N-CLEX Questions

What should the summer camp nurse include when teaching a group of adolescents about West Nile Virus? 1. Antiviral medications are used to treat West Nile Virus 2. Using insect repellent containing DEET will kill the virus when a mosquito makes skin contact 3. Nothing can be done to prevent West Nile virus. 4. Symptoms of West Nile Virus include headache, fever, and fatigue

4 The West Nile Virus begins with flu-like symptoms such as headache, fatigue, and fever. These symptoms, however, may continue for several months.

A client with distended and tortuous veins along the inner aspects of both legs ask the nurse how to decrease the development of these veins. What should the nurse advise? 1. Exercise 2. Follow a low protein diet 3. Wear low heeled shoes 4. Elevate legs above heart several times per day 5. Do not cross legs

1,3,4,5

What interventions should the nurse include when teaching a client how to prevent and treat fungal infections of the feet? 1. Apply cornstarch to the feet after bathing 2. Put terbinafine hydrochloride cream 1% on affected areas twice a day for two weeks. 3. Wear socks at all times until infection has cleared up. 4. Wash feet daily with soap and water 5. Wear shower sandals when showering in public places 6. Wear shoes that allow feet to breathe

2,4,5,6

Which prescription by the ED physician for a client who fell from a ladder should the nurse question? 1. Record intake and output hourly 2. Prepare the client for a lumbar puncture? 3. Perform neurologic checks every 10 minutes 4. Schedule a brain computed tomography (CT) scan.

2. The traumatic injury to the brain from the fall may result in increased intracranial pressure. The reduction of pressure in the lumbar spine during a lumbar puncture may result in the potential for herniation of the brain. A lumbar puncture should not be performed.

A client is admitted from the emergency department to a medical unit. What acid base imbalance do the lab values indicate? Lab Values: pH = 7.44 PaCO2 = 30 HCO3 = 20

Compensated respiratory alkalosis The pH is normal but on the alkaline side of normal. The PaCO2 is also alkaline and matches the pH. So it's respiratory alkalosis, and its compensated because the pH is within normal range.

A alert elderly client has been admitted to the hospital and placed on bedrest following a fall at home. During evening medication rounds, the nurse notes the client has become disoriented to time and place. The nurse is aware a new onset of confusion could be the result of what factors? 1. admission to the hospital 2. amount of physical pain 3. current best confinement 4. advanced age 5. response to analgesic

1, 2, 3, 5 The sudden relocation to a new environment, along with pain from injury, could definitely contribute to an acute onset of confusion. The client's ordered bedrest and response to new pain medication and additional factors that could produce an acute change in mental status.

A nurse is developing a proposal to implement a pet therapy program at a nursing home. What information should the nurse include in the proposal to support this program? 1. evidence has shown that animals can directly influence a person's mental and physical well-being. 2. Bringing a pet into a nursing home for the elderly has been shown to enhance social interaction. 3. Petting an animal can be helpful in lowering bp. 4. some researchers believe that animals actually may retard the aging process among those who live alone. 5. Nursing home clients are more submissive after petting an animal

1, 2, 3, 4 Petting a dog or cat has been shown to lower bp. Studies indicate a 7 mm Hg drop in systolic and 8 mm drop in diastolic BP. When volunteers talked to or would pet their dogs as opposed to reading aloud or resting quietly.

The nurse initiated teaching for a client newly diagnosed with hypertension. What comments by the client indicate to the nurse that teaching have been successful? 1. "I have to take my medications on time every morning." 2. "One glass of wine with dinner would be acceptable." 3. "I will eliminate sodium from my daily food intake." 4. "Stress-reduction techniques can lower my pressure." 5. "Walking once a week is good exercise for me." 6. "I should add more fresh fruits and vegetables to my diet."

1, 2, 4,6

Which signs/symptoms does the nurse expect to see in a client diagnosed with Bell's Palsy? 1. Drooping one side of the face 2. Inability to wrinkle forehead 3. Excessive tearing 4. Decreased sensitivity to sound 5. Inability to taste 6. Numbness of affected side of face

1,2,3,5,6 Symptoms of Bell's Palsy include sudden weakness or paralysis on one side of face that causes droop (main sx), drooling, eye problems (such as excessive tearing or dry eye), loss of ability to taste, pain in or behind ear, numbness in the affected side of face, increased sensitivity to sound.

The nurse is caring for a client admitted with a diagnosis of pheochromocytoma. What signs/symptoms does the nurse expect during an acute episode? 1. Profuse sweating 2. Hypertension 3. Hypoglycemia 4. Tachycardia 5. Palpitations

1,2,4,5 The disease is characterized by hypometabolism which results in perfuse sweating, hypertension, tachycardia, hyperglycemia, palpitations and severe headaches. This is due to an increased release of epinephrine and norepinephrine.

