NCLEX PREP
To assess the development of a 1-month-old, the nurse asks the parent if the infant is able to demonstrate which skill?
lift head from prone position Explanation: A 1-month-old infant is usually able to lift the head from a prone position. The full-term infant with no complications has probably been able to do this since birth. Smiling and laughing is expected behavior at 2 to 3 months. Rolling from back to side and holding a rattle are characteristics of a 4-month-old.
A client is admitted for treatment of the syndrome of inappropriate antidiuretic hormone (SIADH). Which nursing intervention is appropriate?
restricting fluids Explanation: To reduce water retention in a client with the SIADH, the nurse should restrict fluids. Administering fluids by any route would further increase the client's already heightened fluid load.
A 10-month-old child with phenylketonuria (PKU) is being weaned from breast-feeding. When teaching the parents about the proper diet for their child, the nurse should stress the importance of restricting meats and dairy products because:
they contain high levels of phenylalanine. Explanation: PKU is an inherited disorder characterized by the inability to metabolize phenylalanine, an essential amino acid. Phenylalanine accumulation in the blood results in central nervous system damage and progressive intellectual disability. However, early detection of PKU and dietary restriction of phenylalanine can prevent disease progression. Intake of high-protein foods, such as meats and dairy products, must be restricted throughout life because they contain large amounts of phenylalanine.
The nurse is assessing a client recovering from a hemorrhagic cerebral vascular accident (CVA) that occurred 7 days ago. Which assessment finding should be reported to the healthcare provider?
worsening headache Explanation: A worsening headache is a clinical manifestation associated with a vasospasm. The development of cerebral vasospasm is a serious complication of subarachnoid hemorrhage and is a leading cause of morbidity and mortality in those who survive the initial hemorrhage. Frequent coughing, tachycardia, and diminished pedal pulses are not as concerning as a worsening headache.
The nurse is caring for a 7-year-old child who has just returned from the postoperative unit after surgery. The child is playing in bed with toys. The child's parents are smiling and state, "Isn't it great that our child does not have any pain?" What is the best response by the nurse?
"Some children distract themselves with play while in pain." Explanation: Some children distract themselves with play or music while in pain and may sleep as a result of exhaustion. Nurses commonly underestimate children's pain when they do not rely on children's self-reports. Narcotics can be used safely with children.
Which health-promoting activity should the nurse teach the client who recently underwent a laryngectomy?
Cleanse the mouth three times a day. Explanation: Oral hygiene is an important aspect of self-care for the laryngectomy client, who is less able to detect mouth odor. Additionally, the mouth harbors bacteria. Good mouth care reduces the risk of infection.The client is able to take tub baths with careful instruction on ways to avoid slipping, the need to make sure the water is no more than 6 inches (15 cm) deep, and other safety measures that will prevent water from entering the laryngectomy site.Moderate exercise may be beneficial, but an aggressive exercise program is not usually part of the plan of care.Air should be humidified to enhance comfort.
The nurse is assessing a client who is in her first trimester of pregnancy. The client states that her nausea has been problematic at times, but says that she is able to partially control it using ginger supplements. What is the nurse's best response?
Have you let your care provider know that you are taking ginger?" Explanation: A priority is ensuring that the care provider is aware of the client's use of a herbal supplement during pregnancy. Ginger is not associated with hyperglycemia or hypoglycemia. Exploring the source of the client's information or the possible use of pharmacologic alternatives are secondary to ensuring there is communication with the care provid
The nurse is reviewing the laboratory data for a young client in acute kidney failure and notes an elevated serum potassium level. What is the priority assessment action for the nurse based on the laboratory data?
Institute telemetry monitoring. Explanation: Slow, weak, irregular pulse; lethal arrhythmias; and sudden cardiac collapse are serious complications of an elevated potassium level. The elevated value will have less impact on renal, respiratory, and neurologic function.
A diabetic client with peripheral vascular disease is ordered to wear knee-high elastic compression stockings continuously until discharge. Which would be the priority after the stockings are applied?
Remove elastic stockings once per day and observe lower extremities. Explanation: Elastic stockings are used to promote venous return and prevent deep vein thrombosis. A client with peripheral vascular disease and diabetes is at risk for skin breakdown, and the nurse must therefore remove the stockings once per day to observe the condition of the skin. Elevating the client's legs while out of bed and teaching isometric leg exercises will promote venous return. However, after applying the stockings, the nurse's priority should be the client's skin integrity. Ordering a second pair of stockings would not be a priority.
