NCLEX Review 2

A woman has been recently diagnosed with systemic lupus (SLE) and shares with the nurse, "I am thinking about getting pregnant, but I don't know how I will be able to tolerate a pregnancy because I have lupus." Which of the following responses by the nurse is BEST?

"How long have you been in remission?" should be in remission for at least 5 months prior to conceiving maternal morbidity and mortality are increased with SLE

A woman at 38 weeks' gestation comes to the emergency room with complaints of vaginal bleeding. Which of the following statements, if made by the client, suggests to the nurse placenta previa as the cause of the bleeding?

"I feel fine, but the bleeding scares me." placenta previa is characterized by painless vaginal bleeding

The school nurse instructs a group of preschool mothers about poison prevention in the home. Which of the following statements, if made by a mother to the nurse, indicates further teaching is necessary?

"I should induce vomiting if my child swallows lighter fluid." vomiting contraindicated when child ingests hydrocarbons because of danger of aspiration

The nurse provides care for a client who is prescribed levothyroxine. Which client statements indicate to the nurse a correct understanding of the medication therapy? (Select all that apply.)

"I will feel more energetic when this medication works. " "I will take this medication on an empty stomach when I wake up. " "This medication replaces the hormone I don 't produce. " NOT blood TSH levels will increase.

The nurse cares for a patient following an appendectomy. The patient takes a deep breath, coughs, and then winces in pain. Which of the following statements, if made by the nurse to the patient, is BEST?

"Take three deep breaths, hold your incision, and then cough." most effective way of deep breathing and coughing, dilates airway and expands lung surface area

After attending a presentation on sexually transmitted infections (STIs), an adolescent participant asks the nurse if the human papillomavirus (HPV) vaccination is necessary if a person is not sexually active. Which response will the nurse make to this adolescent? (Select all that apply.)

"Immunizations are recommended to provide immunity before exposure." "This vaccine is recommended for males and females at 11 -12 years of age." "The human papillomavirus can cause cervical or penile cancer." NOT reduces the risk of ovarian cancer as you get older. NOT condoms prevent the spread of; Condoms may reduce the risk of STIs, but the virus can be transmitted to other areas of the body.

The nurse provides medication teaching to a client who is prescribed losartan. The client asks the nurse why the medication is required since lower leg swelling only occurs when standing too long. Which responses will the nurse make to this client? (Select all that apply.)

"It works by dilating blood vessels, which then reduces your blood pressure." "Do you have a bathroom scale at home?" "You may feel dizzy at first when taking this medication. Get up slowly to avoid falls."

The young adult is brought to the emergency department after a motorcycle accident. A closed head injury with suspected subdural hematoma is diagnosed. The client is alert and answers questions appropriately and reports a severe headache. The nurse questions which order?

"Morphine sulfate 10 mg IM q3 4h." narcotic analgesic, causes CNS and respiratory depression, contraindicated in head injury because it masks signs of increased intracranial pressure

The nurse in the outpatient clinic instructs the mother of a school-aged child diagnosed with asthma how to prevent future asthmatic attacks. The nurse is MOST concerned if the mother states which of the following?

"My son loves to help his dad rake leaves." main cause of asthma is inhaled allergens (animal dander, mold, pollen, dust), would expose child to pollen and dust from leaves

A client diagnosed with bipolar disorder receives haloperidol (Haldol) 2 mg PO tid. The client tells the nurse, "Milk is coming out of my breasts." Which of the following responses by the nurse is BEST?

"You are experiencing a side effect of Haldol."

The nurse performs triage on a group of clients in the emergency department. Which of the following clients should the nurse see FIRST?

A 19-year-old with a fever of 103.8°F (39.8°C) who is able to identify her sister but not the place and time. disoriented, requires immediate assessment to determine underlying cause Someone who is hyperglycemic just needs insulin. This girl is more important.

The nurse cares for clients on the medical/surgical unit. The nurse identifies which of the following clients is MOST at risk for developing herpes zoster?

A 62-year-old heart transplant with suspected rejection. immunocompromised due to immune suppression therapy; clients with compromised immune system at risk for reactivation of the varicella zoster virus

The charge nurse is making client assignments for the nursing team. Which client will the charge nurse assign to the LPN/LVN?

A client in skin traction. It is a stable client with an expected outcome. Other options are unstable.

The nurse provides care for clients in the emergency department. Which client does the nurse assess first?

A client reporting a dry cough for several weeks with frequent night sweats. These are classic symptoms of tuberculosis. Place the client in an airborne infection isolation room or fit with an appropriate mask to prevent spread of the disease until evaluation confirms.

