NCLEX RN #09

3

In the emergency department, a pediatric client is placed on mechanical ventilation by means of an endotracheal tube. Several hours later, the nurse enters the room and finds the client in respiratory distress. It is "MOST IMPORTANT" for the nurse to take which of these actions? #71941465 (14) 1. Assess the client for intercostal retractions 2. Assess the client's blood pressure in both arms 3. Auscultate the client's lung sounds 4. Observe the color of the client's fingernails beds.

ruptured cerebral aneurysm.

Sudden onset of a severe headache described as "the worst headache of my life" is characteristic of a ______________________ and should be treated as an emergency. #71941465 (31)

3

The breakfast trays arrive on the unit, and a newly admitted client with type 1 DIABETES MELLITUS is hungry and wants to eat. The nurse reviews the vital signs, laboratory results, and medication administration record. Why does the nurse contact the health care provider before administering the client's 0700 medications. ? CLICK ON THE EXHIBIT BUTTON FOR ADDITIONAL INFORMATION: Vital signs at 0600 Blood pressure 156/84 mm Hg, Pulse 60/min & regular, Respirations 16/min. #71941465 (25) 1. To question the determir prescription 2. To question the spironolactone prescription 3. To report the serum glucose level 4. To report the serum potassium level.

4

The nurse should consider which of the following client reports as an indication of an ALLERGIC REACTION? #71941465 (21) 1. "I can't eat broccoli or cabbage when I take warfarin." 2. "I get a headache when using my nitro- glycerin patch." 3. "My feet swell when I take felodipine." 4. "My lips swell when I eat bananas or avocados."

2,3,5

The school nurse creates a cafeteria menu for a newly enrolled child with celiac disease. Which lunches would be APPROPRIATE for this child. "SELECT ALL THAT APPLY" #71941465 (19) 1. Beef barley soup with mixed vegetables and French bread. 2. Grilled chicken, baked potato, and strawberry yogurt. 3. Mexican corn tacos with ground beef and cheese 4. Peanut butter and jelly on rice cakes with an oatmeal cookie. 5. Rice noodles with chicken and broccoli.

1

The telemetry nurse is reviewing a client's cardiac rhythm strip. What is the correct interpretation for this strip? #71941465 (28) 1. Atrial paced rhythm 2. First degree atroventricular block with bigeminy. 3. Sinus rhythm with premature ventricular contractions. 4. Ventricular paced rhythm with failure to sense.

4

A client comes to the emergency department with DIPLOPIA and recent onset of nausea." Which statement by the client would indicate to the nurse that this is an EMERGENCY? #71941465 (31) 1. "I am very tired, and it's hard for me to keep my eyes open" 2. "I don't feel good and I want to be seen." 3. "I have not taken my blood pressure medicine in over a week." 4. "I have the worst headache I've ever had in my life."

1,4,5

A client is suspected of having GRAVE'S DISEASE (hyperthyroidism). Which signs and / or symptoms are EXPECTED to be present in this client. "SELECT ALL THAT APPLY" #71941465 (15) 1. Anxiety 2. Bradycardia 3. Dry skin 4. Heart palpitation 5. Protrusion of the eyeballs 6. Weight gain

2,4,5

A client with an asthma exacerbation has been using her albuterol rescue inhaler 10-12 times a day because she cannot take a full breath. What possible SIDE EFFECTS of albuterol does the nurse anticipate the client will report? SELECT ALL THAT APPLY #71941465 (26) 1. Constipation 2. Difficulty sleeping 3. Hives with pruritus 4. Palpitations 5. Tremor

2

A nurse in a pediatric clinic is preparing to administer ear drops for a 5 year old. Whiich is an APPROPRIATE action by the nurse? #71941465 (24) 1. Have the child sit upright with the chin titled down 2. Pull the pinna upward and back 3. Remove the medication from the refrigerator just before use 4. Touch the dropper to the entrance of the ear canal.

4

A nurse is assisting a new mother as she is breastfeeding her infant. The infant has been diagnosed with TETRALOGY OF FALLOT. During feeding, the infants becomes cyanotic and is having difficulty of breathing. What should be the nurse's"FIRST" action ? #71941465 (18) 1. Administer morphine to the infant. 2. Administer oxygen via mask 3. Assess the infant's vital signs and pulse oximetry. 4. Place the infant in the knee-chest position.