A 1-year-old child is scheduled for surgery to correct hypospadias and chordee. The nurse explains to the parents that this is the preferred time for surgical repair based on which factor?
The child is too young to have developed castration anxiety. Explanation: The preferred time for surgery is between the ages of 6 and 18 months, before the child develops castration and body image anxiety. Children learn early on about society's emphasis on the importance of genitals. Pain is different for each child and is not related to the preferred time for repair of the hypospadias or chordee. Although the child will probably not remember the experience, this is not the basis for having the surgery at this age. If the condition is not repaired, the child will have difficulty with toilet training because urine is not eliminated through the tip of the penis.
The nurse evaluates the effectiveness of the client's postoperative plan of care. Which outcome is expected for a client with an ileal conduit?
The client will empty the drainage pouch frequently throughout the day. Explanation: It is important that the client empty the drainage pouch throughout the day to decrease the risk of leakage. The client does not normally need to curtail physical activity. Aspirin should never be placed in a pouch because aspirin can irritate or ulcerate the stoma. The client does not catheterize an ileal conduit stoma.
The client who is in Buck's traction is constipated. A plan of care that incorporates which breakfast would be most helpful in reestablishing a normal bowel routine?
an orange, raisin bran and milk, and wheat toast with butter Explanation: High-fiber foods provide bulk and decrease water absorption in the bowel. Whole grains and fruits (not juices, which often are strained) are recommended. Of all the breakfast options listed, the one that includes an orange, raisin bran, and wheat toast is highest in fiber and most likely to enhance bowel elimination. Proteins, white bread, processed foods, and liquids contain very little fiber.
Which measure is contraindicated when the nurse assists a child who has leukemia with oral hygiene?
cleaning the teeth with a toothbrush Explanation: The oral mucous membranes are easily damaged and are commonly ulcerated in the client with leukemia. It is better to provide oral hygiene without using a toothbrush, which can easily damage sensitive oral mucosa. Applying petroleum jelly to the lips, swabbing the mouth with moistened cotton swabs, and rinsing the mouth with a nonirritating mouthwash are appropriate oral care measures for a child with leukemia.
A 22-year-old client reports substernal chest pain and states that their heart feels like "it's racing out of my chest." The client reports no history of cardiac disorders. The nurse attaches the client to a cardiac monitor and notes sinus tachycardia with a rate of 136 beats/minute. Breath sounds are clear, and the respiratory rate is 26 breaths/minute. When a cardiorespiratory basis is eliminated, which drug would the nurse question about usage?
cocaine Explanation: Because of the client's age and negative medical history, the nurse would question about cocaine use. Barbiturate overdose may trigger respiratory depression and a slow pulse. Opioids can cause marked respiratory depression, while benzodiazepines can cause drowsiness and confusion. Cocaine increases myocardial oxygen consumption and can cause coronary artery spasm, leading to tachycardia, ventricular fibrillation, myocardial ischemia, and MI.
A client has been diagnosed with a basal skull fracture following a motor vehicle accident and now presents with increasing drowsiness and is febrile. The nurse knows that the client is most at risk for developing which condition?
meningitis Explanation: Head trauma and fractures place an individual at high risk for meningitis. A client who is febrile with increasing drowsiness should be investigated for posttraumatic meningitis. It is unlikely that pneumonia, renal failure, or a paralytic ileus would occur as a result of a basal skull fracture.
The membranes of a multigravid client in active labor rupture spontaneously, revealing greenish-colored amniotic fluid. How does the nurse interpret this finding?
passage of meconium by the fetus Explanation: Greenish-colored amniotic fluid is caused by the passage of meconium, usually secondary to a fetal insult during labor. Meconium passage also may be related to an intact gastrointestinal system of the neonate, especially those neonates who are full term or of postdate gestational age. Amnioinfusion may be used to treat the condition and dilute the fluid. Cloudy amniotic fluid is associated with an infection caused by bacteria or a sexually transmitted disease. Severe yellow-colored fluid is associated with Rh incompatibility or erythroblastosis fetalis.