The nurse is caring for a ventilator-dependent client assisted with positive expiratory end pressure (PEEP). The high-pressure alarm begins sounding. What actions should the nurse initiate? 1. Check to see if the client is biting ET tube 2. Examine tubing for presence of water 3. Inspect for any loose connections 4. Reduce the amount of PEEP used 5. Assess client's need for suctioning

1,2,5 The high-pressure alarm on a ventilator indicates the machine is pushing against excessive resistance while trying to deliver oxygen to the client. There are multiple potential causes for a high pressure alarm. the client could be fighting against the ventilator and thus biting down on the endotracheal tube. Another possible issue may be the water that accumulates in the vent tubing from condensation. Or the client may have excessive mucus in the airways that requires the nurse to suction lungs frequently. Any of these problems could initiate the high pressure alarm. Loose or disconnected tubing results in low pressure alarm. indicating the ventilator is unable to exert the expected amount of pressure needed to oxygenate client. The amount of PEEP provided to the ventilator-dependent client is determined by respiratory diagnosis or ABG's and is ordered by the primary healthcare provider. The high pressure alarm does not generally indicate a problem with the peep setting.

The nurse is preparing to administer a dose of ondansetron 0.15 mg /kg. The nurse has not administered this medication before and is using a drug reference to review information about the medication. Which client drug reference information supports the nurse's decision to withhold the ondansetron? 1. nystagmus 2. concurrent use of apomorphine 3. pill rolling movement 4. tachycardia 5. maximum dose 16 mg 6. elevated liver enzymes

1,3 Nystagmus and the pill rolling movement are signs of extrapyramidal effects of ondansetron, which would require the nurse to hold the medication and notify the primary healthcare provider.

A community health nurse is planning to discuss how to prevent pesticide ingestion at a local health fair. What should the nurse include in this teaching? 1. Discard the outer leaves of lettuce. 2. Wash fruits and vegetables with dish soap 3. Buy organic produce 4. Peel fruits prior to eating 5. Dry produce thoroughly with disposable paper towels after washing 6. Use a scrub brush when washing fresh fruits and vegetables

1,3,4,5,6

The nurse is teaching a client who is at risk for developing a stroke. What primary strategies should the nurse include? 1. Promote a diet rich in fruit and vegetables 2. Provide instruction on benefits of carotid endocardectomy 3. Limit sodium intake to 2 grams/day 4. Engage in low intensity exercise once a week. 5. Avoid tobacco products. 6. Decrease alcohol consumption to 2 drinks per day.

1,3,5,6

The nurse is caring for a client who has been receiving treatment for systolic heart failure. What assessment findings would indicate to the nurse that further treatment is necessary? 1. 3+ pedal edema 2. CVP of 6 mm Hg 3. One day weight loss of 2 lbs 4. Purse-lip breathing 5. Pail nail beds 6. Urine output at 50 mL/hr

1,4,5 These 3 findings would indicate further treatment is needed. Pail conjunctiva, nail beds, buccal mucosa are signs of impaired gas exchange.

An elderly client is admitted to the outpatient unit with anemia and is receiving a blood transfusion. What is the nurse's priority assessment? 1. Monitor for peripheral edema 2. Assess breath sounds 3. Keep bedrails up at all times 4. Monitor hemoglobin every 6 hours.

2. Assess breath sounds The client receiving a blood transfusion is at greater risk for fluid volume overload. The nurse should recognize that the very old and the very young are at increased risk for fluid volume overload which could manifest as wet breath sounds.

Which client should the nurse assess first? 1. Client who reports increasing size, firmness, and discomfort in the abdomen. 2. Client who develops a headache and dizziness after being started on losartan. 3. Client with a chest tube whose pulse oximeter reading is 92 mmHg while on 2L 02 4. Client who is receiving TPN and has a bg level of 140 mg/dL.

1. Client who reports increasing size, firmness, and discomfort in the abdomen. Increasing size, firmness, and discomfort in the abdomen can be an indicator of a serious issue such as peritonitis, bowel obstruction, or other abdominal issue that would require immediate notification of the healthcare provider. This is an unexpected change in the clients status that would require the nurses immediate respond.

The nurse recognizes which manifestation as signs of community-acquired pneumonia? 1. cough 2. decreased respiratory rate 3. fever 4. myalgia 5. pleuritic chest pain

1. cough 2. fever. 4. myalgia 5. pleuritic chest pain Rationale: signs of CAP include cough, crackles, egophony, tactile fremitus, fever, dyspnea, sputum production, myalgia, and pleuritic chest pain. A client with an infection (particularly pna) will exhibit these symptoms.

A client has been admitted with a stroke on the right side of the brain. What clinical manifestations does the nurse expect to find when assessing this client? 1.Right sided hemiplegia 2. Impaired judgement 3. Depression 4. Impaired language comprehension 5. Impulsiveness 6. Impaired speech

2, 5 The client with right sided brain damage will have left sided hemiplegia and will exhibit impulsive behavior and impaired judgement. All other answers (1,3,4,6 are incorrect because they are seen with left brain damage.

