NCLEX-PN PRACTICE
Which identifies accurate nursing documentation notations? Select all that apply. 1)The client slept through the night. 2)Abdominal wound dressing is dry and intact without drainage. 3)The client seemed angry when awakened for vital sign measurement. 4)The client appears to become anxious when it is time for respiratory treatments. 5)The client's left lower medial leg wound is 3 cm in length without redness, drainage, or edema.
1)The client slept through the night. 2)Abdominal wound dressing is dry and intact without drainage. 5)The client's left lower medial leg wound is 3 cm in length without redness, drainage, or edema. Factual documentation contains descriptive, objective information about what the nurse sees, hears, feels, or smells. The use of inferences without supporting factual data is not acceptable because it can be misunderstood. The use of vague terms, such as seems or appears, is not acceptable because these words suggest the nurse is stating an opinion.
The nurse who is caring for a client with kidney failure notes that the client is dyspneic, and crackles are heard when listening to breath sounds in the lungs. Which additional sign/symptom would the nurse expect to note in this client?
An increase in blood pressure Rationale:Impaired cardiac or kidney function can result in fluid volume excess. Findings associated with fluid volume excess include cough, dyspnea, crackles, tachypnea, tachycardia, an elevated blood pressure, a bounding pulse, an elevated central venous pressure, weight gain, edema, neck and hand vein distention, an altered level of consciousness, and a decreased hematocrit level.
Hypermagnesemia
The normal magnesium level is 1.3 to 2.1 mEq/L (0.65 to 1.05 mmol/L). A client with a magnesium level of 3.6 mEq/L (1.8 mmol/L) is experiencing hypermagnesemia. Loss of deep tendon reflexes is characteristic of this condition. Twitching, irritability, and hyperactive reflexes should be noted in a client with hypomagnesemia.
The licensed practical nurse (LPN) enters a client's room and finds the client lying on the bathroom floor. The LPN calls the registered nurse, who checks the client thoroughly and then assists the client back into bed. The LPN completes an incident report, and the nursing supervisor and primary health care provider (PHCP) are notified of the incident. Which is the next nursing action regarding the incident? 1)Place the incident report in the client's chart. 2)Make a copy of the incident report for the PHCP. 3)Document a complete entry in the client's record concerning the incident. 4)Document in the client's record that an incident report has been completed.
3)Document a complete entry in the client's record concerning the incident. The incident report is confidential and privileged information, and it should not be copied, placed in the chart, or have any reference made to it in the client's record. The incident report is not a substitute for a complete entry in the client's record concerning the incident.
Hypocalcemia
Calcium is an electrolyte that is necessary for muscle movement. The adult normal calcium level is 9 to 10.5 mg/dL (2.25-2.75 mmol/L). A low calcium level tends to cause muscle irritability. A positive Chvostek sign (striking the side of the face and noting twitching) and positive Trousseau sign (applying a blood pressure cuff and pumping it up above the systolic BP for 3 to 5 minutes results in a carpal spasm or palmar flexion) are indicative of hypocalcemia. Other signs and symptoms include tachycardia, hypotension, paresthesia, twitching, cramps, tetany, seizures, hyperactive bowel sounds, and a prolonged QT interval on the electrocardiogram rhythm.
The nurse is assigned to assist with caring for a client with esophageal varices who had a Sengstaken-Blakemore tube inserted because other treatment measures were unsuccessful. The nurse would check the client's room to ensure that which priority item is at the bedside? 1)An obturator 2)A Kelly clamp 3)An irrigation set 4)A pair of scissors
4)A pair of scissors Rationale:When the client has a Sengstaken-Blakemore tube, a pair of scissors must be kept at the client's bedside at all times. If the gastric balloon of the tube ruptures, the tube will move upward and potentially occlude the client's airway. The client needs to be observed for sudden respiratory distress. If this occurs, the RN is notified immediately, and the balloon lumens will be cut. An obturator and a Kelly clamp are kept at the bedside of a client with a tracheostomy. An irrigation set may also be kept at the bedside, but it is not the priority item.
An unconscious client, bleeding profusely, is brought to the emergency department after a serious accident. Surgery is required immediately to save the client's life. With regard to informed consent for the surgical procedure, which is the best action? 1)Call the nursing supervisor to initiate a court order for the surgical procedure. 2)Try calling the client's spouse to obtain telephone consent before the surgical procedure. 3)Ask the friend who accompanied the client to the emergency department to sign the consent form. 4)Transport the client to the operating department immediately without obtaining an informed consent.
