NCLEX-RN
A physician orders an intestinal tube to decompress a client's GI tract. When gathering equipment for this procedure, a nurse should obtain a: Sengstaken-Blakemore tube. Miller-Abbott tube. Levin tube. Salem sump tube.
A Miller-Abbott tube is an intestinal tube. A Sengstaken-Blakemore tube is an esophageal tube. Levin tubes and Salem sump tubes are nasogastric tubes.
Which symptom would the nurse most likely observe in a client with cholecystitis from cholelithiasis? black stools nausea after ingestion of high-fat foods elevated temperature of 103°F (39.4°C) decreased white blood cell count
A client with cholecystitis from cholelithiasis may experience nausea, vomiting, abdominal discomfort, and other gastrointestinal symptoms after eating high-fat foods. This is due to decreased fat absorption related to lack of normal bile flow from the gallbladder.Black stools are indicative of gastrointestinal bleeding, not gallbladder disease.Clients are more likely to have a low-grade fever.Clients are more likely to have an elevated white blood cell count due to inflammation.
A nurse is assessing an elderly client with senile dementia. Which neurotransmitter condition is most likely to contribute to this client's cognitive changes? decreased acetylcholine level increased acetylcholine level increased norepinephrine level decreased norepinephrine level
A decreased acetylcholine level has been implicated as a cause of cognitive changes in healthy elderly clients and in the severity of dementia. Choline acetyltransferase, an enzyme necessary for acetylcholine synthesis, has been found to be deficient in clients with dementia. Norepinephrine is associated with aggression, sleep-wake patterns, and the regulation of physical responses to emotional stimuli, such as the increased heart and respiratory rates caused by panic.
A nurse performs cardiopulmonary resuscitation (CPR) for 2 minutes on an infant without calling for assistance. In reassessing the infant after 2 minutes of CPR, the nurse finds the infant still isn't breathing and has no pulse. The nurse should then: resume CPR beginning with breaths. reposition the infant. resume CPR beginning with chest compressions. call for assistance.
After 2 minutes of CPR, the nurse should call for assistance and then resume efforts. CPR shouldn't be stopped after it has been started unless the nurse is too exhausted to continue. A cycle usually ends with breaths, so the next beginning cycle after pulse check and summoning help would begin with chest compressions.
While auscultating the heart sounds of a client with heart failure, the nurse hears an extra heart sound immediately after the second heart sound (S2). The nurse should document this as a first heart sound (S1). a third heart sound (S3). a fourth heart sound (S4). a murmur.
An S3 is heard following an S2, which commonly occurs in clients experiencing heart failure and results from increased filling pressures. An S1 is a normal heart sound made by the closing of the mitral and tricuspid valves. An S4 is heard before an S1 and is caused by resistance to ventricular filling. A murmur is heard when there is turbulent blood flow across the valves.
A middle-aged female client complains of anxiety, insomnia, weight loss, the inability to concentrate, and eyes feeling "gritty." Thyroid function tests reveal the following: thyroid-stimulating hormone (TSH) 0.02 U/ml, thyroxine 20 g/dl, and triiodothyronine 253 ng/dl. A 6-hour radioactive iodine uptake test showed a diffuse uptake of 85%. Based on these assessment findings, the nurse should suspect: thyroiditis. Graves' disease. Hashimoto's thyroiditis. multinodular goiter.
Graves' disease, an autoimmune disease causing hyperthyroidism, is most prevalent in middle-aged females. In Hashimoto's thyroiditis, the most common form of hypothyroidism, TSH levels would be high and thyroid hormone levels low. In thyroiditis, radioactive iodine uptake is low (?2%), and a client with a multinodular goiter will show an uptake in the high-normal range (3% to 10%).
A neonate weighing 3 lb, 5 oz (1,503 g) is born at 32 weeks' gestation. During an assessment 12 hours after birth, a nurse notices these signs and symptoms: hyperactivity, a persistent shrill cry, frequent yawning and sneezing, and jitteriness. These symptoms indicate sepsis. hepatitis. drug dependence. hypoglycemia.
Hyperactivity, a persistent shrill cry, frequent yawning and sneezing, and jitteriness are classic symptoms of drug dependency that usually appear within the first 24 hours after birth. Sepsis is indicated by temperature instability and tachycardia. Hepatitis will manifest as jaundice. Hypothermia, muscle twitching, diaphoresis, and respiratory distress may be signs of hypoglycemia.
While the nurse is caring for a neonate born at 32 weeks' gestation, which finding would most suggest the infant is developing necrotizing enterocolitis (NEC)? the presence of 1 mL of gastric residual before a gavage feeding jaundice appearing on the face and chest an increase in bowel peristalsis abdominal distention
Indications of NEC include abdominal distention with gastric retention and vomiting. Other signs may include lethargy, irritability, positive blood culture in stool, absent or diminished bowel sounds, apnea, diarrhea, metabolic acidosis, and unstable temperature. A gastric residual of 1 mL is not significant. Jaundice of the face and chest is associated with the neonate's immature liver function and increased bilirubin, not NEC. Typically with NEC, the neonate would exhibit absent or diminished bowel sounds, not increased peristalsis.
