NCLEX challenge 8

A nurse is assessing a client who has a suspected diagnosis of Gullian-Barre syndrome. Which of the following questions should the nurse ask the client?

"Have you had a recent influenza infection?"

A nurse is assessing a client who has had staples removed from an abdominal wound postoperatively. the nurse notes separation of the wound edges with copious light-brown serous drainage. Which of the following actions should the nurse perform first?

Cover the wound with a moist sterile gauze dressing

A nurse is caring for a client involved in a suspected bioterrorism event involved in a suspected bioterrorism event involving exposure to cutaneous anthrax. Which of the following manifestations should the nurse anticipate?

Skin lesions with pruritus

A nurse is caring for a 2-year-old child who has seizures and is receiving phenytoin in suspension form. Which of the following actions should the nurse take before administering each dose?

Shake the container vigorously

A nurse is preparing to administer PO medication to a client who has myasthenia gravis. Which of the following actions should the nurse take prior to administering the client medication?

Ask the client to take a few sips of water

A nurse in the emergency room is assessing a client who was brought in following seizure. The nurse suspects the client may have meningococcal meningitis when assessment findings include nuchal rigidity and a petechial rash. After implementing droplet precautions, which of the following actions should the nurse initiate next?

Assess the cranial nerves

A nurse is caring for a child who has a suspected diagnosis of bacterial meningitis. Which of the following actions is the nurse's priority?

Place the child in isolation

A nurse is assessing a client who has rea score of 6 on the Glasgow Coma Scale. The nurse should expect which of the following outcomes based on this score?

The client needs total nursing care

A nurse is receiving a transfer report for a client who has a head injury. The client has a Glasgow Coma Scale score of 3 for eye opening, 5 for best verbal response, and 5 for best motor response. Which of the following is an appropriate conclusion based on this data?

The client opens his eyes when spoken to

A nurse is teaching a client about nutritional requirements necessary to promote wound healing. Which of the following nutrients should the nurse include in the teaching?

Protein

A nurse on a long-term care unit is creating a plan of care for a client who has Alzheimer's disease. Which of the following interventions should the nurse include in the plan?

Talk the client through the tasks one step at a time

A nurse is caring for a client who has a new diagnosis of myasthenia gravis. For which of the following manifestations should the nurse monitor?

Weakness

A nurse is assessing for cyanosis in a client who has dark skin. Which of the following sites should the nurse examine to identify cyanosis in this client?

Conjunctivae

A nurse is providing teaching to a client who has a new diagnosis of Parkinson's disease. On which of the following medications should the nurse prepare to instruct the client?

Levdopa/carbidopa

A nurse is teaching a female client who has a new prescription for transdermal sumatriptan to treat migraine headaches. Which of the following instructions should the nurse include?

"Use contraception while taking this medication"

A nurse is assessing a client's cranial nerves as part of a neurological examination. Which of the following actions should the nurse take to assess cranial nerve III?

Checking the pupillary response to light

A nurse is caring for a client who has a wound infection. Which of the following actions should the nurse take when obtaining a wound-drainage specimen for culture?

Cleanse the wound with 0.9% sodium chloride saline irrigation before obtaining the specimen

A nurse is caring for a client who is 2 days postoperative following abdominal surgery and observes that the client's wound has eviscerated. After calling for help, which of the following actions should the nurse take first?

Cover the area with a sterile dressing moistened with 0.9% sodium chloride irrigation

A nurse in the emergency department is caring for a client who has myasthenia gravis and is in crisis. Which of the following factors should the nurse identify as a possible cause of myasthenic crisis?

Developing a respiratory infection

A nurse caring for a client who has an infected wound removes a dressing saturated with blood and purulent drainage. How should the nurse dispose of the dressing material?

Dispose of the dressing in a biohazardous waste container

A nurse at a community health clinic is caring for a client who reports a headache and stiff neck. Which of the following actions should the nurse take first?

Evaluate the client's neurological status

A nurse is preparing to exit the room of a client who has methicillin-resistant Staphylococcus aureus (MRSA) in a draining wound. Identify the sequence the nurse should follow before leaving the client's room.

Gloves Goggles Gown Mask Perform hand hygiene

A nurse is caring for a client who has a large lower-leg ulcer. Which of the following foods should the nurse suggest to the client to provide the most protein for wound healing?

Grilled salmon

A nurse is assisting a provider with a sterile procedure and prepares to pour solution onto a piece of sterile gauze. In what order should the nurse perform the following steps when pouring sterile solution?

Hand hygiene Remove bottle cap Place cap on a clean surface Palm label against the hand Pour 1 - 2 mL of solution into a receptacle Pour solution onto sterile gauze

A nurse in an emergency department is caring for a client who had a seizure and became unresponsive after stating she had a sudden, severe headache and vomiting. The client's vital signs are as follows: blood pressure of 198/110 mm Hg, pulse of 82/min, respirations of 24/min, and a temperature of 38.2 degrees celsius, Which of the following neurologic disorders should the nurse suspect?

Hemorrhagic stroke

A nurse is caring for a client who reports a throbbing headache after a lumbar puncture. Which of the following actions is most likely to facilitate resolution of the headache?

