NCLEX-RN
A nurse is developing a teaching plan for a client diagnosed with osteoarthritis. To minimize injury to the osteoarthritic client, the nurse should instruct the client to install safety devices in the home. wear worn, comfortable shoes. get help when lifting objects. wear protective devices when exercising.
Most accidents occur in the home, and safety devices such as hand rails are the most important element in minimizing injury. Shoes should be supportive and not too worn. The client needs to use proper body mechanics when stooping or lifting objects. Protective devices aren't usually necessary when the client exercises.
The health care provider prescribes risperidone for a client with Alzheimer's disease. The nurse anticipates administering this medication to help decrease which behavior? sleep disturbances concomitant depression agitation and aggression confusion and withdrawal
Antipsychotics are most effective with agitation and aggression. Antipsychotics have little effect on sleep disturbances, concomitant depression, or confusion and withdrawal.
A client infected with human immunodeficiency virus (HIV) has a low CD4+ level. What intervention should the nurse implement? Increase nutritional protein with each meal. Request human granulocyte colony-stimulating factor to improve WBC production. Place the client in reverse isolation. Provide antibiotics as per order.
CD4+ levels in the blood of an individual with HIV infection determine the extent of damage to the individual's immune system. The test indicates the individual's risk of an opportunistic infection, but does not identify specific infections. Viral loads and resistance to specific antigens are determined using other diagnostic tests. Because of the client's risk, isolation is recommended.
A client receiving a blood transfusion begins to have chills and headache within the first 15 minutes of the transfusion. What should the nurse do first? Administer acetaminophen. Take the client's blood pressure. Discontinue the transfusion. Check the infusion rate of the blood.
Chills and headache are signs of a febrile, nonhemolytic blood transfusion reaction, and the nurse's first action should be to discontinue the transfusion as soon as possible and then notify the health care provider (HCP). Antipyretics and antihistamines may be prescribed. The nurse would not administer acetaminophen without a prescription from the HCP. The client's blood pressure should be taken after the transfusion is stopped. Checking the infusion rate of the blood is not a pertinent action; the infusion needs to be stopped regardless of the rate.
A nurse is caring for a client who is having an allergic reaction to a blood transfusion. In what order from first to last should the nurse provide care for this client? 1Stop the transfusion. 2Keep the vein open with normal saline solution. 3Administer an antihistamine as directed. 4Send the blood bag and blood slip to the blood bank.
The nurse should first stop the transfusion. The nurse should next keep the IV open at the original blood transfusion site with normal saline at a keep-vein-open rate. Then, the nurse should administer an antihistamine. Last, the nurse should return the blood bag and blood slip to the blood bank for testing.
A client asks a nurse a question about the tuberculin skin test for tuberculosis. The nurse should base their response on the fact that the area of redness is measured in 3 days and determines whether tuberculosis is present. skin test doesn't differentiate between active and dormant tuberculosis infection. presence of a wheal at the injection site in 2 days indicates active tuberculosis. test stimulates a reddened response in some clients and requires a second test in 3 months.
The tuberculin skin test doesn't differentiate between active and dormant infections. If a positive reaction occurs, a sputum smear and culture as well as a chest X-ray are necessary to provide more information. Although the area of redness is measured in 3 days, a second test may be needed; neither test indicates that tuberculosis is active. In the tuberculin skin test, an induration 5 to 9 mm in diameter indicates a borderline reaction; a larger induration indicates a positive reaction. The presence of a wheal within 2 days doesn't indicate active tuberculosis.
Which philosophy should the nurse integrate into the plan of care for a client and family to help them best cope during the final stages of the client's illness? living each day as it comes as fully as possible reliving the pleasant memories of days gone by expecting the worst and being grateful when it does not happen planning ahead for the remaining good times that will be spent together
When supporting the friends or family of a terminally ill client, it is best to focus on the present. This can be accomplished by living each day to its fullest. Friends and families also want to know what to expect and want someone to listen to them as they express grief over the approaching death. Focusing on the past can interfere with enjoying the present. Expecting the worst interferes with focusing on day-to-day positive experiences. Planning ahead is inappropriate because of uncertainty when the length of life is unknown.
The nurse would question the prescription for a fetal scalp electrode on which client? client with an HIV infection client with late decelerations client with significant meconium stained fluid client with a prolonged second stage of labor
Placement of a fetal scalp electrode should be avoided when a client has HIV because it increases the risk of transmission to the fetus. The use of a fetal scalp electrode is indicated when precise tracing are needed to monitor changes associated with fetal hypoxia and satisfactory tracing cannot be obtained with external methods.The presence of decelerations, meconium stained fluid, and prolonged second stage of labor may all be indications for placing a fetal scalp electrode.
After insertion of bilateral tympanostomy tubes in a toddler, which instruction should the nurse include in the child's discharge plan for the parents? Insert ear plugs into the canals when the child bathes. Gently clean the ear canal with cotton swabs. Administer antibiotics daily while the tubes are in place. Disregard any drainage from the ear after 1 week.
