nclex study feb 19 pt.1

The nurse is performing discharge teaching to the parents of a child with a newly applied plaster cast for a fractured arm. Which of the following statements made by the parents would require follow-up?

The client should not apply lotion on the edges of the cast because it may trap moisture and lead to fungal infection.

Which of the following best describes an appropriate outcome for a 75-yr-old patient with a history of Huntington's disease, which has developed contractures?

The patient will participate in range of motion exercises to reduce the effects of contractures.

The nurse is caring for a client with a chest tube drainage system. The nurse notes that the fluid in the water seal column is not fluctuating. The nurse knows that the best explanation of fluctuation cessation is that:

There may be fibrin clots in the tubing

The nurse is caring for a client who has generalized urticaria. The nurse should implement which disease transmission precautions?

standard

erythema infectiosum (Fifth disease) percautions

standard

The nurse is caring for a client who has been prescribed prednisone. Which of the following statements, if made by the nurse, would be correct? Select all that apply. 1."This medication may make you gain weight." 2"It is best to take this medication in the morning with food." 3"If you have pain, it is okay to take ibuprofen." 4"Your blood pressure may decrease while taking this medication." 5"You may experience mood changes while on this medicine."

1,2,5 Corticosteroids should not be taken concurrently with NSAIDs such as naproxen or ibuprofen. The steroid itself may increase the risk of a gastric ulcer; when combined with an NSAID, the risk of an ulcer increases tremendously causes increase BP causes insomnia- take in A.M.

The nurse is taking a sample of the fluid pulled from a nasogastric tube to ensure proper placement. The nurse will confirm appropriate placement of the NG tube if the stomach contents have a pH of:

3.4

The nurse is caring for a child admitted with a concussion. Which assessment finding would be the earliest in determining the client's worsening neurological status? A. Level of consciousness B. Glasgow Coma Scale C. Intracranial pressure (ICP) measurement D. Pupil assessment

A

Which of the following statements correctly outlines the proper flow of blood through the heart?

A. Superior and Inferior vena cavas → Right atrium → Tricuspid valve → Right ventricle → Pulmonary valve → Pulmonary artery → Lungs → Pulmonary veins → Left atrium → Mitral valve → Left ventricle → Aortic valve → Aorta → Systemic circulation

The nurse prepares to suction a tracheostomy tube to help clear a patient's secretions. After opening the package, filling the cup with sterile water, and putting on sterile gloves, the nurse uses one hand to connect the catheter to the suction. What action would be most appropriate for the nurse to take next?

A. Use the contaminated hand to preoxygenate the patient prior to suction.

The nurse is caring for a client experiencing acute mountain sickness (AMS). The nurse anticipates a prescription for which medication?

Acetazolamide

The nurse is performing a physical assessment. When assessing a client's eyes for accommodation, which of the following actions would the nurse perform?

Ask the client to gaze at a distant object and then at a test object.

The nurse is caring for a client whose caregiver is under significant stress and using drugs and alcohol as a means of self-medication to cope with caregiver stress. What would be the most appropriate nursing diagnosis in this situation? A. Ineffective coping related to alcohol and abuse B. Ineffective coping related to responsibilities required in the caregiver's role

B

The nursing supervisor has implemented a new assignment system for nursing staff. In order to reduce resistance to this new system, the nurse manager should A. Provide incentives to foster the change B. Allow nursing staff to discuss potential concerns C. Provide statistical support for the change D. Detail the changes in a multimedia presentation

B

The nurse is teaching a client about isoniazid (INH). Which of the following statements should the nurse include? A. "This medication may turn your secretions reddish/orange." B. "Yellowing of your eyes is a normal side-effect." C. "A B-complex vitamin should be taken to help with the neuropathy." D. "This medication will need to be taken every day for at least one week."

B B- watch for liver function D- take for at least 6 months

The nurse is teaching a client newly diagnosed with multiple sclerosis. Which of the following statements by the client would indicate a correct understanding of the teaching? A. "If I experience double-vision, I should put an eye patch on both eyes for a few hours." B. "Planning my activities should help manage the fatigue." C. "I should plan to take a hot bath for my muscle spasms." D. "This disease may cause me to have an increased sensitivity to pain."

B Fatigue is a significant clinical feature associated with MS.

An emergency department (ED) nurse establishes continuous cardiac monitoring for a client. The following tracing is observed on the monitor. The nurse should take which initial action? See the image below. Sinus bradycardia A. Establish vascular access and request a prescription for atropine B. Assess the client's blood pressure and level of consciousness C. Obtain and review the client's current medications D. Document the findings and reassess the client in one hour

B ASSESS first especially before giving atropine

A nurse is caring for a client with a history of seizures who is at risk for injury. Which intervention is the highest priority to reduce the client's risk of injury? A. Keeping the client's room dimly lit to minimize visual stimulation B. Administer antiepileptic medications as prescribed. C. Implement seizure precautions, including padded side rails up and the bed in the lowest position. D. Provide education to the client and family about seizure triggers and safety measures.