Increase fluid intake

A nurse is caring for a confused client who has Alzheimer's disease. Which of the following actions should the nurse take?

Keep familiar personal items at the bedside

A nurse is caring for a client who has a suspected diagnosis of myasthenia gravis. The provider prescribes a Tensilon test. Which of the following findings indicates a positive test?

Muscle contractions become progressively stronger

A nurse is assessing a client who has Bell's palsy. Which of the following findings should the nurse expect?

Muscle distortion Pain behind the ear Impaired taste

A school nurse is teaching a group of nurses newly hired to work in the school system about pediculosis capitis (head lice). Which of the following information is appropriate to include in the teaching?

Nits that are shed into the environment are capable of hatching for up to 10 days.

A nurse is providing teaching to the family of a client who has Parkinson's disease. Which of the following information should the nurse include in the teaching?

Provide client supervision

A nurse is caring for a client who has pruritus following treatment for scabies. Which of the following actions should the nurse take?

Provide mittens for the client to wear at night

A school nurse is performing a routine health assessment for a school-age child. Which of the following findings indicates the nurse should investigate further for pediculosis capitis?

Pruritus of the scalp

Nurse should follow when pouring solution....

Remove the bottle cap Place bottle cap face up on a clean surface Pick up the bottle with the label facing palm Pour 1 - 2 mL of solution into a receptacle Pour solution onto the gauze

A home health nurse is planning care for a client who has Alzheimer's disease. The client's partner is her primary caregiver and reports not having enough time to complete his errands. Which of the following referrals should the nurse plan to make?

Respite care

A nurse suspects that a client admitted for treatment of bacterial meningitis is experiencing increased intracranial pressure. Which of the following assessment findings by the nurse supports this suspicion?

Restlessness

A nurse is preparing to discharge a client who has an abdominal wound that is healing by secondary intention. Which of the following actions is the nurse's priority?

Schedule a follow-up visit by a home health nurse for dressing changes

A nurse is making a home visit to a client who has Alzheimer's disease and the client's partner. Which of the following observations indicates to the nurse that the partner is experiencing caregiver role strain?

The partner has lost 20 lbs in the past 2 months

A nurse is teaching the family of an older adult client who has a new diagnosis of dementia. Which of the following statements should the nurse include in the teaching?

The signs of dementia are progressive and irreversible

A nurse is caring for a client who has a stage 1 pressure ulcer. Which of the following dressings should the nurse plan to apply?

Transparent dressing

A nurse is in a client's room when the client begins having a tonic-clonic seizure. Which of the following actions should the nurse take first?

Turn the client's head to the side

A charge nurse is making a room assignment for a client who has scabies. In which of the following rooms should the nurse place the client?

A private room

A nurse is caring for a client who has dementia. When performing a mental status examination the nurse should include which of the following data?

Ability to perform calculations Recall ability Long-term memory level of orientation

A nurse is assessing a client who has Parkinson's disease. Which of the following manifestations should the nurse expect?

Bradykinesia

A nurse working on a medical unit is caring for a client who is prescribed seizure precautions. Which of the following interventions should the nurse include in the client's plan of care?

Obtain IV access

A nurse is caring for a client who has a history of dementia. The client is alert and oriented to person, place, and time, and has advanced directives. The client is scheduled for a procedure that requires informed consent. Which of the following persons should sign the informed concent?

The client

A nurse is caring for a client who has a stage 3 pressure ulcer. The nurse should recognize that which of the following laboratory findings will affect wound healing?

Serum albumin 3.2 g/dL

A nurse is preparing a sterile field prior to inserting a urinary catheter for a client. Identify the sequence of steps the nurse should plan to follow.

Perform hand hygiene Place package on work surface Open outermost flap away from self Open side flap, pulling to the side Open innermost flap toward self Use inner surface of package as sterile field.

A nurse is preparing to perform wound irrigation on a client who has a puncture wound to the left leg. Identify the sequence of steps the nurse should take to perform the irrigation.

Place a waterproof pad on the bed under the client's leg The nurse should apply clean gloves and remove old dressing Clean the puncture site in a circular motion Open sterile dressing set and supplies Irrigate the wound until the solution becomes clear

A nurse enters a client's room and finds the client on the floor having a seizure. Which of the following actions should the nurse take?

Place the client on his side

A nurse is assessing a client's wound dressing, and observes a watery red drainage. The nurse should document this drainage as which of the following?

Serosanguineous

A nurse in a long-term care facility is caring for an older adult client who has dementia and begins to have frequent episodes of urinary incontinence. After the provider determines no medical cause for the client's incontinence, which of the following interventions should the nurse initiate to manage this behavior?

Take the client to the bathroom every 2 hrs

A nurse is caring for a client who has dementia due to Alzheimer's disease and was admitted to a long-term care facility following the death of her partner of 40 years. The client states, "I want to go home; my husband is waiting for me to cook dinner." Which of the following responses by the nurse is appropriate?

Tell me what you like to cook for dinner

A nurse is planning to care for an older adult client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin?

Use a transfer device to lift the client up in bed.

A nurse is completing discharge teaching to a client about nutrition therapy for wound healing following major surgery. Which of the following vitamins that promote wound healing should the nurse include in the teaching?

Vitamin A Vitamin B12 Vitamin C Vitamin K