4)Transport the client to the operating department immediately without obtaining an informed consent. Generally there are only two instances in which the informed consent of an adult client is not needed. One instance is when an emergency is present and delaying treatment for the purpose of obtaining informed consent would result in injury or death to the client. The second instance is when the client waives the right to give informed consent. Options 1, 2, and 3 are inappropriate.
administration of Enema
The administration of an enema is a clean procedure, and standard precautions must be used. The nurse applies disposable gloves when administering an enema to prevent the transfer of microorganisms. To administer an enema, the nurse places the client in the left Sims' position because the enema solution will flow downward by gravity along the natural curve of the sigmoid colon and rectum, improving retention of the enema solution. The tube is lubricated for easy insertion and is inserted approximately 3 to 4 inches in an adult. If the client complains of cramping or discomfort during the procedure, the nurse clamps the tubing until the discomfort subsides. The container containing the enema solution is hung about 12 to 18 inches above the client's anus. A flow of solution that is too forceful can damage the bowel. The temperature of the solution should be between 100°F (37.8°C) and 105°F (40.5°C). Solution that is too hot will burn the client, and solution that is too cool will cause cramping.
The client asks the nurse about various herbal therapies available for the treatment of insomnia. The nurse would encourage the client to discuss the use of which product with the primary health care provider? 1)Garlic 2)Valerian 3)Lavender 4)Glucosamine
2)Valerian Valerian has been used to treat insomnia, hyperactivity, and stress. It has also been used to treat nervous disorders such as anxiety and restlessness. Garlic is used as an antioxidant and to lower cholesterol levels. Lavender is used as an antiseptic and fragrance for a mild sedative effect. Glucosamine is an amino acid that assists with the synthesis of cartilage.
A client is diagnosed with cancer and is told that surgery followed by chemotherapy will be necessary. The client states to the nurse, "I have read a lot about complementary therapies. Do you think I should try any?" The nurse would respond by making which appropriate statement? 1)I would try anything that I could if I had cancer. 2) No, because it will interact with the chemotherapy. 3)Tell me what you know about complementary therapies. 4)You need to ask your primary health care provider about it.
3)Tell me what you know about complementary therapies.
The nurse in a long-term care facility is observing a nursing student provide foot care to a client with diabetes mellitus. Which action by the nursing student would indicate a need for further teaching? 1) The nursing student tells the client to avoid soaking the feet. 2) The nursing student dries the feet thoroughly, including in between the toes. 3) The nursing student advises the client to consult the physician or a podiatrist regarding nail trimming. 4) The nursing student applies lotion to the dorsal and plantar surfaces of the feet and in between the toes.
4) The nursing student applies lotion to the dorsal and plantar surfaces of the feet and in between the toes. Clients with diabetes mellitus are at an increased risk for impaired skin integrity related to peripheral neuropathy or vascular insufficiency. The feet are at an increased risk for the development of wounds and some client's may not be able to thoroughly inspect the feet regularly due to impaired mobility or other impairments. Meticulous foot care is necessary to prevent complications. The client's feet would not be soaked to prevent maceration, or skin softening, as this increases the risk of infection. Regarding nail trimming, a podiatrist or a physician's order may be necessary to trim the nails, as a client with diabetes mellitus is at increased risk for infection if the skin were to be accidentally cut. The feet need to be dried thoroughly, with special attention given to the areas in between the toes, as skin breakdown or ulcers can go undetected in this area. Lotion needs to be applied to the dorsal and plantar surfaces of the foot. However, it would not be applied in between the toes as this area needs to be kept dry. Therefore, option 4 is the action by the nursing student that requires a need for further teaching.
The nurse is reviewing the health records of assigned clients. The nurse would plan care knowing that which client is at risk for a potassium deficit? 1)The client with Addison's disease 2) The client with metabolic acidosis 3)The client with intestinal obstruction 4)The client receiving nasogastric suction
4) the client receiving nasogastric suction Rationale:Potassium-rich gastrointestinal (GI) fluids are lost through GI suction, which places the client at risk for hypokalemia. The client with intestinal obstruction, Addison's disease, or metabolic acidosis is at risk for hyperkalemia.
