NCLEX RATIONALES

A nurse is caring for four clients. Which of the following clients should the nurse assign to an assistive personnel (AP) to assist with meals?

A client who has Alzheimer's disease and is demonstrating aphasia Aphasia impairs the client's ability to communicate, but does not interfere with nutritional intake or place the client at a safety risk while eating. Therefore, assisting the client at mealtimes is within the AP's scope of practice. A client who has asthma and an increased respiratory rate A client who has asthma and an increased respiratory rate requires assessment by the nurse; therefore, assigning the AP to assist the client at meal time is a safety risk for the client. A client who had a stroke and is to start oral intake A client who had a stroke and is to start oral intake requires assessment by the nurse. Therefore, assigning the AP to assist the client at mealtimes is a safety risk for the client because of the risk for aspiration. A client who had diabetic ketoacidosis and is difficult to arouse. A client who had diabetic ketoacidosis and is difficult to arouse requires assessment by the nurse. Therefore, assigning the AP to assist the client at mealtimes is a safety risk for the client.

A nurse is caring for a newborn whose parent asks why her baby is receiving vitamin K. The nurse should explain to the parents that the newborn should receive vitamin K to prevent which of the following?

Bleeding Newborns should receive vitamin K at birth because they have low levels of vitamin K, which can lead to bleeding. Potassium deficiency Vitamin K does not prevent potassium deficiency in a newborn. Infection Vitamin K does not prevent infection in a newborn. Hyperbilirubinemia Vitamin K does not prevent hyperbilirubinemia in a newborn.

A nurse is planning to teach a client who is to start a new prescription for fluoxetine. For which of the following findings should the nurse instruct the client to monitor and report to the provider?

Jaundice The nurse should inform the client that fluoxetine can cause a rash, which she should report to the provider. However, jaundice is not an adverse effect of fluoxetine. Constipation The nurse should instruct the client to monitor for and report dark or tarry stools, because fluoxetine can cause gastrointestinal bleeding. However, constipation is not an adverse effect of fluoxetine. Tremors CORRECT Fluoxetine can cause serotonin syndrome within 2 to 72 hr after starting treatment. The client can experience tremors, agitation, confusion, anxiety, and hallucinations. The nurse should instruct the client to report these manifestations to the provider and to stop taking the medication. Weight loss The nurse should inform the client that weight gain is an adverse effect of fluoxetine.

A nurse is assessing a client who is 18 hr postoperative following a cesarean birth and is breastfeeding her newborn. Which of the following findings is the priority?

Unilateral tenderness of the left lower extremity When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is unilateral tenderness of the left lower extremity, which can indicate the client is developing deep-vein thrombosis. CORRECT Oral temperature 37.7° C (99.8° F) A low-grade fever is a nonurgent finding because it is an expected finding for a client who is postoperative following a cesarean birth. Therefore, another finding is the priority. Uterine contractions when breastfeeding Uterine contractions during breastfeeding is a nonurgent finding because it is an expected finding for a client who is postpartum. Therefore, another finding is the priority. Abdominal guarding when assessing the fundus Abdominal guarding in a client when assessing the fundus is a nonurgent finding because it is an expected finding for a client who is postpartum. Therefore, another finding is the priority.

A nurse is caring for an older adult client who reports that he is taking the herbal supplement saw palmetto along with his other medications. Which of the following responses should the nurse make?

"This herb can cause gastrointestinal upset such as bloating and abdominal pain." The herbal supplement flaxseed, which clients can use for migraine prophylaxis, can lead to gastrointestinal symptoms such as bloating, abdominal pain and flatulence. "This herb can interact with caffeine and cause irritability." The herbal supplement ginseng, which clients can use to stimulate mental activity and increase the appetite, can interact with caffeine and cause irritability. "This herb can result in a false low prostate-specific antigen level." CORRECT The nurse should instruct the client that taking saw palmetto can result in false low prostate-specific antigen levels, which can delay diagnosis of prostate cancer. "This herb can lower your blood pressure." The herbal supplement valerian, which clients can use as a tranquilizer or sedative, can lower blood pressure.