A 25-year-old primiparous client who gave birth 2 hours ago has decided to breastfeed her neonate. Which instruction should the nurse address as the highest priority in the teaching plan about preventing nipple soreness?
placing as much of the areola as possible into the baby's mouth Explanation: Several methods can be used to prevent nipple soreness. Placing as much of the areola as possible into the neonate's mouth is one method. This action prevents compression of the nipple between the neonate's gums, which can cause nipple soreness. Other methods include changing position with each feeding, avoiding breast engorgement, nursing more frequently, and feeding on demand. Plastic liners are not helpful because they prevent air circulation, thus promoting nipple soreness. Instead, air drying is recommended. Pulling the baby's mouth out smoothly after only 10 minutes may prevent the baby from getting the entire feeding and increases nipple soreness. Any breast milk remaining on the nipples should not be wiped off because the milk has healing properties.
The nurse is conducting preoperative teaching for a client with gestational diabetes scheduled for a repeat cesarean. The client tells the nurse that she has been taking gingko biloba to help manage her blood sugars. The nurse notifies the health care provider because this herbal supplement puts the client at risk for which complication?
prolonged bleeding Explanation: Gingko biloba is an herbal supplement commonly taken to improve memory or improve glycemic control. It has known antiplatelet effects and can put surgical clients at risk for bleeding. It not known to cause hypertension or sedation. Gingko's primary medication interaction relates to its potential to enhance the effects of other anticoagulants and lead to prolonged bleeding.
When teaching a multigravid client diagnosed with mild preeclampsia about nutritional needs, the nurse should discuss which type of diet?
regular diet Explanation: For clients with mild preeclampsia, a regular diet with ample protein and calories is recommended. If the client experiences constipation, she should increase the fiber in her diet, such as by eating raw fruits and vegetables, and increase fluid intake. A high-residue diet is not a nutritional need in preeclampsia. Sodium and fluid intake should not be restricted or increased. A high-protein diet is unnecessary.
A client is being treated for left lower lobe pneumonia. In what position should the nurse position the toddler to maximize oxygenation?
right lateral Explanation: The client should be positioned on the right side because gravity contributes to increased blood flow to the right lung, thereby allowing for better gas exchange. Positioning the client prone, supine, or in the left lateral position doesn't allow for better gas exchange in this client.
A nurse is auscultating for heart sounds in a client. The nurse notes a grade 1 heart murmur. Which characteristic best describes a grade 1 heart murmur?
softer than the heart sounds Explanation: A grade 1 heart murmur is commonly difficult to hear and softer than heart sounds. A grade 2 murmur is usually equal in sound to the heart sounds. A grade 4 murmur is associated with a precordial thrill (a palpable manifestation associated with a loud murmur). A grade 6 murmur can be heard without a stethoscope.
The nurse is caring for a client with knee high antiembolism stockings. Which assessment finding does the nurse prioritize as needing notification of the healthcare provider?
unilateral swelling Explanation: Despite the use of antiembolism stockings, a client may develop deep vein thrombosis. Unilateral swelling may be an indication of deep vein thrombosis development and would be reported immediately to the healthcare provider. Dry, flaking skin is not a priority and can be remedied with the use of lotion prior to applying the antiembolism stockings. Capillary refill less than 2 seconds and posterior tibial pulses +2 bilaterally are normal findings and would not require notification of the healthcare provider.
A middle-aged male client comes to the clinic for an evaluation of difficulty urinating and nocturia. His father died from prostate cancer. He asks the nurse what he can do to ensure early detection of this disease. What question will the nurse ask next?
"Do you have a digital rectal examination and prostate-specific antigen tests yearly?" Explanation: Prostate-specific antigen (PSA) and digital rectal examinations, although not specific for prostate cancer, will indicate possible changes in the prostate gland. The transrectal ultrasound would be performed as a follow-up for an increased PSA and/or an enlarged prostate gland. Testicular exams will not reveal changes in the prostate. The client already told the nurse he has nocturia, so this question is gathering more information about symptoms, not detection of the disease.
The client with type 1 diabetes mellitus says, "If I could just avoid what you call carbohydrates in my diet, I guess I would be okay." What is the best response by the nurse?
"A person with diabetes should monitor their eating of proteins, fats, and carbohydrates." Explanation: Diabetes mellitus is a multifactorial, systemic disease associated with problems in the metabolism of all food types. The client's diet should contain appropriate amounts of all three nutrients, plus adequate minerals and vitamins. Limiting carbohydrate intake is just part of a comprehensive diabetic diet plan. A client with type 1 diabetes will need lifelong insulin therapy. Carbohydrates from fruit and vegetable sources will still need to be factored into carbohydrate intake. Telling a client "all we ask you to do" is a value-judgement and is not therapeutic communication.
The client with Cushing's disease needs to modify dietary intake to control symptoms. In addition to increasing protein, which strategy would be most appropriate?
