NCLEX REVIEW

A client admitted to ICU has a prescription for an arterial line insertion to the right radial artery. What assessment findings by the nurse would be of concern?

1., 3. & 5. Correct: Right sided mastectomy would be a contraindication. A negative Allen's test means that the ulnar artery is not patent enough to supply blood to the hand. An A-V shunt would be a contraindication. 2. Incorrect: This assesses peripheral nerve function which is used for musculoskeletal assessment. The nurse needs to check the circulatory system. 4. Incorrect: Normal finding. This would not cause the nurse to be concerned.

A client admitted to a long-term care facility is legally blind and partially deaf. How would the nurse best provide for the client's safety in the event of an emergency?

3 & 4. Correct: When faced with a new or challenging situation involving client safety, the nurse manager should employ the Nursing Process to assess needs and collect contributing data. Asking for input from emergency preparedness groups, such as the Red Cross or FEMA, could provide ideas about assisting individuals with sensory deficits. Secondly, the nurse should discuss the situation with both client and family to determine appropriate methods of communicating with client, particularly in an emergency situation.

A farm worker comes into the clinic reporting headache, dizziness, and muscle twitching after working in the fields. What condition does the nurse suspect?

These are symptoms of pesticide exposure when combined with the details given of coming from the fields. Death can result from severe acute pesticide poisoning.

The school nurse has educated a group of teens concerned about acquiring the Ebola virus. Which statement by the students would indicate to the nurse that further teaching is necessary?

. Correct: This is an incorrect statement. At present, there is no vaccine to prevent Ebola.

The nurse is observing a new nurse inserting a nasogastric (NG) tube. Which action by the student nurse needs to be corrected by the nurse? 1. Measures from the tip of the nose to the xiphoid process of the client. 2. Lubricates the NG tube with petroleum gel. 3. Aspirates the NG tube to test gastric contents with a pH stip. 4. Marks the tubing at measurement mark with tape and secures to nose. 5. Places tube end into a glass of water to assess for bubbling.

1., 2., & 5. Correct: These actions by the new nurse are not done properly. The measurement for tube placement should be nose to ear and then xiphoid process. Lubricate the tube with a water solution, not a petroleum gel. Never place the tube in water because if the tube is in the trachea, the client can aspirate the water into the lungs. 3. Incorrect: This is the proper technique for checking placement of the NG tube. The pH should be less than 5 if in the stomach. 4. Incorrect: Yes, the tubing should be marked with a piece of tape and secured to the nose with tape or a commercial device if available.

What test should the nurse use to test a client's gross hearing acuity? 1. Weber's 2. Rinne 3. Audiometry 4. Whisper 5. Monofiliment testing

1., 2., 3., & 4. Correct: The Weber test uses a tuning fork to assess bone conduction by examining the lateralization of sounds. The Rinne test compares air to bone conduction. Audiometric testing determines the degree and type of hearing loss. The audiometer produces pure tones at varying intensities to which the client can respond. The ticking of a watch has a higher pitch than the normal voice. Have client occlude one ear. Out of the client's sight, place a ticking watch 1 inch (2-3 cm) from the unoccluded ear. Ask what the client can hear. Repeat with the other ear. With the whisper test, the examiner stands 12-24 inches (30-61 cm) to the side of the client and, after exhaling, speaks using a low whisper. The client is asked to repeat numbers or words or answer questions. Each ear is tested. 5. Incorrect: Monofiliment testing identifies sensory neuropathy, particularly of the feet.

A client requires external radiation therapy. The nurse knows external radiation may cause which problems?

1., 3. & 5. Correct: Effects of radiation therapy include, but are not limited to pancytopenia (marked decrease in the number of RBCs, WBCs and platelets), erythema (redness of the skin), and fatigue. 2. Incorrect: Leukocytosis is an increase in WBCs. External radiation causes pancytopenia which is a decrease in the number of blood cells including WBCs. 4. Incorrect: Fever is not typically seen with external radiation. High doses of radiation therapy are used to destroy cancer cells. Side effects occur because radiation therapy can also damage healthy cells and tissues near the treatment area. Side effects vary based on where the radiation therapy is aimed. In general, external radiation causes pancytopenia, skin problems, and fatigue. Now you should automatically know that options 1 and 5 are true. Pancytopenia (marked decrease in the number of RBCs, WBCs, and platelets), and fatigue are commonly seen with external radiation therapy. But let's look at the other options as well. Option 2. Leukocytosis. What is that? Leukocytosis is white cells (the leukocyte count) above the normal range in the blood. It is frequently a sign of an inflammatory response, most commonly the result of infection, but may also occur following certain parasitic infections or bone tumors as well as leukemia. So this option is false. Option 3. Erythema. Do you know what that is? It is defined as superficial reddening of the skin, usually in patches, as a result of injury or irritation causing dilatation of the blood capillaries. True or False? True. Option 4. Fever. External radiation does not typically cause fever. Keep in mind that pancytopenia causes a decrease in WBCs. So don't rule out infection, but you typically will not see fever.