The nurse supervises care on the medical-surgical unit. Which situation does the nurse attend to first?

A client who returned to the unit after a right pneumonectomy is placed in a room with a client diagnosed with emphysema who is receiving IV antibiotics. Post-operative clients are considered "clean" or uncontaminated and should not be placed with the client who is considered contaminated. The client who is diagnosed with emphysema and receiving IV antibiotics is considered contaminated. Therefore, this situation requires immediate intervention by the nurse.

A client is in the emergency department to rule out a cerebral vascular accident (CVA). The client suddenly develops a severe headache and loses consciousness. Which finding is a priority for the nurse to report to the health care provider?

A history of atrial fibrillation. Atrial fibrillation results in a decrease in cardiac output because of ineffective atrial contractions or a rapid ventricular response. Thrombi form in the atria because of blood stasis. An embolus may develop and move to the brain, causing a CVA. Atrial fibrillation accounts for as many as 17% of all CVAs.

A client diagnosed with multiple sclerosis (MS) is at 39 weeks' gestation. The client is admitted to the labor and delivery unit in active labor. The client's vital signs are BP 127/72; pulse 72 bpm; cervix is 4 cm dilated; FHT 124 bpm; moderate contractions are 4 minutes apart. The nurse should anticipate the need for which of the following?

A reduction in the amount of pain medication administered. less pain medication is required because of overall decrease in pain perception due to MS

A school-age client injured the right knee yesterday. The client's right knee is painful, swollen, and bruised. The parent says that the child has hemophilia A. The nurse determines which medication is safest for this client?

Acetaminophen. Acetaminophen is a non-opioid, non-salicylate analgesic that can be effective in treating mild to moderate pain. NSAIDS like ibuprofen and naproxen increases bleeding time.

The nurse prepares for the admission of a client diagnosed with diabetes mellitus (DM) who also has a latex allergy. The only private room on the unit is occupied by a client diagnosed with tuberculosis. The nurse will take which action when assigning the new client to a room on the unit?

Admit the client diagnosed with latex allergy to a room with a client diagnosed with Parkinson disease and treat both clients as being latex-sensitive.

The nurse provides care for a client diagnosed with ventricular tachycardia and angina. Which medication does the nurse administer first?

Amiodarone The nurse administers a drug that will terminate the rhythm causing the angina first. Ventricular tachycardia indicates severe myocardial irritability and causes chest pain, dizziness, and fainting. Amiodarone is the drug of choice for hemodynamically unstable ventricular tachycardia. This medication inhibits adrenergic stimulation and prolongs repolarization, allowing for a normal rhythm to occur.

A severe storm has blown out the windows on a 30-bed medical/surgical unit. The nurse determines that clients have to be evacuated to other rooms throughout the hospital. Which client does the nurse transfer first?

An adult client admitted with exacerbation of asthma who is receiving nebulizer treatments. This client is unstable and is currently experiencing breathing concerns. The client is at risk of ineffective airway clearance due to particles in the air from storm debris and damage to the windows.

The nurse assesses a newborn whose parent is unsure of the date of conception. Which assessment finding indicates to the nurse that the newborn is preterm?

Arms and legs are extended at rest. Normally, the full-term newborn's extremities are flexed when the newborn is at rest. The preterm newborn may demonstrate limp or flaccid extremities that are extended when at rest. Preterm newborns also may demonstrate rigid extension of extremities.

A client has abdominal surgery for colon cancer. The nurse cares for the client just returning to the post-surgical unit. It is best for the nurse to take which action?

Ask the client to lift the head off the pillow. Asking the client to lift the head off the pillow assesses whether any remaining effects of neuromuscular-blocking agents are present. If remaining effects are present, the client's ability to breathe deeply will likely be affected.

The nurse provides care for a client prescribed gemfibrozil. Which laboratory value does the nurse review based on this prescribed medication?

Aspartate aminotransferase (AST).An AST is a lab that is monitored to assess liver function. The normal range is 10 to 30 units/L (0.17-0.51 μkat/L). Lipid-lowering agents such as gemfibrozil are prescribed for clients with high serum triglyceride levels. Adverse effects for this medication include abdominal pain and cholelithiasis. The client is instructed to take the medication 30 minutes before breakfast and dinner.