Restrict sodium. Explanation: A primary dietary intervention is to restrict sodium, thereby reducing fluid retention. Increased protein catabolism results in loss of muscle mass and necessitates supplemental protein intake. The client may be asked to restrict total calories to reduce weight. The client should be encouraged to eat potassium-rich foods because serum levels are typically depleted. Although reducing fat intake as part of an overall plan to restrict calories is appropriate, fat intake of less than 20% of total calories is not recommended.
The nurse is developing a plan of care for a client who has joint stiffness due to rheumatoid arthritis. Which measure will be the most effective in relieving stiffness?
a warm shower before performing activities of daily living Explanation: Warm showers, baths, or hand soaks can help relieve joint stiffness and allow the client to more comfortably perform activities of daily living. Aspirin or other anti-inflammatory drugs should be taken before activity to help decrease inflammation and reduce joint pain and inflammation. Although weight loss may decrease stress on joints, pain and stiffness will continue to be a problem. Cold compresses are most effective for relieving joint pain, whereas moist heat is useful for decreasing pain and stiffness. When cold compresses are applied, their use should be limited to 10 to 15 minutes at a time to decrease the risk of tissue damage.
Parents bring a child to the clinic who has not been eating or drinking well for the last few days. What action should the nurse take first to assess the child's overall hydration status?
Weigh the child. Explanation: When implementing nursing care, the nurse should complete any noninvasive procedures before invasive ones. Therefore, the first step the nurse should take is to weigh the child. A decrease in body weight gives the most accurate information about the infant's hydration status. Monitoring vital signs would be the next step in the assessment process. The blood pressure reading would yield information about hypotension. A urinalysis would provide information about urine osmolality and specific gravity of the urine, which indicates dehydration. Obtaining electrolytes would provide information about electrolyte disturbances, not strictly about hydration.
A client with pancreatic cancer, who has been bed-bound for 3 weeks, has just returned from having a left subclavian, long-term, tunneled catheter inserted for administration of analgesics. The nurse has not yet received radiographic results for confirmation of placement. The client becomes restless and dyspneic and has chest pain radiating to the middle of the back. Physical assessment reveals tachycardia and absent breath sounds in the left lung. What should the nurse further assess?
a pneumothorax Explanation: The client is exhibiting signs and symptoms of a pneumothorax from the insertion of the subclavian venous catheter. Although it is possible that the client suffered an air embolus during the procedure, and the client is at risk for pulmonary emboli because of his immobility, absent breath sounds immediately after insertion of a subclavian line are strongly suggestive of a pneumothorax. Unilateral absent breath sounds are not associated with a myocardial infarction
A client with suspected rheumatic fever is admitted to the pediatric unit. When obtaining the client's history, the nurse considers which information to be most important?
a recent episode of pharyngitis Explanation: A recent episode of pharyngitis is the most important factor in establishing the diagnosis of rheumatic fever. Although the client may have a history of fever or vomiting or lack interest in food, these findings are not specific to rheumatic fever.
A client with a recent history of rectal bleeding is being prepared for a colonoscopy. The nurse knows that positioning the client lying on the left side with the knees bent is an appropriate intervention. The nurse recognizes that this position wi
allow proper visualization of the large intestine. Explanation: For a colonoscopy, the nurse initially should position the client on the left side with knees bent to permit proper visualization of the large intestine. Visualization of the small intestine is not a goal of the procedure. This positioning of the client does not necessarily make the client more comfortable, and it does not affect the amount of any bleeding that may occur.
A nurse is instructing a client with newly diagnosed hypoparathyroidism about the regimen used to treat this disorder. The nurse should state that the physician probably will order daily supplements of calcium and
vitamin D. Explanation: Typically, clients with hypoparathyroidism are ordered daily supplements of vitamin D along with calcium because calcium absorption from the small intestine depends on vitamin D. Hypoparathyroidism doesn't cause a deficiency of folic acid, potassium, or iron. Therefore, the client doesn't require daily supplements of these substances to maintain a normal serum calcium level.
Which finding is considered normal in the neonate during the first few days after birth?
weight loss then return to birth weight Explanation: Neonates lose approximately 10% of their birth weight during the first 3 or 4 days, because of loss of excess extracellular fluids and meconium and limited oral intake, until breast-feeding is established. Return to birth weight should occur within 10 days after birth. Normal birth weights range from 6 to 9 lb (2,700 to 4,000 g).