2,3,4

A nurse is teaching a parent of an infant about administration of an oral medication. What should be included in the teaching? "SELECT ALL THAT APPLY." #71941465 (33) 1. Add the medication to the formula bottle before feeding. 2. Direct liquid medication toward the inside of the infant's cheek. 3. Hold the infant in a semi-reclining position during administration. 4. Measure and administer the medication using an oral syringe 5. Open the infant's mouth by gently pinching the nose shut.

4

A young adult with obesity comes to the free clinic for a 2 week post antibiotic follow-up visit for a superficial abdominal skin abscess. The client has a history of major depressive disorder and was hospitalized twice in the past 6 months for ATTEMPTED SUICIDE. The client now reports feeling"EMOTIONALLY UPSET, alone and a the end of my rope." due to difficulty finding a job and inability to qualify for medical insurance. The client is currently prescribed fluoxetine but has not been able to follow up with the prescribing health care provider (HCP). What is the "PRIORITY" nursing diagnosis (ND) at this time? #71941465 (12) 1. Hopelessness 2. Ineffective coping 3. Risk for infection 4. Risk for suicide

serum creatinine

An elevated __________________ level preoperatively increases the risk for postoperative kidney injury. #71941465 (23)

4

Four clients come to the emergency department and are assessed by the triage nurse. Which client should be "PRIORITIZED" for more definitive care.?" #71941465 (27) 1. Client with history of gout who has severe pain in the right foot 2. Client with history of migraines reporting headache and phtophobia 3. Client with severe epigastric pain radiating to the back after an alcohol binge. 4. Client with sudden onset of the "worst headache of my life"

1

The evening shift nurse reviews the preoperative checklist and latest serum laboratory values for an elderly client with a ruptured DIVERTICULUM who is scheduled for surgery in the early morning. Which laboratory value is "MOST IMPORTANT" for the nurse to report to the health care provider?" #71941465 (23) 1. Creatinine level 2.5 mg/dL 2. Potassium level of 3.5 mEq/L 3. Sodium level 134 mEq/L 4. White blood cell count 16,000/mm

1

The nurse assesses a client diagnosed with chronic kidney disease who had an internal arteriovenous fistula performed on the left arm yesterday. Which assessment finding would require "IMMEDIATE" follow-up? #71941465 (32) 1. A bruit cannot be auscultated over the fistula 2. Capillary refill of 2 seconds is assessed on the left hand. 3. Client reports squeezing a rubber ball with the left hand several times daily. 4. Incision is dry with no redness and has sterile skin closures in place.

2

The nurse at the radiological imaging center is admitting a client for an MRI of the right knee. Which information obtained by the nurse should be reported IMMEDIATELY to the prescribing health care provider? #71941465 (13) 1. The client ate a full breakfast that morning 2. The client has an implantable cardioverter defibrillator. 3. The client is allergic to providone-iodine 4. The client took all prescribed cardiac medications before arriving.

4

The nurse cares for a group of clients on a medical surgical floor. The client with which condition is of "HIGHEST RISK" for developing syndrome of inappropriate antidiuretic hormone (SIADH)? #71941465 (34) 1. Carpal tunnel syndrome 2. Diabetes mellitus 3. Sciatica 4. Small cell lung cancer.

2

The nurse is admitting a client with heart failure related fluid overload. Which ACTION should the nurse complete "FIRST"? #71941465 (11) 1. Administer oxygen 2. Assess the client's breath sounds 3. Initiate cardiac monitoring 4. Insert a peripheral IV catheter.