The nurse provides care to a client diagnosed with a pelvic fracture after a motor vehicle accident. The nurse notes that the client is agitated and attempting to get out of bed. The client has removed the IV and reports shortness of breath. The client's blood pressure is 90/58 mm Hg, respirations 28 breaths/minute, pulse 133 beats/minute, and O2 sat 78% on 3.5 L/minute of oxygen. Which action will the nurse perform? (Select all that apply.)

Assess breath sounds. Obtain arterial blood gases (ABG). Establish vascular access. Oxygen level should be INCREASED

The nurse in a psychiatric emergency room cares for a client who is a victim of interpersonal violence. The INITIAL priority of the nurse is which of the following?

Assess for physical trauma. physical, victim may have physical trauma and concealed injuries; assessment is of utmost importance so that the client's physiologic integrity is maintained Will also be providing privacy at the same time.

The nurse provides care to a client who is newly diagnosed with myasthenia gravis. Which intervention represents the nurse's highest priority?

Assist the client during mealtime. Dysphagia is hallmark of MG.

A client on the psychiatric unit begins to pace and continuously wring hands, and the nurse notes the client's voice is becoming louder and angrier. Which action does the nurse take?

Assist the client to express feelings of anger and frustration. This behavior indicates increased agitation and may indicate impending violence. The nurse de-escalates the client's behavior. The nurse will help the client to verbalize feelings, avoid disagreeing with or threatening the client, and remove threatening components of the environment.

The health care provider prescribes famotidine 40 mg PO daily for a client. At which time does the nurse advise the client to take the medication for the best results?

At bedtime. For the best results, famotidine, an H2-histamine blocker, should be taken before meals or at bedtime. Doing so decreases food-induced acid secretion. Famotidine may be prescribed to treat gastric or duodenal ulcers.

During shift hand-off report, a client's ventilator alarm is activated. Which action does the nurse take first?

Auscultate breath sounds. The nurse must support the client while identifying and correcting the ventilator problem. The nurse observes rate and quality of respirations and assesses for hypoxia. NOT assess the tubing: The nurse should first assess the client, even if the ventilator is the problem, because the client's respiratory functioning must be supported.

The client is being discharged with sublingual nitroglycerin. Which information should the nurse give to the client?

Avoid abrupt changes in posture. nitroglycerin can cause hypotension; client should avoid changing positions quickly to decrease the chances of falling

A client with type 2 diabetes mellitus is prescribed pioglitazone and metformin. Which client health history information causes the nurse to question the prescription of these medications? (Select all that apply.)

Being 6 weeks pregnant. History of heart failure. Pioglitazone is contraindicated in clients with a history of heart failure. History of lactic acidosis. Metformin is contraindicated in clients with a history of lactic acidosis.

A client takes perphenazine by mouth for 2 days. The client now reports the head turned to the side, the neck arched at an angle, and stiffness and muscle spasms in the neck. The nurse expects to give which PRN medication?

Benztropine. Benztropine is an anti-parkinsonian agent. It is used to counteract the extra-pyramidal adverse effects the client is experiencing.

The nurse provides care for a client in cardiogenic shock after a myocardial infarction (MI). Which is the priority nursing diagnosis for the client?

Cardiac tissue death. priority nursing diagnosis, nothing else will work if you can not fix the heart muscle

The nurse discusses skateboard safety with a group of parents. Which statement is most important for the nurse to include?

Carefully check the surface where your child will be skateboarding

After caring for a client, the nurse needs to dispose of which item in the biohazard bin?

Canister of gastric secretions. NOT blood-tinged adhesive bandage. It would need to be soaked.

The nurse provides nutrition teaching to the parent of a client with deep partial thickness burns on the legs. Which meal does the nurse suggest?

Cheeseburger, fruit-flavored yogurt, carrots, and milk. Protein is found in the cheeseburger, yogurt, and milk. A burn injury requires a high-protein diet for wound healing.

A nurse prepares to perform blood pressure screenings at a health fair in the local community center. Which part of the preparation receives the most attention?

Collect blood pressure cuffs of varied sizes. to ensure accurate readings

The multidisciplinary team decides to implement behavior modification with a client. Which of the following nursing actions is of primary importance during this time?

Confirm that all staff members understand and comply with the treatment plan. to implement a behavior modification plan successfully, all staff members need to be included in program development, and time must be allowed for discussion of concerns from each nursing staff member; consistency and follow-through is important to prevent or diminish the level of manipulation by the staff or client during implementation of this program

The nurse prepares a child client for emergency surgery. The informed consent for surgery has been signed by one parent. Which action by the nurse is best?

Continue the child's preoperative preparation. No need to notify the health care team. Emergency surgery, so need to keep going.