An occupational health nurse is planning to teach a group of manufacturing workers how to prevent back injuries. What teaching points should the nurse plan to include? 1. Wear comfortable, low-heeled shoes. 2. When sitting, keep knees slightly lower than the hips. 3. Avoid movements that require spinal flexion with straight legs. 4. Squarely face the direction of anticipated movement. 5. Pivot to turn while holding an object.

1., 3., 4., & 5. Correct: Comfortable, low heeled shoes provide good foot support and reduce the risk of slipping, stumbling, or turning your ankle. Flexion of the spine with the legs straight (toe-touches, sit-ups) will injure the back. Avoid twisting of the back by squarely facing the direction of movement. Move toward or away from your center of gravity. Pivoting is a technique in which the body is turned in a way that avoids twisting of the spine. 2. Incorrect: When sitting, keep knees slightly higher than the hips.

A nurse is educating the family of a client in the middle stages of Alzheimer's disease how to encourage independence during meals. What points should the nurse include? 1. Serve meal in a quiet environment 2. Give 30 minutes to eat 3. Serve finger foods 4. Serve one dish at a time 5. Do not worry about neatness

1., 3., 4., & 5. Correct: Limit distractions by serving meals in quiet surroundings, away from the television and other distractions. Too many foods at once may be overwhelming. Simplify by serving one dish at a time. For example, mashed potatoes followed by meat. Serve finger foods, which are foods easy to pick up to eat. Do not worry about neatness. Let the person feed self as much as possible. Consider plates with suction, built-up rims and no spill glasses to allow users to more easily place food on their utensils. 2. Incorrect: Give the person plenty of time to eat. Remind client to chew and swallow carefully. Keep in mind that it may take an hour or longer to finish eating.

The nurse is talking with the mom of a preschooler at the well-child visit. The mom reports that her 3 year old has a lot of energy and sleeps 9 hours per night. What assessment questions should the nurse ask in response to this comment? 1. Nothing, as this is normal for preschoolers. 2. Does your child take naps during the day? 3. Does your child wake up spontaneously or do you wake her? 4. Does your child appear rested upon awakening? 5. Does your child have trouble settling down for sleep?

2., 3., 4. & 5. Correct: Preschoolers typically require 11 - 13 hours of sleep per day. The child may be supplementing nighttime sleep with long naps. It is important to determine if the child has to be awakened after nine hours or if the child awakens spontaneously. The child may have to be awakened due to mom's work schedule. The adequacy of rest should be determined, as the child is sleeping less than is typical. The nurse should determine if the child has difficulty falling asleep. If so, perhaps more restful nighttime rituals should be implemented. 1. Incorrect: Preschoolers typically require 11-13 hours of sleep per day. Nine hours is not enough.

What dietary information should the nurse provide to a client diagnosed with Celiac disease?

2., 3., 4., & 5. Correct: Soups and sauces are one of the biggest sources of hidden gluten, as many companies use wheat as a thickener. It is always a good idea to read the label of any pre-prepared or canned soups and sauces, paying special attention to those that are cream based. Grains that are naturally gluten free include rice, corn, potato, quinoa, kasha, flax, and nut flours. Malt flavoring or extract, which contains gluten may be found in cornflakes and puffed rice cereal. It is also found in beers, ales, and malt vinegars. As a rule, traditional wheat products such as pastas, breads, crackers, and other baked goods are not gluten-free. However, there are many gluten-free options available that use alternative flours and grains.

A homecare nurse is attempting to visit clients isolated during the pandemic. Upon arriving at one small rural home, the nurse discoveries the client is almost out of food, has no wood for heating and has a broken water faucet. The client is alert, oriented and refuses to leave the home. There is no family to help the client. How could the nurse best assist the client to remain home at this time? . Call local ambulance crew to transport client to the hospital. 2. Ask the healthcare provider to order emergency placement. 3. Request immediate evaluation by senior protective services. 4. Run to the local store to obtain food and water for the client. 5. Develop a plan of care with client, based on present needs.

