NClEX

An Appalachian family has brought a toddler to the emergency department with a fractured arm. The nurse knows that nonverbal communication is important to evaluate with assessing the family. Which factors are involved in non-verbal communication? Select all that apply.

-Touch -Body posture -Use of space -Eye behavior -Facial expressions

The nurse is caring for a client who has a wound infection. Contact precautions are being followed. Which are correct actions by the nurse when using personal protective equipment (PPE)? Select all that apply.

-Perform hand hygiene after removal of PPE. -Perform hand hygiene before donning any PPE. -Protective eyewear and face shield are indicated if there is risk of splatter.

The nurse is collecting data on a child recently diagnosed with glomerulonephritis. Which question to the mother should elicit information about the cause of this disease?

"Did your child sustain any injuries to the kidney area?"

The nurse knows when preparing the Filipino American client for a surgical procedure it is important to assess for which culturally relevant influences? Select all that apply.

-Familial hierarchy -Cultural practices -Reactions to surgery -Pain management plans

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. -Eat plenty of fresh fruits, salads, and vegetables. -Wash your hands frequently with antibacterial soap.

A health care provider's prescription reads as follows: "Ampicillin, 125 mg intramuscular every 6 hours." The medication label reads, "1 gram when reconstituted with 7.4 mL of bacteriostatic water." How many milliliters should the nurse draw up for one dose?

0.92

The nurse will perform a sterile dressing change after removing the old dressing with clean gloves. The nurse removes the gloves, uses alcohol-based hand sanitizer to perform hand hygiene, and prepares to perform open sterile gloving. The nurse removes the gloves from the outer package. The nurse is right-handed. Arrange the steps the nurse should follow in the open sterile gloving process. All options must be used.

1. Open inner wrapper and flatten wrapper to expose the gloves. 2. Pick up right glove at cuff with left thumb and forefinger. 3. Insert right hand into right glove. 4. Place gloved right hand under the cuff of left glove. 5. Insert left hand into left glove. 6. Pull down cuffs of gloves maintaining sterility.

The sister of a client with human immunodeficiency virus (HIV) asks the nurse to review once more what she needs to know in order to take care of her brother. Which instructions would be appropriate for the nurse to reinforce? Select all that apply.

1. Wash soiled clothes in hot water. 3. Use gloves when handling body fluids. 5. Other members of the household should not share a bathroom. 6. Soak cleaning rags, sponges and mops in 1:10 bleach solution for 5 minutes.

The nurse has just received report on a newly admitted client who is cognitively impaired and experiencing pain. Which data collection techniques should be included in this client's plan? Select all that apply.

1.Observe for grimacing. 2.Listen for vocalizations. 3.Observe facial expressions. 5.Monitor for changes in behavior.

The parents of a child with sickle cell disease are both carriers of the gene and ask the nurse how likely it is that they will have another biological child with the disease. What is the correct percent? Fill in the blank.

25

The nurse should implement which interventions for a child older than 2 years with type 1 diabetes mellitus who has a blood glucose level of 60 mg/dL? Select all that apply.

3.Give the child a teaspoon of honey. 6.Prepare to administer glucagon subcutaneously if unconsciousness occurs.

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?

300 units/L

The nurse is checking the remaining volume in a 1000-mL intravenous (IV) bag that is scheduled to infuse over 8 hours on an electronic infusion pump. The nurse has just noted at 11:00 am that the remaining IV fluid is at the 500-mL level. At 12:00 noon at which numerical level (mL) should the IV fluid be? Fill in the blank.

375mL

The nurse is assisting in the care of a client who is at risk for hyponatremia. The nurse should monitor this client for which symptoms of this electrolyte imbalance?

Abdominal cramping

The nurse is reviewing the health care record of an infant suspected of having unilateral hip dysplasia. Which finding should the nurse expect to note documented in the infant's record regarding this condition?

Asymmetry of the gluteal skin folds when the infant is placed prone and the legs are extended against the examining table

A 24-year-old Chinese American is breastfeeding her infant girl. The client's mother asked the nurse not to include cold foods on her daughter's tray because they are not good for the baby. The nurse responds by telling the client that she can have what she wants; it is not up to her mother. This response demonstrates which cultural characteristic?

Ethnocentrism

The nurse reviews the record of a child who was just seen by a health care provider (HCP). The HCP has documented a diagnosis of suspected aortic stenosis. Which specific sign/symptom of aortic stenosis should the nurse anticipate?

Exercise intolerance

The nurse is caring for a client whose magnesium level is 4 mg/dL, and the client is being treated for the magnesium imbalance. The nurse interprets that the electrolyte imbalance is resolving if which sign or symptom is no longer present?

Loss of deep tendon reflexes

The nurse is getting a postoperative client out of bed for the first time since surgery. The nurse raises the head of the bed, and the client complains of dizziness. Which action should the nurse take first?

Lower the head of the bed slowly until the dizziness is relieved

The nurse is reviewing the immunization schedule for a child with human immunodeficiency virus (HIV) infection with the mother. Which should be a component of the instructions that the nurse reinforces to the mother?

No live virus vaccines should be administered to the child.

The nurse is reviewing the health record of a 14-year-old child who is suspected of having Hodgkin's disease. Which is the primary characteristic of this disease?

Painless, firm, and movable lymph nodes in the cervical area

The nurse reinforces instructions regarding respiratory precautions to the mother of a child with mumps. The mother asks the nurse about the length of time required for the respiratory precautions. The nurse should base the response on which information about mumps?

Respiratory precautions are indicated during the period of communicability.

A 24-hour urine specimen for creatinine and electrolytes has been prescribed for a hospitalized client to evaluate kidney function. The nurse explains the procedure to the client. The client voids at 0900, and the urine is discarded. The client voids at 1200 and the urine is measured and placed in the collection container. At which time the next day should the 24-hour urine collection be complete? Fill in the blank with the correct military time.

0900

An 8-year-old boy is being treated with percussion treatments for cystic fibrosis. Which indicates that the treatment is effective?

The child has a productive cough of thick sputum.

The nurse knows that spatial behavior is related to territoriality in many Latino cultures. Which client needs are associated with territoriality? Select all that apply.

-Privacy -Security -Autonomy -self-identity