When performing the nursing history, which information would be most important for the nurse to obtain from the mother of an infant with suspected colic? the type of formula the infant is taking the infant's crying pattern the infant's sleep position the position of the infant during burping
Information on the crying pattern of the infant is most helpful in confirming the diagnosis of colic. Typically the colic attack begins abruptly, with the infant crying loudly and continuously, possibly for hours. The attack may end when the child becomes exhausted. The child also may attain some relief after passing stool or flatus. Often, in an attempt to alleviate the infant's crying, parents try to feed the infant, resulting in overfeeding leading to discomfort and distention. Asking about the type of formula, sleep position, or position for burping will not provide sufficient information to confirm the diagnosis of colic. However, the nurse can obtain additional information after determining the nature of the crying pattern.
The nurse is assessing a client who is suspected of being in the early symptomatic stages of human immunodeficiency virus (HIV) infection. Which indication of infection should the nurse detect during this stage? whitish yellow patches in the mouth dyspnea bloody diarrhea raised, hyperpigmented lesions on the legs
Oropharyngeal candidiasis, or thrush, is the most common infection associated with the early symptomatic stages of HIV infection. Thrush is characterized by whitish yellow patches in the mouth. Various other opportunistic diseases can occur in clients with HIV infection, but they tend to occur later, after the diagnosis of acquired immunodeficiency syndrome has been made. Dyspnea can be indicative of pneumonia, which is caused by a variety of infective organisms. Bloody diarrhea is indicative of cytomegalovirus infection. Hyperpigmented lesions are indicators of Kaposi's sarcoma.
A child with hemophilia is hospitalized after falling. Now the child complains of severe pain in the left wrist. What should the nurse do first? Perform passive range-of-motion (ROM) exercises on the wrist. Massage the wrist and apply a warm compress. Elevate the affected arm and apply ice to the injury site. Notify the health care provider.
Severe joint pain in a child with hemophilia indicates bleeding; therefore, the nurse should first elevate the affected extremity and apply ice to the injury site to promote vasoconstriction. ROM exercises may worsen discomfort and bleeding. Massage and warm compresses also may increase bleeding. The nurse should notify the health care provider only after taking measures to stop the bleeding.
When teaching the parents of a child diagnosed with tetralogy of Fallot about the cardiac defects involved with this condition, which defects should the nurse describe? Select all that apply. right ventricular hypertrophy aortic valve stenosis ventricular septal defect overriding aorta atrial septal defect pulmonary stenosis
Tetralogy of Fallot involves four defects: right ventricular hypertrophy, ventricular septal defect, overriding aorta, and pulmonary stenosis.Aortic valve stenosis and atrial septal defect are not components associated with this condition.
A client was brought to the emergency department following a motor vehicle accident and has phrenic nerve involvement. The nurse should assess the client for which nursing problem? alteration in level of consciousness altered cardiac functioning ineffective breathing pattern alteration in urinary elimination
The diaphragm is the major muscle of respiration; it is made up of two hemidiaphragms, each innervated by the right and left phrenic nerves. Injury to the phrenic nerve results in hemidiaphragm paralysis on the side of the injury and an ineffective breathing pattern. Consciousness, cardiac function, and urinary elimination are not affected by the phrenic nerve.
The nurse is conducting an initial nursing history of a client who is experiencing pain related to bone cancer. The most important information to gather in this initial assessment is the: nurse's physical assessment of the client. amount of pain medication the client is taking. client's self-reporting of the pain experience. family's response to the client's illness.
The most important component of pain assessment is the client's self-report of the pain. The nurse should have the client describe the quality, location, and intensity of the pain; the client's response to the pain; and any alleviating or aggravating factors affecting the pain.The physical assessment should follow the pain assessment and should be delayed if the client is uncomfortable.The amount of pain medication the client is currently taking is an important component of the pain assessment, but it is meaningless without the client's self-report of the pain and the effectiveness of the pain therapy.The family's response to the client's illness may indicate the amount of support the client has and alerts the nurse to potential problems. With care, however, these concerns are secondary to the issue of pain control.
Which item must the nurse consider when positioning a client for tracheal suctioning? Position in low-Fowler's position. Maintain the head in a hyperextended position. Ensure that the client's neck is flexed. Position in a semi-Fowler's position.
The semi-Fowler's position is the correct position for suctioning a client. The other answers are incorrect based on incorrect positioning of client for suctioning. The neck should be in neutral position.
A client arrives at a public health clinic worried that she has breast cancer after finding a lump in her breast. When assessing the breast, which assessment finding provides an indication that the lump is more typical of fibrocystic breast disease? One breast is larger than the other. The lump is firm and non-movable. The lump is round and movable. Nipple retractions are noted.
When assessing a breast with fibrocystic disease, the lumps typically are different from cancerous lumps. The characteristic breast mass of fibrocystic disease is soft to firm, circular, movable, and unlikely to cause nipple retraction. A cancerous mass is typically irregular in shape, firm, and non-movable. Lumps typically do not make one breast larger than the other. Nipple retractions are suggestive of cancerous masses.