3 & 5. Correct: In such an unstable environment, the nurse should not leave this client. Attempts should be made to correct client needs as quickly as possible. Senior services are available in most areas and have extensive resources which can readily provide the help needed, including food, heating and even repairs for the plumbing. In the meantime, the nurse could evaluate what supplies the client may have on the premise and create temporary solutions for the current issues. The important point is the nurse should remain with the client until the situation is stable, with at least the basic needs of food and water corrected, and possibly providing heat from alternative sources. 1. Incorrect: The client has no physical or psychologic issues requiring transport to an emergency room. Ambulance personnel cannot force an individual to go to the hospital, and insisting the client do so could be considered harassment or even assault. 2. Incorrect: The client is of sound mind and cannot be forced to leave the home, even with an order from the healthcare provider. This is not a psychological emergency. 4. Incorrect: While obtaining food and water is a basic need for the client, the nurse realizes it is not appropriate to leave the client to do so. It is better to remain with the client until the situation is stabilized and use the phone to request whatever may be needed.

The nurse is making an initial home visit to a client newly diagnosed with diverticulitis. The client had been on a liquid diet but is now to begin solid foods appropriate for the disease process. The nurse knows dietary teaching has been successful when the client selects which meal? 1. Hamburger on sesame roll, macaroni and cheese, tossed salad 2. Lamb chop with brown rice, cooked broccoli, baked potato 3. Pork with sauerkraut, baked beans, and coconut cake 4. Spaghetti with meatballs, fruit cocktail, garlic bread

4. CORRECT. Diverticulitis is an inflammation within the small, out pouching which can develop in the colon. A low residue/low fiber diet limits the amount of food waste passing through the large intestine, allowing the intestinal tract to rest and heal. Cooked pasta, along with ground, well cooked meatballs, is tolerated well. Canned fruits like fruit cocktail are far better than fresh fruit to control diarrhea and cramping. Garlic bread is also acceptable. 1. INCORRECT. A hamburger is well ground, cooked meat, which is acceptable for this client, but not when served on the sesame roll. Seeds and nuts tend to lodge in the diverticula, leading to pain or infection. Macaroni and cheese is a great menu item for the client. However, fresh vegetables, though healthy, do not breakdown easily, resulting in large amounts of undigested material passing through, or getting stuck, in the large intestine. 2. INCORRECT. Lamb is an acceptable as part of a low residue diet, but clients are instructed to eat white rice rather than the whole grain brown rice. Vegetables which create gas even when cooked, such as broccoli, could lead to a serious exacerbation of diverticulitis. Well cooked potatoes are permitted, but not if prepared with the skin, such as the baked potato. 3. INCORRECT. Several parts of this menu selection present a major problem for the client; in fact, only the pork is acceptable. Sauerkraut is prepared cabbage, and even when cooked, causes digestive and gas issues. Baked beans should be avoided for the same digestive reasons, and coconut is in the category with nuts or seeds.

The pathology report on a client diagnosed with urolithiasis reveals calcium oxalate stones. Which food selections by the client would indicate to the nurse that the client understands the prescribed low oxalate diet? 1. Spinach 2. Raspberries 3. Almonds 4. 100% bran cereal 5. Bananas 6. Raisins

5., & 6. Correct: Fruits provide valuable amounts of water, fiber, and antioxidants, all of which may help lower your risk for kidney stone symptoms. Many fruits are considered low-oxalate, meaning they contain less than 2 milligrams per serving. These include bananas, cherries, grapefruit, grapes, mangoes, melons, green and yellow plums and nectarines. Canned fruits, including peaches, pears, and dried fruits such as raisins, are also low in oxalate. 1. Incorrect: 1 cup of cooked spinach contains 1510 mg of oxalate. 2. Incorrect: Raspberries are the most significant fruit source of oxalate. One cup of raspberries contains 48 mg of oxalate. 3. Incorrect: 1 oz (28 g) of almonds contains 122 mg of oxalate. 4. Incorrect: One cup of 100% bran cereal contains 75 mg of oxalate.

right hip replacement, which action by LPN would cause Rn to intervene

Providing socks for client. This is a safety issue and the RN must intervene to prevent possible dislocation of the hip. If the hip becomes dislocated, it could result in neuro-vascular damage as well as result in the client having to go back to surgery. If the LPN gives the client socks to put on, it would require the client to have flexion at the hip to apply the socks. Hip flexion is a leading cause of hip dislocation following hip surgery and should be avoided.