1

The nurse is assessing for the presence of jugular venous distension (JVD) on a newly admitted client with a history of heart failure. Which is the "BEST" position for the nurse to place the client in when observing for JVD? #71941465 (20) 1. Head of the bed elevated to a 45 degree angle 2. Head of the bed elevated to a 60 degree angle 3. Head of the bed elevated to a 90 degree angle 4. Head of the bed flat

4

The nurse is caring for a client who just had a permanent pacemaker inserted. The nurse observes PACER SPIKES and electrical capture on the cardiac monitor. How will the nurse ASSSESS for mechanical capture of the pacemaker? #71941465 (29) 1. Aucultate the client's heart sounds" 2. Measure the client's blood pressure. 3. Observe for widened QRS complex following pacer spike on ECG. 4. Palpate the client's pulse rate

3

The nurse is performing discharge teaching for the parents of a 4 year old with heart failure. Which statement by the parents indicates the NEED FOR FURTHER TEACHING related to the administration of digoxin? #71941465 (35) 1. "If our child vomits after a dose, we won't give a second one." 2. "Symptoms of nausea and vomiting should be reported to our health care provider." 3. "We will hold the dose if our child's heart rate is above 90/min 4. "We will not mix the medication with other foods or liquids. "

2

The nurse prepares to administer morning medications to assigned clients. Which prescription should the nurse CLARIFY with the health care provider? #71941465 (22) 1. Clopidogrel for client with history of stroke and platelet count of 154,000/mm 2. Losartan for client with hypertension who is 8 weeks pregnant. 3. Prednisone for client with herpes simplex lesions and bells palsy. 4. Tiotropium for client with pneumonia and chronic obstructive pulmonary disease.

3,2,4,1,5

The nurse receives notification from the telemetry room that a client appears to be in ventricular fibrillation (VF). The nurse immediately goes to the client's room and finds the client unresponsive and pulseless. Place the intervention in the "APPRO- PRIATE ORDER. ALL OPTIONS MUST BE USED. #71941465 (16) 1. Administer IV epinephrine 1 mg push 2. Initiate cardiopulmonary resuscitation 3. Call the emergency response team 4. Defibrillate the client at 200 joules 5. Administer intravenous (IV) amiodarone 300 mg push

4

The nurse reviews the most current laboratory results clients. Which result should the nurse report to the health care provider "IMMEDIATELY"? #71941465 (17) 1. Client who has cellulitis of the leg with a white blood cell (WBC) count of 13,000 2. Client who has chronic kidney injury with hematocrit 0f 28% and hemoglobin of 9 g/dL. 3. Client who has type 2 diabetes mellitus with a 2 hour postprandial serum glucose of 165 mg/dL 4. Client who is 1 month post kidney transplant with a urinalysis showing WBCs and bacteria.

seizure

The nurse should assess the client with _______________ activity first. This client is at increased risk for injury, aspiration, and airway obstruction. #71941465 (10)

upward and back

When administering otic medication to children AGE 3 AND OLDER the pinna is pulled ___ and ___ to straighten the ear canal. The child placed in a prone or supine position with the head turned to the appropriate side, and the medication is allowed to drop against the wall of the canal. #71941465 (24)

1

Which client statement demonstrates mental health well-being when considering STRESS AND ANXIETY? #71941465 (30) 1. "I know that relaxation techniques help me deal with my life's stress and anxiety." 2. "I understand stress and anxiety because my family has a history of depression." 3. "You must understand that stress and anxiety affect everyone's life." 4. "You should identify and then avoid those things that cause you stress and anxiety.

Tetralogy of Fallot

is a congenital cardiac defect that typically has 4 characteristics pulmonary stenosis, right ventricular hypertrophy, overriding aorta and ventricular septal defect. #71941465 (18)

arteriovenous fistula

is a surgical connection of an artery to a vein created to provide vascular access for hemodialysis therapy in clients with kidney disease. #71941465 (32)

Losartan

is an ace inhibitors have black box warnings that indicate contraindication in pregnancy. #71941465 (22)

Latex allergy

is suspected when there is a food allergy to banana, kiwis, or avocados. #71941465 (21)

Bell palsy

presents as acute onset of unilateral facial paralysis related to inflammation of the facial nerve (ie. cranial nerve V11) that may be triggered by a viral illness (eg. herpes simplex virus. ) Standard treatment includes corticosteroids ( eg. prednisone) within 72 hours of symptom onset. #71941465 (22)

Hyperthyroidism

refers to a sustained hyperfunctioning of the thyroid gland due to an increase in thyroid hormones (T3 and T4), It causes symptoms with a high metabolic rate, including weight loss, heart palpitations, heat intolerance, anxiety , hand tremors and insomnia. #71941465 (15)