The nurse notes that the edges of a client's surgical abdominal wound are separated and a small loop of bowel protrudes through the incision. Which action will the nurse take first?

Cover the wound with a sterile dressing soaked with sterile normal saline. The nurse should cover the wound with a sterile dressing soaked with sterile normal saline before contacting the health care provider. Covering the wound will keep the intestinal area moist until the client can return to surgery. The client should also be placed in low-Fowler position and instructed not to cough.

The client is admitted with a diagnosis of subdural hematoma and cerebral edema after a motorcycle accident. Which symptoms should the nurse expect to see initially?

Decreasing level of consciousness. Ipsilateral pupil dilation. Headache.

The nurse assesses a client in an outpatient clinic. The client was diagnosed with osteoarthritis 15 years ago and takes aspirin multiple times per day. Which intervention does the nurse complete first?

Determine if the client experiences tinnitus. Determining if the client is experiencing tinnitus is the first action the nurse should take. Tinnitus indicates aspirin toxicity. If the client is experiencing tinnitus, the nurse needs to contact the health care provider.

The nurse provides care for a young adult female client undergoing peritoneal dialysis. The nurse notes that the outflow appears red-tinged. Which action does the nurse take first?

Determine if the client is menstruating. Because of the hypertonicity of the dialysate, blood from the uterus can be pulled through the fallopian tubes into the effluent. This is common in premenopausal female clients during menstruation. No intervention is required.

The nurse provides care to a client with hypernatremia. Which is a risk factor for the development of this electrolyte imbalance?

Diabetes insipidus. Diabetes insipidus increases the risk for hypernatremia, if the client does not experience thirst, cannot respond to thirst, or if fluids are excessively restricted. Normal sodium level is 135 to 145 mEq/L (135 to 145 mmol/L). 1) INCORRECT - Excessive water intake increases the risk for hyponatremia, not hypernatremia. 2) INCORRECT - Diuretic use increases the risk for hyponatremia, not hypernatremia. 3) INCORRECT - Vomiting increases the risk for hyponatremia, not hypernatremia.

A client received six units of regular insulin 3 hours ago. The nurse is MOST concerned if which of the following is observed?

Diaphoresis and trembling. regular insulin peaks in 2 to 3 hours; indicates hypoglycemia; give skim milk

When assisting with a bone marrow aspiration, the nurse should take which of the following actions?

Drop additional sterile supplies onto a sterile tray.

A client returns to the room following a myelogram. The nursing care plan includes which intervention? (Select all that apply.)

Encourage oral fluid intake. Elevate head of bed 30 to 45 degrees. Monitor vital and neurological signs.

An older man is seen in the outpatient clinic for treatment of an acute attack of gout. Which of the following nursing interventions is MOST beneficial in decreasing the client's pain during ambulation?

Encourage partial weight bearing while ambulating. would relieve weight, pressure, and stress on affected leg, may use walker (4) immobility would aggravate pain and inflammation

An elderly client returns to the room after an open reduction and internal fixation of the left femoral head after a fracture. It is MOST important for the nursing care plan to include which of the following?

Encourage the client to cough and deep breathe. They may be positioned on affected side after the incision heals.

A young adult patient constantly seeks attention from the nurses, stomping away from the nurses' station and pouting when requests are refused. Which of the following responses by the nurse is MOST appropriate?

Give the patient unsolicited attention when the patient is exhibiting acceptable behaviors. reward non-attention-seeking behaviors by giving the patient unsolicited attention

A patient is admitted to the surgical unit with a diagnosis with rule out (R/O) intestinal obstruction. The nurse prepares to insert a Salem sump NG tube as ordered. It is BEST for the nurse to place the patient in which of the following positions?

Head of bed elevated 60-90°. facilitates swallowing and movement of tube through gastrointestinal tract

A 2-month-old with a temperature of 102°F (39°C) is brought to the emergency department by his mother. The mother tells the nurse that the infant had a DPaT injection 1 week ago, and asks if this fever is related to the immunization. The nurse's response should be based on which of the following?

If there is a fever after a DPaT, it is usually low-grade and appears within the first 48 hours.

A nonstress test is scheduled for a client at 34 weeks' gestation who developed hypertension, periorbital edema, and proteinuria. Which of the following nursing actions should be included in the care plan in order to BEST prepare the client for the diagnostic test?

Instruct client to push a button when she feels fetal movement.

A client diagnosed with AIDS is seen in the emergency room with complaints of mouth pain, difficulty swallowing, and a white discharge in the back of the throat. The nurse expects the physician to order which of the following?

