NCLEX RN #40

1,3,5

A 12 month old has a high blood lead level of 18 mcg/dL . The nurse educates the parents about lead poisoning. Which statements made by the parent indicate that teaching has been successful? SELECT ALL THAT APPLY. #70666278 (22) 1. "I should get our home inspected for the source of lead." 2. "I will vacuum out hard-surface floors daily." 3. "I will wash my child's hand often, especially before eating." 4. "We should use hot water from the tap for cooking." 5. " We will have to return for a follow-up lead level."

3

A child with attention-deficit hyperactivity disorder (ADHD) has been taking methylphenidate for a year. What are the PRIORITY nursing assessments when the client comes for a well-child visit? #70666278 (35) 1. Attention span and activity level 2. Dental health and mouth dryness 3. Height/weight and blood pressure 4. Progress with schoolwork and in making friends.

1

A client had a thoracotomy 2 days ago to remove a lung mass and has a right chest tube attached to negative suction. Immediately after turning the client to the left side to assess the lungs, the nurse observes a rush of approximately 125 mL of dark bloody drainage into the drainage tubing and collection chamber. What is the appropriate nursing action? CLICK ON THE EXHIBIT BUTTON FOR ADDITIONAL INFORMATION . Laboratory and output values. #70666278 (31) Hemoglobin Chest drainage output Preoperative 15 g/dL Postoperative 12.5 g/dL 400 mL/24 hr Postoperative 13 g/dL 50 mL/12 hr 1. Document and continue to monitor chest drainage 2. Immediately clamp the chest tube 3. Notify the health care provider 4. Request repeat hematocrit and hemoglobin levels.

4

A client has just returned from having a cast placed on the right forearm and is found putting a lead pencil in the cast to "reach the itch." What is the nurse's PRIORITY action? #70666278 (50) 1. Offer the client a straw to reach the itch instead of a lead pencil 2. Perform a peripheral neurovascular check the cashed extremity. 3. Pour a generous amount of baby powder or corn starch in the cast to reach the itch. 4. Review appropriate itch relief technique using the cool setting of a hair dryer.

1

A client having an ishcemic stroke arrives at the emergency department. The health care provider prescribes TISSUE PLASMINOGEN ACTIVATOR (tPA). Which client statement would be MOST important to clarify before administering tPA? #70666278 (21) 1. "I can't believe this is happening right after my stomach surgery." 2. "I had a concussion after a car accident a year ago." 3. "I started noticing my right arm becoming weak approximately an hour ago." 4. "I stopped taking my warfarin 4 weeks ago."

3

A client is admitted to the hospital for chemothe-rapy complications. Laboratory results show an absolute neutrophil count of 450 cells/mm. What information contained in the admission history of this client will need to be ADDRESSED during discharge education? #70666278 (38) 1. East steamed vegetables daily 2. Enjoys eating grilled shrimp weekly. 3. Gardens as hobby 4. TAkes a bth daily and applies moisturizer.

1

A client is receiving lithium carbonate 900 mg/day for a schizoeffective disorder. The laboratory notifies the nurse that the client's lithium level is 1.0 mEq/L (1.0 mmol/L. Based on this result, which prescription does the nurse anticipate receiving from the health care provider? #70666278 (28) 1. Continue at the current dosage. 2. Decrease the dosage 3. Discontinue the medication 4. Increase the dosage.

4,3,5,1,2

A client on fall precautions is found on the floor by the bed when the unlicensed assistive personnel make hourly rounds. Place the actions the registered nurse should take in the appropriate ORDER. ALL OPTIONS MUST BE USED. #70666278 (47) 1. Notify the client's health care provider 2. Complete an incident report 3. Inspect the client for injuries 4. Assess the presence of adequate pulse 5. Get help and move the client to the bed.

3

A client receives an injection of botulinum toxin type A for facial and neck rejuvenation. What complications of this procedure should the nurse be aware of for monitoring and teaching? #70666278 (32) 1. Abdominal rigidity and diarrhea 2. Back pain and urge incontinence 3. Difficulty swallowing and breathing 4. Difficulty walking and hand tremor.

1.3

A client with left-sided pneumonia is admitted to the medical unit. The nurse assesses intermittent cough productive of copious amounts of thick yellow sputum and identifies ineffective airway clearance as the priority nursing diagnosis. Which interventions are appropriate to facilitate secretion removal? SELECT ALL THAT APPLY #70666278 (26) 1. Chest physiotherapy 2. Cough suppressant 3. Huff coughing technique 4. Left side lying position 5. Pursed lip breathing.

1

A client with schizophrenia that is resistant to other antipsychotiic medications is about to start on a course of CLOZAPINE. Which of these periodic measurements has the HIGHEST PRIORITY in this client? #70666278 (30) 1. Complete blood count (CBC) and absolute neutrophil count . 2. Electrocardiogram 3. Fasting blood sugar and fasting lipids 4. Height, weight, and waist circumference.

