client immediately. The nurse prepares to administer the medication by which route?

fat free

A client is scheduled for an oral cholecystography, the nurse should plan to obtain what type of diet for the evening meal before the test?

Void then bladder scan and straight cath if 100mls in bladder

A client is to be monitored for residual urine every 8 hours. Which are appropriate nursing actions for the nurse to complete this task?

can't copy diamond shape

7 year old is delayed if?

toxic megacol causing massive dilation of the colon and can result in perforation and peritonitis

A patient with ulcerative cholitis develps a fever and tachycardia. She complains of abdominal cramps and the PN palpates an abnormal mass over the area of the transverse colon. What does the PN recognize as a complication of ulcerative cholitis?

Count the client's radial pulse rate.

When observing hypostatic vital sign changes, after taking the first blood pressure, what action will the PN take?