A nurse is teaching an adolescent who has a tunneled central venous catheter. Which of the following information should the nurse include in the teaching?

"You should flush the catheter with 0.9% sodium chloride solution daily when not using it regularly." The nurse should instruct the adolescent to flush the catheter daily with heparin when not using it regularly. "You should keep the catheter clamped when not in use." CORRECT The adolescent should keep the catheter clamped to prevent blood backflow. A tunneled catheter does not have a two-way valve. "You should swim twice weekly to prevent tissue from adhering to the cuff." The nurse should instruct the adolescent to restrict physical activities until the tissue adheres to the cuff. The adolescent should not participate in water sports because of the risk of infection. "You should change your dressing every 10 days." The nurse should instruct the adolescent to change the dressing at least every 5 to 7 days.

A community health nurse is reviewing the medical records of four clients. The nurse should report which of the following clients to the CDC?

A client who is pregnant and has cytomegalovirus (CMV) The nurse should not report CMV, a herpes virus, to the CDC. CMV can cause mild influenza-like symptoms or no symptoms in adults. Women who are pregnant can transmit a primary infection to the fetus in utero and during vaginal delivery. An adolescent client who has foodborne botulism The nurse should report botulism to the CDC. Clients who ingest the botulism toxin can develop dysphasia, dropping eyelids, and vision changes, and in 12 to 36 hr can develop neurologic symptoms such as symmetric, flaccid paralysis, and cranial nerve impairment. CORRECT A child who has erythema infectiosum The nurse should not report erythema infectiosum to the CDC. Parvovirus is the cause of erythema infectiosum resulting in a red facial rash that spreads over the body. A young adult client who has herpes simplex virus type 1 (HSV-1) The nurse should not report HSV-1 to the CDC. It causes painful blisters to form on the mouth or the genitals. Transmission of HSV-1 can occur during sexual contact.

A nurse is providing client education to a postpartum client who has decided to bottle feed her newborn. Which of the following instructions should the nurse include in the teaching to help prevent the discomfort of engorgement?

Allow the newborn to breastfeed temporarily. The nurse should instruct the client to avoid nipple stimulation to prevent further milk production. Relieve pressure by expressing milk daily. The nurse should tell the client to avoid expressing milk to prevent further milk production. Place ice packs on the breasts for 15 min several times per day. CORRECT The client should use ice packs on the breasts to reduce swelling and relieve pain. Sleep with a loose-fitting bra to prevent nipple stimulation. The client should wear a tight-fitting, supportive bra or wear a breast binder to decrease discomfort.

A nurse is caring for a group of clients. For which of the following events should the nurse complete an incident report?

An IV pump delivers an inadequate dose of medication. The nurse should complete an incident report to record occurrences, such as a failure of the IV pump which resulted in a medication error, as part of the quality improvement process. CORRECT A nurse discontinues a client's enteral feedings according to her advance directives. The nurse is legally responsible for adhering to the instructions in a client's advance directive. A nurse discards unused bags of IV fluids because they are expired. The nurse should discard any materials that have met their expiration date to prevent injury to clients. A client refuses an IV bolus of pain medication. The client has the right to refuse treatment and the nurse should document that the client refuses the medication in the medical record.

A nurse is caring for a client who had a recent stoke. Prior to transferring the client to the bedside commode, which of the following actions should the nurse take first?

Ask for help with a two-person assist transfer. The nurse should ask for help when transferring a client to prevent injury to himself and the client, but this is not the first action the nurse should take. Assess the client for functional limitations. CORRECT Using the nursing process, the first action the nurse should take is to assess the client's functional limitations to determine how much the client can assist with the transfer. Request a mechanical lift device. The nurse should request a mechanical lift when transferring a client to prevent injury to himself and the client, but this not the first action the nurse should take. Medicate the client for pain. The nurse might need to medicate the client for pain to decrease discomfort, but this is not the first action the nurse should take.