Ketoconazole (Nizoral) 200 mg daily. drug of choice for treatment of candidiasis

The nurse monitors a client's EKG strip and notes coupled premature ventricular contractions greater than 10 per minute. The nurse should expect to administer which of the following?

Lidocaine hydrochloride (Xylocaine) IV. lidocaine is the drug of choice for frequent premature ventricular contractions (PVC) occurring in excess of 6 to 10 per minute; for coupled PVCs or for a consecutive series of PVCs that may result in ventricular tachycardia

The nurse provides care for an adolescent admitted for burns to 50% of the body. What action is the highest priority for the nurse?

Maintain sterile technique during procedures.

The nurse provides care for a client who anticipates using a prosthesis after an above-the-knee amputation. Which action should the nurse take when caring for this client?

Maintain the compression dressing to the amputation site. When caring for a client after an above-the-knee amputation, the nurse needs to maintain the compression dressing to the amputation site. This minimizes edema and prevents infection.

The nurse provides care for a client diagnosed with left-sided weakness and impaired speech. Which intervention is appropriate for the nurse to assign to the unlicensed assistive personnel (UAP)? (Select all that apply.)

Maintain the head of the bed less than 30 degrees. Assist the client with frequent oral care. NOT monitor blood pressure regularly. Nurse will need to do this as a focused assessment.

What statements indicate adverse med effects of furosemide:

My legs don't want to hold me up - muscle weakness is a symptom of hypokalemia - caused by excessive diuresis I can't get enough to drink today I feel like I might pass out

Which task does the nurse properly delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)

Measure the diameter of the client's calf.3.Obtain a midstream urine specimen.4.Cleanse a superficial wound with an antiseptic solution.5.Measure a client's rectal temperature.

The nurse provides care for a client with an ileostomy. For which acid-base disorder does the nurse monitor the client?

Metabolic acidosis. - intestinal secretions are high in bicarbonate.

An extremely agitated client receives haloperidol (Haldol) IM every 30 minutes while in the psychiatric emergency room. It is MOST important for the nurse to take which of the following actions?

Monitor blood pressure every 30 minutes. assessment; monitoring vital signs is of utmost importance to ensure client safety and physiological integrity; rapid neuroleptization is a pharmacological intervention used to rapidly diminish severe symptoms that accompany acute psychosis; alpha-adrenergic blockade of peripheral vascular system lowers BP and causes postural hypotension

The nurse assesses a client with Addison disease. Which finding will the nurse expect the client to exhibit?

Muscle cramps, fatigue, and hypotension. symptoms of hyponatremia because the disease is characterized by hyposecretion of the adrenal hormones.

A client in the ICU is given procainamide HCl (Pronestyl) slowly by IV push. The nurse should withhold the next dose if which of the following is observed?

Occurrence of severe hypotension. severe hypotension or bradycardia are signs of an adverse reaction to this medication

The nurse provides instruction for a client receiving furosemide. Which potassium-rich food selections by the client indicate to the nurse that the teaching was effective? (Select all that apply.)

One medium baked potato. 1 cup of cantaloupe. NOT apple or egg.

The home health care nurse provides care for a client diagnosed with type 1 diabetes. The client is maintained on a regimen of intermediate-acting insulin and short-acting insulin and a 1,800-calorie diabetic diet with normal blood glucose levels. Morning self-monitored blood glucose (SMBG) readings the past 2 days were 205 and 233 mg/dL (11.4 and 12.9 mmol/L) . The nurse expects the health care provider to take which action?

Order three additional units of intermediate-acting insulin at 2200. dawn phenomena, treatment is to adjust evening diet, bedtime snack, insulin dose, and exercise to prevent early morning hyperglycemia

A child diagnosed with status asthmaticus, receiving oxygen 50% per an air-entrainment mask, has a pulse of 120 beats/min, respirations 26 breaths/min, and a temperature of 98.6°F (37.0°C). Which observation causes the nurse the most concern?

Oxygen saturation is 85%. NOT dusky fingertips - not an absolute indicator of poor oxygenation, could be circulation problem

The nurse provides care for a client who is preoperative for a discectomy/laminectomy. The client has a history of obesity and sleep apnea. The nurse administers diazepam 10 mg orally for pain reported as 9 out of 10 on a numerical pain scale. Which additional action is appropriate for the nurse to take? (Select all that apply.)