C

The nurse is caring for a client experiencing an episode of vertigo. The nurse should plan to take which essential action? A. Avoid sudden movement changes B. Provide additional pillows to support the client's head C. Raise the upper side rails of the bed D. Instruct the client to move the head slowly

C safety is essential

hyponatremia s/s

Confusion Abdominal cramps N/V hyperactive bowel Sodium also plays an important role in muscle cells; when levels are too low, this results in cramping, spasms, and hyperactive bowel sounds. seizures

The nurse is conducting a health screening at a local health fair. Which of the following should the nurse recognize as a risk factor for developing testicular cancer? Cryptorchidism Human immunodeficiency virus (HIV) Vasectomy Family history Herpes simplex virus (HSV)

Cryptorchidism Human immunodeficiency virus (HIV) Family history

A 30-year old patient presents to the Emergency Department with alcohol withdrawal seizures. The psychiatry nurse understands that the patient will soon be admitted to the non-medical psychiatric care unit. To keep this patient safe, the nurse must perform which priority nursing action? A. Ask the physician for a clonazepam prescription, an anxiolytic that may help with the withdrawal symptoms. B. Ensure that a working IV pump is set up at the patient's bedside. C. Order a STAT arterial blood gas (ABG). D. Pad the side rails of the patient's assigned bed.

D

The nurse is caring for a client who has been ordered a 24-hour urine specimen. After explaining the procedure to the client, the nurse collects the first specimen. What step should the nurse take next?

Discard it, then the collection process begins

Which of the following interventions is helpful in reducing the effects of GERD?

Elevate the head of the bed on 4-6 inch blocks.

The nurse is assessing a client with acute cholecystitis. Which of the following physical assessment findings would be expected?

Episodic upper abdominal pain

Ketorolac teaching

Ketorolac is a nonsteroidal anti-inflammatory drug (NSAID). NSAIDs should be avoided for those with cardiovascular disease because of their potential to trigger cardiovascular events such as heart failure or myocardial infarction avoid this med if had MI oxycodone is fine to take

The nurse is caring for a 30-year-old client who has developed iron-deficiency anemia during pregnancy. Which complication would this client be at an increased risk for due to iron deficiency anemia?

Low birth weight Preterm delivery Perinatal mortality

The nurse is teaching a class on acid-base imbalances. It would be correct for the nurse to identify which of the following would cause respiratory acidosis? Select all that apply. Aspirin overdose Pneumothorax Opioid overdose Anxiety Renal disease

Pneumothorax Opioid overdose

ephedrine teaching

Raynaud's disease or any other peripheral vascular disease are contraindicated to receive ephedrine or any other adrenergic agonist as these diseases could be exacerbated by systemic vasoconstriction.

The nurse is providing teaching to the mother of an infant with a diagnosis of heart failure. Which of the following educational points would be helpful for optimizing feedings for this infant?

Small, frequent feedings. Feed for a maximum of 30 minutes. Increased calorie formula.

neologisms

Words or phrases with meaning only for the client

Oprelvekin purpose

a hematopoietic agent used to stimulate the production of platelets. Platelets 155,000 mm3 [150,000 - 400,000 mm3]= therapeutic

Huntington's disease

a progressive condition that can lead to muscle atrophy and potential contractures.

The nurse is inserting an indwelling urinary catheter in a male client. It would be appropriate for the nurse to inflate the catheter's balloon when

after advancing to the point of bifurcation.

The nurse is caring for a client who has recently arrived at the emergency department after experiencing a very traumatic event. The client appears calm and in control. The nurse assesses this behavior as which of the following defense mechanisms?

denial

The nurse in a community-based setting teaches clients about prostate cancer risk factors. Which of the following risk factors should the nurse share with the group?

diet high in animal fat

ferrous sulfate elixir teaching

dilute in juice/water Once the medication has been consumed, the client should rinse their mouth out to prevent any staining to the teeth calcium decreases the absorption- no milk administer on empty stomach

The nurse is caring for a client who has rubella. The nurse should isolate the client using which of the following?

droplet

pertussis percaution

droplet

green tea teaching

has caffeine, causes insomnia

A night shift nurse is caring for a pediatric client admitted earlier in the day following a severe asthma attack. To promote comfort at the time the client is going to bed for the night, the nurse instructs the client to assume which position?

high fowler/semi fowler

The nurse is caring for a client who is postoperative ordered incentive spirometry. The nurse understands that this device will help prevent which complication?

hypostatic pneumonia Hypostatic pneumonia is caused by pulmonary congestion in the dorsal region of the lungs. not aspirated pneumonia

The nurse in the mental health unit is assessing a client with moderate anxiety. The nurse would anticipate which signs and symptoms to support this finding? Select all that apply.

increased pulse reports of headache narrowing of the perceptual field

how to calculate drops

mL X drop over minutes ignore strength

The nurse is caring for an older adult following a total hip arthroplasty. The nurse should anticipate a prescription for which postoperative medication?

morphine Enoxaparin

The nurse is performing a medication reconciliation for a client taking prescribed phenytoin. Which medication should the nurse question with the physician while the client is taking phenytoin?

warfarin