A nurse is caring for a client who had a stroke 6 hr ago. Which of the following interventions should the nurse implement to lower the risk of increased intracranial pressure (ICP)?

Elevate the head of the client's bed to 45°. The nurse should elevate the head of the client's bed no more than 25° to reduce the risk of increasing ICP from hip flexion. Group several nursing activities to be completed at one time. The nurse should spread out nursing activities throughout the day to minimize fatigue and the risk of increasing ICP. Perform tracheopharyngeal suctioning every 2 hr. The nurse should only perform tracheopharyngeal suctioning when the client's airway is not clear because this intervention can increase ICP. Hyperoxygenating the client prior to performing suctioning will help minimize ICP increases. Place the client in a quiet environment. The nurse should keep the client's environment quiet to minimize the risk of increasing ICP. CORRECT

A nurse is preparing to administer 2 units of packed RBCs to a client who has anemia. Which of the following actions should the nurse take prior to initiating the blood transfusion?

Ensure that the client has been NPO for 4 hr. The client does not need to restrict food intake prior to receiving a blood transfusion. The nurse should encourage oral intake due to the client's anemia. Initiate lactated Ringer's solution to infuse with the blood product. The nurse should only use 0.9% sodium chloride solution when transfusing blood because other solutions can cause clotting or hemolysis of the blood cells. Obtain venous access using a 20-gauge needle. CORRECT The nurse should obtain venous access using a 20-gauge needle or larger. The large size needle allows the blood cells to flow more easily through the IV catheter without occluding the lumen. Collect both units of blood from the blood bank. The nurse should collect 1 unit of blood at a time. The nurse should initiate the blood transfusion within 30 min of removing it from the blood bank refrigerator to prevent bacterial growth in the blood.

A nurse is assessing a client who has been taking lithium carbonate for the past month to treat bipolar disorder. Which of the following assessment findings should the nurse identify as the priority?

Headache A headache is a nonurgent finding because it is an expected adverse effect of lithium therapy. Therefore, there is another finding that is the priority. Confusion CORRECT When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is confusion because it indicates advanced lithium toxicity. The nurse should monitor the client for additional indications of lithium toxicity, including coarse hand tremors, confusion, ECG changes, and sedation. Polyuria Polyuria is a nonurgent finding because it is an expected adverse effect of lithium. Therefore, there is another finding that is the priority. Hyperglycemia Hyperglycemia is a nonurgent finding because it is an expected adverse effect of lithium therapy. Therefore, there is another finding that is the priority.

A nurse is caring for a toddler who has infectious gastroenteritis. Which of the following actions should the nurse take?

Include chicken broth in the toddler's diet. The nurse should identify that chicken and beef broths contain excessive amounts of sodium and too little carbohydrates. Feed the toddler the BRAT diet. The BRAT diet (bananas, rice, applesauce, and toast) contains little nutritional value, containing inadequate amounts of protein and electrolytes but is high in simple carbohydrates. Initiate oral rehydration therapy for the toddler. Diarrhea causes dehydration, which results in fluid volume deficit. With the goal of restoring fluid balance, the nurse should administer an oral rehydration solution that contains sodium, potassium, chloride, citrate or bicarbonate, and glucose. CORRECT Offer the toddler flavored gelatin. Gelatin is high in carbohydrates, low in electrolytes, and high in osmolality which can prolong diarrhea and electrolyte imbalance.

A nurse is providing discharge instructions to an older adult client following a total hip arthroplasty. Which of the following instructions should the nurse include?

Install a raised toilet seat at home. CORRECT To minimize hip flexion and prevent hip dislocation, the client should use a raised toilet seat at home. Maintain the hip at an angle greater than 90°. The client should maintain the hip at an angle less than 90° to minimize hip flexion and prevent hip dislocation. Minimize the use of a walker. The client should use a walker to minimize the risk of falls or injury. Place a pillow under the knees when lying down. The client should not have a pillow under the knees when lying down because it can impede circulation and result in flexion contractures.