Perform frequent respiratory checks if the client is drowsy. Inform anesthesiology of administration of oral medication. Reassess the client for pain level and anxiety. do NOT administer the prescribed narcotic as it may worsen respiratory issues

The client develops right-sided heart failure. The nurse expects to observe which symptoms?

Peripheral edema and anorexia. Polycythemia: increased RBC as compensation for decreased oxygenation. Distended neck veins.

The nurse cares for patient placed in balanced suspension traction with a Thomas splint and Pearson attachment because of a fractured right femur. The nurse notes that the patient's left leg is externally rotated. The nurse should take which of the following actions?

Place a trochanter roll on the outer aspect of the thigh. holds hip in neutral position and leg in normal alignment, entire weight of leg cannot be held by props placed below knee

A patient is returned to the room after a subtotal thyroidectomy for treatment of hyperthyroidism. Which of the following, if found by the nurse at the patient's bedside, is nonessential?

Potassium chloride for IV administration.

The nurse instructs a group of parents about age-appropriate toys for toddlers. Which toys will the nurse recommend that toddlers use? (Select all that apply.)

Pounding board. Cloth picture books. Play clothes for dress-up, tricycle and skates are appropriate for preschoolers, not toddlers.

The nurse provides care for a client who had an exploratory laparotomy a day ago due to a small-bowel obstruction. Upon assessment, the client reports the pain is 4 out of 10. Which actions will the nurse implement? (Select all that apply.)

Prepare a dose of ketorolac 30 mg by IV push. - its an NSAID Assist the client to ambulate in the hall. Auscultate for bowel sounds in four quadrants. ALSO an NG tube would be in place, don't encourage fiber.

The novice nurse administers RBCs to a client. Which actions by the novice nurse are deemed safe by the nurse preceptor? (Select all that apply.)

Priming the intravenous tubing with 0.9% sodium chloride. Obtaining and documenting a full set of baseline vital signs. NOT setting the infusion rate to deliver blood within 6 hours - it should be 4 hours. Also require large gauge catheters 20-24 gauge. Should stay with client for first 15 minutes

A client has a history of oliguria, hypertension, and peripheral edema. Current lab values are BUN 25 and K+ 4.0 mEq/L. The nurse should restrict which of the following in the client's diet?

Protein decreased production of urea nitrogen can be achieved by restricting protein; metabolic wastes cannot be excreted by the kidneys

A woman is admitted to the labor and delivery unit in a sickle cell crisis. Which of the following nursing actions is the HIGHEST priority?

Provide adequate hydration.

The nurse plans care for an older adult client with pernicious anemia who lives at home. Which goal is the most important for the client?

Receive monthly vitamin B 12 injections.Pernicious anemia is caused by failure to absorb vitamin B 12 because of a deficiency of intrinsic factor from the gastric mucosa. For the client with pernicious anemia, vitamin B 12 is given on a monthly basis. Without it, death may occur within 1 to 3 years.

Psych admit: pt frequently changes the subject. Which response is appropriate/

Recognize client's behavior relieves discomfort.

The nurse cares for a client receiving IV antibiotics for 4 days. Which of the following should cause the nurse to be concerned about postinfusion phlebitis?

Reddened area or red streaks at the site. Swelling is infiltration, not infection.

During a first aid class, the nurse instructs clients on the emergency care of partial thickness burns. The nurse identifies which of the following interventions for partial thickness burns of the chest and arms BEST prevents infection?

Remove clothing, and wrap the victim in a clean sheet.

Which technique is correct for the nurse to use when changing a large abdominal dressing on an incision with a Penrose drain?

Remove the dressing layers one at a time. to avoid dislodging drain, remove the dressing layers one at a time

The nurse cares for a postcholecystectomy client who had the T-tube removed this morning. Two hours after removal of the T-tube, the nurse notes that the 4 × 4 dressing covering the stab site is saturated with dark, greenish-yellow drainage. It is MOST appropriate for the nurse to take which of the following actions?

Remove the dressing, and replace it with a more absorbent dressing. expected that a stab wound will continue to drain until the wound seals; nurse should keep wound clean and dry This is likely bile, which is expected. No indication of infection.

The nurse provides care for clients in the pediatric clinic. The nurse performs an assessment of a toddler-age client. The nurse recognizes appropriate cognitive development when the client exhibits which behavior?

Removes wet diaper and discards it. According to Erikson's stages of psychosocial development, from 12 months to 3 years the toddler learns self-control and how to directly influence the environment. Failure to develop autonomy results in defiance and negativism, shame and doubt. Toddlers who remove their own diaper, try toilet training, attempt to dress themselves, or say no when offered food are exercising autonomy. They are not yet playing with peers.