1

A male client has terminal metastatic disease. He arrives at the emergency department with respira-tions of 6/min and an advance directive indicating to withhold resuscitative efforts. What should the nurse's response be? #70666278 (44) 1. Apply oxygen at 2 L by nasal cannula 2. Ask the client if he wants to change his mind. 3. Ask the spouse what she wants done 4. Determine who has medical power of attorney.

2

A nurse in the pediatric unit is preparing a 16 year old for a surgical procedure and observes that the client has signed the informed consent for surgery. What should be the FIRST action by the nurse? #70666278 (36) 1. Cancel the procedure until a valid consent form is signed. 2. Determine if the client meets legal require- ments to sign the consent form. 3. Locate the client's parent or guardian to sign the consent form 4. Verify that the consent is properly witnessed and send the client to surgery.

1

A nurse is planning to complete a physical exami-nation of a toddler. Which approach is an appro- priate intervention by the nurse? #70666278 (24) 1. Encourage the parent to be involved with the child 2. Engage in physical contact by removing the toddler's outer clothing first. 3. Have medical equipment lying on a counter within view. 4. Perform an examination in a head to toe order.

2

A postoperative client who is receiving continuous enteral feedings via a nasoenteric tube becomes dyspneic with a productive cough, and the nurse auscultates crackles and diminished breath sounds in lung bases. Which action is appropriate at this time? #70666278 (46) 1. Administer an inhaled bronchodilator 2. Check marked insertion depth of the tube. 3. Request a prescription for a diuretic 4. Start the client on incentive spirometry

2,3,4

A registered nurse is making pre-procedure phone calls to clients scheduled for cardiac pharmacologic nuclear stress testing the following day. Which instructions should the nurse give the clients? SELECT ALL THAT APPLY #70666278 (40) 1. Decaffeinated coffee or tea can be consumed 2. Do not consume caffeine for 24 hours before the test. 3. Do not smoke on the day of the test. 4. Do not take beta blockers on the day of the test. 5. Take diabetic medications as usual before the test.

2,5,6

A sexually active female client has had 3 urinary tract infections (UTIs) in 12 months. Which instruc-tions should the nurse include in teaching the client how to prevent UTI recurrence. SELECT ALL THAT APPLY #70666278 (52) 1. Douche with a water and vinegar solution after intercourse 2. Increase daily intake of fluids 3. Use a spermicidal contraceptive jelly 4. Use fragrance free perineal deodorant products 5. Void immediately after intercourse 6. Wear underwear with a cotton crotch.

4

The charge nurse is preparing for the admission of an elderly client with delirium and agitation associated with urinary tract infection. To promote client safety, which intervention is MOST IMPOR-TANT for the charge nurse to implement? #70666278 (41) 1. A bed near the nursing station 2. Four-point leather restraints 3. Minimizing environmental stimuli 4. One on one supervison from a sitter.

2

The client has a dislocated shoulder and the nurse is assisting the heatlh care provider with bedside procedural moderate sedation (conscious seda-tion). During the procedure, the client becomes restless and cries out "Help me"What action should the nurse take FIRST? #70666278 (39) 1. Administer midazolam per protocol 2. Check the client's pulse oximeter 3. Give more morphine per protocol 4. Open the airway with head tilt-chin lift.

1

The client has increased intracranial pressure with cerebral edema, and mannitol is administered. Which assessment should the nurse make to evaluate if a complication from the mannitol is occuring? #70666278 (20) 1. Auscultate breath sounds to assess for crackles 2. Monitor for >50 mL/hr urine output 3. Monitor Glasglow Coma Scale increasing from 8/15 to 9/15. 4. Press over the tibia to assess for pitting edema.

2,3,5,6

The nurse collects a sputum specimen from a client with pneumonia. Which directions should the nurse give to the client before collecting the specimen ? SELECT ALL THAT APPLY #70666278 (37) 1. "Cough deeply and expectorate into the clean specimen container." 2. "Cough deeply and expectorate into the sterile specimen container." 3. " Inhale deeply several times." 4. "Rinse your mouth with mouthwash." 5. "Rinse your mouth with water." 6. "Sit upright or on the side of the bed."

4

The nurse is assessing a client who had an esopha-gogastroduodenoscopy(EGD) 2 hours ago. Which finding requires an IMMEDIATE report to the health care provider? #70666278 (33) 1. Blood pressure drop from 122/88 mm Hg to 106/72 mm Hg 2. Gag reflex has not returned 3. Sore throat when swallowing 4. Temperature spike to 101.2 F

1

The nurse is caring for a client with schizophrenia who has been experiencing visual hallucinations. The client says in a trembling voice,"There's a bad man standing over there in the corner of my room." What is the BEST response by the nurse? #70666278 (27) 1. "I know you are frightened, but I do not see a man in your room. " 2. "I'll make the bad man go away." 3. "Let's go in to the dayroom and play checkers." 4. "Your illness is making you hallucinate."