A charge nurse is observing a newly licensed nurse administer enteral feedings via NG tube. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure?

Instills 100 mL of air into the NG tube after checking for residual. The nurse should inject 10 to 30 mL of air into the NG tube before checking residual to clear the tube of any feeding. Instilling excessive air into the tube can cause abdominal distention and discomfort. Flushes the NG tube with 0.9% sodium chloride irrigation every 2 hr. The nurse should use 20 mL of tap water to flush the NG tube before and after each feeding. Using 0.9% sodium chloride irrigation can lead to hypernatremia. Adds 20 mL of blue dye to each feeding to help detect aspiration. The nurse should avoid adding dye to the feeding to detect aspiration because using dye can increase the risk of death. Keeps the head of the bed elevated to 45° for 1 hr after feedings. CORRECT The nurse should keep the client's head elevated to 45° for 1 hr after feedings to decrease the risk of aspiration.

A nurse manager is reviewing unit records and discovers that client falls occur most frequently during the hours of 0530 and 0730. Which of the following actions should the nurse take when conducting a root cause analysis?

Investigate environmental factors that might be contributing to client injury during these hours. When conducting a root cause analysis, the nurse should look at the overall systems or processes that affect a situation to identify the fundamental cause of the problem. This can include environmental factors that might be causing the problem. CORRECT Review the performance evaluations of nurses who work during these hours. When conducting a root cause analysis, the nurse does not include how individual nurses perform. Implement a plan to transition from team nursing to primary care nursing during these hours. When conducting a root cause analysis, the nurse focuses on identifying the cause of a problem, not potential solutions to the problem. Discuss a plan with the providers to reduce the use of barbiturate sedatives prior to these hours. When conducting a root cause analysis, the nurse focuses on identifying the cause of a problem, not potential solutions to the problem.

A nurse is assessing a client who has antisocial personality disorder. Which of the following findings should the nurse expect?

Lack of remorse CORRECT Clients who have antisocial personality disorder show a lack of remorse. Fear of public speaking Clients who have social phobia show a fear of public speaking. Extreme mood swings Clients who have bipolar disorders show extreme mood swings. Self-mutilating behavior Clients who have borderline personality disorder show self-mutilating behavior, such as cutting.

A nurse is caring for a client who has active tuberculosis (TB) and is admitted to the unit. Which of the following precautions should the nurse implement to prevent the transmission of the disease?

Maintain contact precautions. The nurse should initiate airborne precautions, rather than contact precautions, for a client who has active TB because mycobacterium tuberculosis is transmitted by air in nuclei smaller than 5 microns. Restrict visitors from visiting the client. Restricting visitors from visiting the client is unnecessary if proper transmission precautions are taken. Wear a surgical mask during contact with the client. The nurse should wear an N95 or HEPA respirator when caring for a client who has active TB. Have the client wear a mask while being transported outside the room. CORRECT A client who has active TB should wear a mask while being transported to prevent transmission of the disease.

A nurse is planning care for a client who has a deep-vein thrombosis of the left lower leg. Which of the following interventions should the nurse include in the plan of care?

Maintain the client on bed rest. The nurse should encourage the client to ambulate, as walking does not increase the risk for pulmonary emboli nor does it worsen the deep-vein thrombosis. Restrict the client to 1 L of fluid per day. The nurse should encourage the client to drink 2 to 3 L of fluid daily to decrease platelet aggregation and prevent dehydration. Place cool compresses on the edematous area. The nurse should place warm compresses on the affected area to reduce swelling and promote comfort. Elevate the affected leg. CORRECT The nurse should elevate the client's affected extremity to reduce edema and minimize the possibility of the thrombus formation and possible pulmonary emboli.