The nurse provides care for a child client with suspected sickle cell disease. Which laboratory result does the nurse expect to be increased in sickle cell disease?

Reticulocyte count.

A child returns to the recovery room after a bronchoscopy. The nurse should position the client in which of the following positions?

Semi-Fowler's position. check vital signs every 15 minutes until stable, assess for respiratory difficulty (stridor and dyspnea resulting from laryngeal edema or laryngospasm) Do not extend the neck - could obstruct airway because tongue falls back of mouth.

The nurse cares for a manic client in the seclusion room, and it is time for lunch. It is MOST appropriate for the nurse to take which of the following actions?

Serve the meal to the client in the seclusion room. Should eat at regular time

The nurse provides care for a client with left-sided hemiparesis from a stroke. The nurse notes a decrease in muscle tone on the client's left side. The nurse determines which nursing diagnosis is the priority?

Skin integrity.

The nurse instructs a client on the newly prescribed medication imipramine. Which symptoms will the nurse teach the client to report immediately to the health care provider?

Sore throat, fever, increased fatigue, vomiting, diarrhea. 1) CORRECT - Sore throat, fever, increased fatigue, vomiting, and diarrhea are possible adverse effects of imipramine, a tricyclic antidepressant medication. These side effects can be resolved by altering the dosage or changing the medication.

Which initial action does the nurse take when managing a physically assaultive client?

Speak calmly and assertively to encourage client control. Maintain the client's dignity and self-esteem by speaking assertively, not aggressively; keep a safe distance from the client, and continue to assess if the behavior is escalating or decreasing.

The newborn infant of an HIV-positive mother is admitted to the nursery. The nurse should include which of the following in the plan of care?

Standard precautions. provides immediate protective care for the staff members

An older adult client has a medical history that includes hypertension. A public health nurse visits this client regularly. Which finding does the nurse expect for this client?

Temperature 96.8°F (36°C), pulse 80 beats/min, respirations 20 breaths/min, blood pressure 160/90 mm Hg.

The nurse observes the unlicensed assistive personnel (UAP) prepare to obtain the vital signs of an infant diagnosed with respiratory syncytial virus (RSV). Which observation requires an intervention by the nurse?

The UAP removes the gown and gloves and places them in a hamper in the hall. They should remove gown and gloves before leaving the room, place them in a hamper in the room.

The nurse supervises the care provided by an unlicensed assistive personnel (UAP) to a client being treated with a radioactive implant for vaginal cancer. Which situation requires the nurse to intervene?

The UAP stands behind the portable bedside shield placed at the foot of the client's bed. The shield should be placed on the hallway side of the client's bed to protect caregivers and visitors who enter the client's room. They should not stand at the foot of bed.

The home health nurse is conducting a home safety assessment in the home of an older adult client who lives alone. Which observation made by the nurse requires follow up and teaching? (Select all that apply.)

The bottom drawer on the client's nightstand is broken and will not stay closed. The client has a weekly laundry service that delivers clean laundry inside the front door. The client may trip over laundry baskets or bags, which creates a risk for falls. This observation would require follow up and teaching by the nurse.

The nurse assesses the development of a 3-month-old boy in the well-child clinic. Which of the following behaviors, if observed by the nurse, is UNEXPECTED?

The boy tries to grasp a toy just out of reach. Not until 6 months.

A 13-year-old male diagnosed with muscular dystrophy (MD) develops nocturia. The client wants to know about external catheters. The nurse should base the response on which of the following statements?

The catheter can be removed during the day. being free from any drain bags during the day would appeal to a 13-year-old

The nurse supervises the staff providing care for an 18-month-old hospitalized with hepatitis A. The nurse determines that the staff's care is appropriate if which of the following is observed?

The child is placed in a private room. contact precautions required for diapered or incontinent clients

The nurse in the outpatient clinic instructs a client diagnosed with a sprained right ankle to walk with a cane. What behavior, if demonstrated by the client, indicates to the nurse that teaching is effective?

The client holds the cane in the left hand. should hold cane on strong side, widens base of support, reduces stress on affected side. Cane should never be behind them.

Which of the following observations BEST indicates to the nurse that a client diagnosed with paraplegia can adequately carry out activities of daily living at home after discharge?

The client transfers himself into and out of his wheelchair. essential if client is to perform ADLs Remember that paraplegic has full use of upper body.

The home care nurse instructs a client recently diagnosed with tuberculosis. It is MOST important for the nurse to include which of the following as a part of the teaching plan?