Placing ear plugs in the ears will prevent contaminated bathwater from entering the middle ear through the tympanostomy tube and causing an infection. Inserting cotton swabs into the ear canal is not recommended. Antibiotics may be given for a short period after insert and are appropriate only when an ear infection is present. Tympanostomy tubes may remain in place for several years. It is not necessary to administer antibiotics continuously to a child with a tympanostomy tube. Drainage from the ear may be a sign of middle ear infection and should be reported to the health care provider (HCP).
While performing an assessment of a 75-year-old client in the emergency department, a nurse notes many bruises in various stages of healing on the client's body. After documenting the locations of the bruises in the medical record, which step should the nurse take immediately? Notify the nursing supervisor. Notify the physician. Obtain more information from the client about the nurse's findings. Follow the facility's policy and procedures for reporting elder abuse.
The nurse should try to obtain more information from the client to complete the assessment. Without supporting information, the nurse shouldn't assume the bruises indicate abuse, and shouldn't notify the nursing supervisor until the nurse has obtained additional facts. The nurse should, however, inform the physician so the physician can examine the client. The nurse should follow the facility's policy and procedure for reporting abuse. The nurse should make a report if, after the assessment, the nurse has a strong suspicion that abuse is the cause.
A multigravid client at 38 weeks' gestation is scheduled to undergo a contraction stress test. What should the nurse include in the explanation as the purpose of this test? evaluation of fetal lung maturity determination of the fetal biophysical profile assessment of fetal ability to tolerate labor determination of fetal response during movements
The purpose of a contraction stress test is to determine fetal response during labor. If late decelerations are noted with the contractions, the test is considered positive or abnormal. Fetal lung maturity is evaluated through amniocentesis to obtain the lecithin-sphingomyelin ratio. The nonstress test is part of the biophysical profile. Determining fetal response during movements is evaluated as part of the nonstress test.
The nurse is planning care for a client with acute myeloid leukemia (AML). What is an appropriate goal for this client? Prevent cardiac arrhythmias Prevent liver failure Prevent renal failure Prevent hemorrhage
Bleeding and infection are the major complications and causes of death for clients with AML. Bleeding is related to the degree of thrombocytopenia, and infection is related to the degree of neutropenia. Cardiac arrhythmias rarely occur as a result of AML. Liver or renal failure may occur, but neither is a major cause of death in AML.
A charge nurse completing a deceased client's chart audit notes that the chart contains a copy of the client's advance directive and the do-not-resuscitate (DNR) order. While reviewing the nurses' notes, the charge nurse finds documentation of a code blue and cardiopulmonary resuscitation with a physician entry to "Discontinue code blue due to existing advanced directives and DNR from client." What does the charge nurse conclude? Select all that apply. The nurse was correct to call a code blue. The physician was correct to stop resuscitation efforts. By calling a code blue, the nurse disregarded the client's advance directives and DNR order. The nurse must have read the chart incorrectly. The code should have continued.
By initiating a code blue, the nurse didn't follow the client's advance directive and DNR order. The physician was correct to follow the client's wishes and stop resuscitation efforts. The physician had the authority to stop the code.
Several high-school seniors are referred to the school nurse because of suspected alcohol misuse. When the nurse assesses the situation, what would be most important to determine? what they know about the legal implications of drinking the type of alcohol they usually drink the reasons they choose to use alcohol when and with whom they use alcohol
Information about why adolescents choose to use alcohol or other drugs can be used to determine whether they are becoming responsible users or problem users. The senior students likely know the legal implications of drinking, and the nurse will establish a more effective relationship with the students by understanding motivations for use. The type of alcohol and when and with whom they are using it are not the first data to obtain when assessing the situation.
A nurse is caring for a newborn exposed to drugs while in utero. Which behaviors will the nurse expect the newborn to exhibit? Select all that apply. tachypnea with excessive secretions effective latch to the breast easily consoled and comforted sensitive gag reflex hyperactivity and increased muscle tone
Newborns exposed to drugs while in utero can have tachypnea, excessive secretions, a sensitive gag reflex, hyperactivity, and increased muscle tone. Newborns exposed to drugs while in utero will not be satisfied with breastfeeding or eating and are not easily consoled or comforted.
A nurse is caring for a client who has had paraplegia for 6 years. The client is admitted with a bleeding peptic ulcer. What would be a priority teaching concern for the nurse? repositioning to prevent pressure ulcers recommending foods included in a bland diet monitoring for signs of urinary retention increasing fluid intake
The nurse should teach the client about consuming a bland diet. Although repositioning and retention is important for paraplegia, the client has dealt with this condition for many years. The more important concern is dealing with the new diagnosis. Increasing fluid intake will prevent constipation in a client with paraplegia, but will not treat the peptic ulcer disease.