3

The nurse is counseling a pregnant client who is HIV POSITIVE. Which information is appropriate to discuss? #70666278 (34) 1. Infant should be exclusively breastfed for 6 months to receive maternal antibodies. 2. Infant will not require treatment for HIV after birth 3. Prescribed antiretroviral therapy should be continued during pregnancy. 4. Tetanus-diphtheria-vaccine should be avoided until after birth.

1.4.5

The nurse is preparing to administer medications to an 84 year old client with dementia, agitation and heart failure. Knowing that this clients does not like to take pills and often allows only a few to be administrated, the nurse prioritizes the oral medications by importance to the client well-being. Which medications would be MOST IMPORTANT for the client to receive ? SELECT ALL THAT APPLY #70666278 (51) 1. Aripiprazole 2. Calcium carbonate 3. Donepezil 4. Furosemide 5. Lisinopril

1

The nurse is reviewing new prescriptions for assigned clients. Which prescription would require further clarification from the health care provider? #70666278 (43) 1. Alteplase for an ischemic stroke in a client with a blood pressure of 192/112 mm Hg 2. Amoxicillin for a respiratory infection in a client who is 20 weeks pregnant 3. Fentanyl for moderate to severe pain in a client who post appendectomy with an allergy to codeine 4. Sodium chloride 3% infusion for a client with syndrome of inappropriate antidiuretic hormone.

3

The nurse obtains the breast self-examination (BSE) history of a group of female clients. Which client NEEDS FURTHER TEACHING on the BEST timing of monthly BSEs? #70666278 (49) 1. A 28 year old taking oral contraceptives who performs BSE when beginning a new set of pills 2. A 35 year old with regular periods who performs BSE 5 days after menstruation 3. A 42 year old with irregular periods who performs BSE when menstruation ends 4. A 56 year old postmenopausal woman who performs BSE on the first day of the month.

1,2,3

The nurse plans care for a 3 year old who was admitted with suspected pertussis infection. Which instructions will the nurse include in the plan of care? SELECT ALL THAT APPLY #70666278 (25) 1. Institute droplet precautions 2. Monitor for signs of airway obstruction 3. Offer small amounts of fluids frequently 4. Place the child in a negative-pressure isolation room. 5. Request an order for cough suppressant.

4

The nurse prepares a client for discharge following a vasectomy. The client asks "When can I have sexual intercourse with my wife without using a condom? " What is the BEST response by the nurse? #70666278 (53) 1. "Discontinue alternative birth control after at least 5 ejaculations" 2. "There is no need to use alternative birth control following today's procedure." 3. "Use alternative birth control for 6 months following today's procedure." 4. "Use alternative birth control until cleared by the health care provider."

1,2,3,5

The nurse will implement which nursing actions when caring for a client recently diagnosed with a hiatal hernia.? SELECT ALL THAT APPLY. #70666278 (23) 1. Elevate the head of the hospital bed. 2. Instruct the client to avoid tobacco and caffeine 3. Offer small, frequent, low fat meals 4. Provide a girdle to reduce the hernia 5. Teach the client to avoid lifting or straining.

1

The registered nurse (RN) on an orthopedic unit is orienting a new graduate nurse (GN) assigned to a client with a fractured hip and in the Buck's traction. The RN intervenes when the GN performs with actions? #70666278 (48) 1. Elevates the head of the bed 45 degrees 2. Holds the weight while the client is repositioned up in bed. 3. Loosens the Velcro straps when the client reports that the boot is too tight. 4. Provides the client with a fracture pan for elimination needs.

2,3,5,6

The student nurse is reviewing the medical record of a 4 year old diagnosed with FAILURE TO THRIVE (FTT) .The nurse correctly identifies which clinical and psychosocial factors that have likely contribu-ted to the child's condition? SELECT ALL THAT APPLY #70666278 (45) 1. Child has 3 older siblings 2. Child is bottle fed 4 times a day and at bedtime 3. Child's parent is incarcerated for spousal abuse 4. Parent works part time as a teacher's aide 5. Parent worries about having enough money to buy food 6. The children eat at various times of the day in front of the television

3

When performing developmental screenings in the well-child clinic, the registered nurse understands that which child is at HIGHEST risk of developing autism spectrum disorder? #70666278 (42) 1. 2 year old who has a vocabulary of 10 words 2. 3 year old who received measles, mumps, and rubella immunization at age 1 year 3. 4 year old whose 10 year old sibling has the disorder 4. 5 year old whose parents were age 42 at the time of birth.

1

Which infant is MOST LIKELY to require oral iron supplementation at this time? #70666278 (29) 1. 2 month old born at 34 weeks gestation who is bottle-fed with breast milk. 2. 4 month old born at term who is breast fed exclusively 3. 6 month old born at term who is formula fed 4. 7 month old who is breast fed and was re- cently started on solid foods.

Mannitol

is an osmotic diuretic used to treat cerebral edema and acute glaucoma. Normal kidney function and adequate urine output are crucial while administering this medication as _________ accumulation can result in significant volume expansion, dilutional hyponatremia and pulmonary edema. #70666278 (20)