The client will be required to take prescribed medication for 6 to 9 months. Can send home with family because they are already exposed.

The nurse provides care for a pregnant client. The client comes for a second prenatal visit at 15 weeks' gestation. The client's blood pressure is 120/72 mm Hg. The client's first blood pressure at 12 weeks' gestation was 124/80 mm Hg. Which action does the nurse implement based on this information?

The client's systolic blood pressure usually remains the same as the pre-pregnancy level, but may decrease slightly as the pregnancy advances. Both of these values are within normal limits. Therefore, the nurse documents the blood pressure.

A client at 32 weeks' gestation is seen in the outpatient clinic. Which of the following findings, if assessed by the nurse, indicates a possible complication?

The client's urine test is positive for glucose and acetone. abnormal finding, could indicate gestational diabetes (GDM), hazard of placental insufficiency

The nurse prepares the client for ambulatory surgery. Which procedural information is important for the nurse to provide? (Select all that apply.)

The methods of pain control that will be used. Any fluid and food restrictions that will be required. Technique and practice of deep breathing and coughing. NOT odors and sensations that may be experienced, because is it subjective and may increase their anxiety.

The nurse provides care for a client who has a prescription for a fecal occult blood test. Which actions indicate that the nurse is using the guaiac test correctly? (Select all that apply.)

The nurse asks the client about taking vitamin C in the past several days. Taking vitamin C is contraindicated for 3 days prior to taking the specimen. Pink results are considered negative and do not require verification. The nurse should observe for a blue color change, which is indicative of a positive result. The nurse collects a sample from two different areas of the stool specimen. NOT The nurse mixes the reagent with the stool sample before applying to the card. The reagent is placed on the specimen after it is applied to the testing card.

Which action, if observed by the charge nurse, indicates appropriate care for a client diagnosed with increased intracranial pressure (ICP)?

The nurse assesses for the gag reflex before administering oral fluids. Increased ICP can adversely affect the gag (or cough) reflex and increase the possibility of aspiration. Suctioning can increase ICP and is avoided unless absolutely necessary.

The nurse knows that the client diagnosed with drug-induced Cushing's syndrome should FIRST be instructed about which of the following?

The schedule for gradual withdrawal of the drug. if steroids are withdrawn suddenly, the client may die of acute adrenal insufficiency

A nurse assesses an older adult client who reports a 2-day history of vomiting and diarrhea. Which findings will the nurse expect during the physical exam? (Select all that apply.)

Urine specific gravity 1.035. 4.Hematocrit 55% (0.55). Fluid volume deficit leads to decreased blood volume, which results in more concentrated blood and a hematocrit greater than the expected reference range. 5.Weak, thready pulse.

The nurse cares for clients in the pediatric clinic. A mother reports that her infant's smile is "crooked". The nurse should assess which of the following cranial nerves?

VII facial; provides motor activity to the facial muscles

The nurse provides care for a postpartum mother who has stopped breastfeeding her newborn. The client reports painful swollen breasts. Which nursing intervention does the nurse include in the client's plan of care?

Wear a snug-fitting supportive bra. NOT warm compresses - would stimulate breast milk and increase discomfort

The nurse provides care for a client who has a positive cytomegalovirus (CMV) titer. Which is the most appropriate action for the nurse to take while caring for the client?

Wear eyewear when emptying a urinary drainage bag. positive CMV titer requires standard precautions; eyewear worn whenever there is risk of splash or splatter

The nurse administers terbutaline (Brethine) to a client in labor. Prior to administration of the medication, the nurse assesses the client's pulse to be 144. Which of the following actions should the nurse take FIRST?

Withhold the medication. maternal tachycardia is a side effect of Brethine; other maternal side effects include nervousness, tremors, headache, and possible pulmonary edema; fetal side effects include tachycardia and hypoglycemia; Brethine is usually preferred over ritodrine (Yutopar) because it has minimal effects on blood pressure

A client who is positive for human immunodeficiency virus (HIV) is to be discharged and will be taking zidovudine (AZT) at home. Which of the following actions by the nurse is BEST?

Write the schedule of when the medicine should be taken. planned and written schedule of administration is more effective for adherence to time frames

The nurse prepares a patient for a cesarean section. The patient says that she had major surgery several years ago and asks if she will receive a similar "shot" before surgery. The nurse's response should be based on an understanding that the preoperative medication given before a cesarean section

contains lower amounts of narcotics than are given before general surgery. decreased so that less narcotic crosses the placental barrier, causing respiratory depression in the infant