An elderly client living in a long-term care facility fell 8 hrs ago causing a laceration on the occipital area of the skull and steri-strips were applied for closure. Which signs/symptoms would indicate to the nurse that he client should be transferred to the emergency department? 1. Purposeful movement 2. Sudden emotional outbursts 3. Client report of blurred vision 4. Pupils equal, react to light, and accommodation 5. Bright red blood oozing from the wound 6. Headache unrelieved by acetaminophen

2,3,6 signs/symptoms of increased ICP include: excessive sleepiness, inattention, difficulty concentrating, impaired memory, faulty judgement, depression, irritability, emotional outbursts, disturbed sleep, diminished libido, difficulty swallowing between tow tasks, and slowed thinking. Abnormalities in vision and extraocular movements occur in early stages of increased ICP. A headache that is unrelieved by acetaminophen warrant further investigation.

A client has been admitted for observation after having a minor automobile accident. During the admission history, the client admits to being an alcoholic. Two hrs after admission the nurse notes the client's cardiac rhythm displayed on the telemetry monitor. The client reports shortness of breath, chest discomfort, and nausea. What initial action should the nurse take? 1. Cardiovert at 200 joules 2. Administer magnesium 1 gm IVP over 30 seconds 3. Begin CPR 3. Obtain a 12 lead ECG

2. Magnesium is the drug of choice for suppressing Torsades and terminating the arrhythmia. Magnesium can be given at 1-2 g IV initially in 30-60 seconds, which then can be repeated in 5-15 minutes. Torsades de pointes is associated with a prolonged QT interval. Torsades usually terminates spontaneously but frequently recurs and may degenerate into ventricular fibrillation. The hallmark of this rhythm is the upward and downward deflection of the QRS complexes around the baseline. The term Torsades de Pointes means "twisting about the points."

A client with a history of alcoholism arrives at the clinic reporting severe abdominal pain with nausea and vomiting. What additional findings would make the nurse suspect the client may have pancreatitis?

Bruising at the unbilicus Fever with tachycardia Pain radiating to back Whether the client is experiencing acute or chronic pancreatitis, symptoms are severe and distinct. Bruising around the umbilicus is referred to as "Cullens's Sign", indicating internal bleeding. Because of inflammation in the pancreas, the client generally becomes febrile and pain ca cause tachycardia. Considering the location of the pancreas, the client frequently experiences pain that radiates from the mid gastric area to the back.

The nurse evaluates an EKG and notices a U-wave. The nurse suspects that his occurrence is caused by which electrolyte imbalance? 1. Hypermagnesemia 2. Hypocalcemia 3. Hypokalemia 4. Hyponatremia

3. Hypokalemia The mose serious complications of hypokalemia are cardiac changes. Hypokalemia impairs myocardial conduction and prolongs ventricular repolarization. This can be seen in a prominent U-wave (a positive deflection following the T-wave on the EKG. The U-wave is not totally unique to hypokalemia, but its presence is a signal for the clinician to check the serum potassium level.

A client newly diagnosed with celiac disease is being instructed on a gluten-free diet. What statement by the client would indicated the nurse that further teaching is needed? 1. "I will still have occasional abdominal discomfort" 2. "I may need to take iron or vitamin supplements" 3. "I can have eggs but not wheat toast for breakfast" 4. "I should avoid fresh apples and strawberries"

4. With celiac disease, intestical villil become inflamed whenever gluten in introduced to the gut through food intake. However, fresh fruits and vegitables do not contain gluten; therefor, fresh apples and strawberries would definitely be acceptable foods for this client.

An 18-year-old football player is admitted to the ortho unit after a femur fracture. He is scheduled for a rod to be placed in the morning, but suddenly develops severe sob, a petechial rash on his chest, and unstable vital signs. What should the nurse do first? 1. Decrease rate of IV fluids. 2. Neurovascular check of affected leg. 3. Elevate the hob 4. Call the active response team.

4. Call the active response team. The client is exhibiting symptoms of a fat embolism, particularly with the petechial rash on his chest and severe sob. due to his age, high risk behaviors with contact sports, and the large long bone fracture, he is the classic example of a client that may experience a fat embolus. This constitutes a medical emergency and activation of the response team.

Which initial ABG results would the nurse expect on a client who has overdosed on ASA?

pH 7.49, PaC02 30, Pa02 88, Sa02 92, HC03 25 This abg result indicates respiratory alkakosis. Aspirin stimulates the respiratory center and causes an increase in respiratory rate and depth. This causes respiratory alkalosis by blowing off C02 and causing pH to increase. Losing C02 (acid) makes the client more alkalotic, which is reflected with an increased pH, decreased PaC02, and normal HC03.

A client with a terminal illness, asks the nurse about palliative care. What would be the nurse's best response?

The goal of palliative care is to help the client living with a chronic, life threatening illness. It focuses on the client's symptoms and the relief of these symptoms. Palliative care helps the client obtain their best quality of life throughout the course of their illness.

the nurse is monitoring a client with DKA. Which ABG value would be expected? 1. pH 7.32 2. PaC02 47 3. HC03 25 4. Pa02 78

pH 7.32 In DKA, the client is acidic. Normal pH is 7.35-7.45. A pH of 7.32 indicates acidosis and will be expected for a client in DKA.