A nurse in an emergency department is preparing to discharge a young adult client who has experienced intimate partner abuse. Which of the following actions should the nurse take first?

Offer a referral to the client for social services. The client who has experienced intimate partner abuse can benefit from a referral to social services, but offering a referral is not the first action the nurse should take. Develop a safety plan with the client. CORRECT The greatest risk to this client is injury from violence. Therefore, the first action the nurse should take is to develop a safety plan with the client. Encourage the client to reach out to family and friends. The client can benefit from the support of family and friends when the client is ready, but encouraging this behavior is not the first action the nurse should take. Provide the client with a list of support groups. The client can benefit from attending a support group, but providing this information is not the first action the nurse should take.

A nurse is teaching a client who is postoperative following a total knee arthroplasty and is to receive enoxaparin. The nurse should explain that the purpose of this medication is to prevent which of the following complications?

Paralytic ileus Paralytic ileus is a potential complication following a total knee arthroplasty due to the effects of anesthesia and opioids on gastric motility, but enoxaparin does not prevent this complication. Atelectasis Atelectasis is a potential complication following a total knee arthroplasty due to the effects of anesthesia and opioids on the respiratory drive, but enoxaparin does not prevent this complication. Deep-vein thrombosis CORRECT Clients who are postoperative following arthroplasty of the knee should receive enoxaparin, an antithrombotic drug, to prevent deep-vein thrombosis. Anemia Anemia is a potential complication following a total knee arthroplasty due to blood loss during the surgical procedure, but enoxaparin does not prevent this complication.

A nurse is caring for a client who has rheumatoid arthritis and has moderate to severe pain in multiple joints. Which of the following actions should the nurse take to provide comfort to this client?

Perform ADLs in the morning. Pain, stiffness, and swelling are worse in the morning for clients who have rheumatoid arthritis. The nurse should postpone assisting the client to perform ADLs until morning analgesics and anti-inflammatory medications provide relief. Allow for frequent rest periods throughout the day. Clients who have rheumatoid arthritis should balance rest with exercise to maintain muscle strength, joint function, and range of motion. CORRECT Encourage the client to take warm tub baths when joints are inflamed. Clients who have inflamed joints can use moist heat to enhance comfort. However, getting into a bath tub places the client at risk for injury from a fall. The nurse should recommend a warm shower. Develop a daily schedule for acetaminophen up to 6 g/day that covers peak periods of pain. A client who has rheumatoid arthritis should not take more than 4 g of acetaminophen each day.

A nurse is caring for a client who has dehydration secondary to nausea and vomiting. The nurse should identify which of the following findings as an indication of fluid volume deficit?

Shortness of breath The nurse should recognize shortness of breath as an indication of fluid volume excess because extra fluid interferes with oxygen exchange at the alveolar level. Visual disturbances The nurse should recognize visual disturbances, such as blurred vision, indicate fluid overload rather than fluid volume deficit. Decreased BUN levels Increased BUN levels should indicate to the nurse that the client has a fluid volume deficit. Orthostatic hypotension Clients who have a fluid volume deficit can have orthostatic hypotension as a result of decreased blood volume.

A nurse is administering medications to several clients and has to discard a portion of the medication dose. For which of the following medications should the nurse ask a second nurse to observe and cosign disposal of a portion of the dose?

Sumatriptan Sumatriptan is an anti-migraine medication, but it is not a controlled substance and does not require two nurses to dispose of a partial dose of this medication. Insulin lispro Insulin is an antidiabetic medication. While it is appropriate for a second nurse to verify the dosage the nurse draws up in the syringe, this medication does not require two nurses to dispose of a partial dose of this medication. Fentanyl CORRECT Fentanyl is an opioid analgesic, which has the risk of abuse; therefore, the nurse has a legal responsibility to have a second nurse observe and cosign disposal of a portion of the dose. Dexamethasone Dexamethasone is an anti-inflammatory, but it is not a controlled substance and does not require two nurses to dispose of a partial dose of this medication.