Nclex- Pass point review

During chemotherapy, an oncology client has a nursing diagnosis of Impaired oral mucous membrane related to decreased nutrition and immunosuppression secondary to the cytotoxic effects of chemotherapy. Which nursing intervention is most likely to decrease the pain of stomatitis?

Providing a solution of viscous lidocaine for use as a mouth rinse

A client is admitted for an exacerbation of irritable bowel syndrome who insists on being allowed to keep a head covering on at all times. What is the best response by the nurse?

"Please help me to understand this practice."

A client with type 1 diabetes mellitus asks the nurse about taking ginseng at home. What should the nurse tell the client?

"Taking ginseng will increase the risk of hypoglycemia."

The decision is made to involuntarily admit a client to a psychiatric hospital on an emergency detention. The nurse explains the involuntary hospitalization process to the client. Which of the following

"You cannot have any visitors while you're here involuntarily."

The nurse is caring for a client in labor who has tested positive for gonorrhea. Which will the nurse include in the client's plan of care?

Administer erythromycin eye drops to the infant after birth.

A client states, "If my heart stops beating, I do not want to be resuscitated." Which action would the nurse take?

Ask if the client discussed this with the healthcare provider.

A nurse assesses a client with psychotic symptoms and determines that the client likely poses a safety threat and needs vest restraints. The client is adamantly opposed to this. What would be the best nursing action?

Contact the physician and obtain necessary orders.

A hospitalized client with end-stage heart failure does not want to be resuscitated. The health care provider (HCP) has written the do-not-resuscitate (DNR) prescription on the client's record. The client has a cardiac arrest, and the wife tells the nurse she wants the client to be resuscitated and asks the nurse to "do something." What should the nurse do?

Discuss the DNR prescription with the wife.

A couple in the antenatal unit is not satisfied with the care they are receiving. They have spent the past 15 minutes expressing dissatisfaction to the nurse about the care the client is receiving today. What is the most appropriate response by the nurse?

Encourage the family to identify their frustrations and fears.

A preterm neonate who has been stabilized is placed in a radiant warmer and is receiving oxygen via an oxygen hood. Which action should the nurse take while administering oxygen in this manner?

Humidify the air being delivered.

A client develops hepatic encephalopathy 1 week after portal caval shunt surgery. The client's physician orders neomycin, 4 g by mouth daily in four divided doses. The client's partner asks how neomycin decreases the serum ammonia concentration. How should the nurse respond?

Neomycin decreases the amount of ammonia-producing bacteria in the GI tract.

A client who follows a vegetarian diet was referred to a dietitian for nutritional counseling for anemia. Which client outcome indicates that the client needs further nutritional counseling?

The client drinks coffee or tea with meals.

The nurse is caring for an infant diagnosed with nonorganic failure to thrive. Which action should be included in the plan of care for the infant?

Weighing the unclothed infant at the same time every day.

The nurse is assessing a client, who has lung cancer with spinal metastasis, for pain. The client tells the nurse that the ordered opioid medication helps, but there is still a shooting pain down the client's left leg. Identify the best pharmacologic measure to address this pain.

an adjuvant, such as gabapentin

After total hip replacement, a client is receiving epidural analgesia to relieve pain. Which action is a nursing priority for this client?

assessing for sensation in the legs

A physician orders a stool culture to help diagnose a client with prolonged diarrhea. The nurse who obtains the stool specimen should

collect the specimen in a sterile container.

When developing a teaching plan for the mother of an infant about introducing solid foods into the diet, the nurse should expect to include which measure in the plan to help prevent obesity?

decreasing the amount of formula or breast milk intake as solid food intake increases

A client tells the nurse that they have been working hard for the past 3 months to control the client's type 2 diabetes with diet and exercise. To determine the effectiveness of the client's efforts, the nurse should check

glycosylated hemoglobin level.

A client in the second stage of labor who planned an unmedicated birth is in severe pain because the fetus is in the ROP position. The nurse should place the client in which position for pain relief?

hands and knees

A nurse is assessing a client with bipolar disorder. Findings include coarse hand tremors, muscle twitching, and mental confusion. These findings suggest:

lithium toxicity.

A client has severe arterial occlusive disease and gangrene of the left great toe. Which finding is expected?

loss of hair on the lower leg

When planning care for a client with a small-bowel obstruction, which should the nurse consider to be the primary goal?

maintaining fluid balance

While caring for a client who has bipolar disorder and alcohol dependency, which area is the priority for daily assessment?

mental status

A person calls the neonatal intensive care unit stating that his child is receiving care there. He tells the nurse that he and the mother "aren't together," and requests information about his child's condition. The nurse should

obtain more data before giving the caller any confidential information

A nurse is monitoring a client for adverse reactions to atropine eyedrops. Systemic absorption of atropine sulfate through the conjunctiva can cause which adverse reaction?

tachycardia

What would the nurse expect to find during the physical examination of a preterm male neonate born at 28 weeks' gestation?

thin, wasted appearance

A client has an ileal conduit. Which solution will be useful to help control odor in the urine collecting bag after it has been cleaned?

vinegar

A nurse has made a medication error. Which information is appropriate to include in the incident report?

what the nurse saw and did