NCLEX study

An explosion occurred at an industrial plant involving injury to 50 victims. The nurse at the scene determines that which of the following victims should be transported to the hospital first? 52 yo w/ closed upper extremity fracture 20 yo who is pulseless w/ fixed dilated pupils 36 yo w/ singed facial and nasal hair and difficulty breathing 43 yo w/ superficial lacerations on the lower extremities and begging for help

36 yo w/ singed facial and nasal hair and difficulty breathing rationale: singed facial and nasal hairs suggests victim has inhaled a heated substance, in addition to the respiratory difficulty and should receive tx at the scene and then be immediately transferred to ED; fixed dilated pupils in pulseless victim indicate that the victim is already deceased

A nurse has been asked to conduct a safety survey at a children's day care center. Of the following safety hazards, which presents the greatest hazard to the toddlers at the center? swimming pool in the neighbor's gated yard water heater set above 120 degrees F toys with small loose parts in the playroom toxic plants located in the front yard of the center

toys with small loose parts in the playroom

A home care nurse is completing a plan of care for a client who has hyperparathyroidism w/ severe osteoporosis. Which of the following problems would be the priority for this client? the client is experiencing a lack of appetite the client is at increased risk for pathological fractures the client is at increased risk for constipation the client is having difficulty performing self care

the client is at increased risk for pathological fractures rationale: home safety priority

A nurse is reading the hx and physical examination of an older adult admitted to the hospital. Which findings documented in the hx place the client at risk for accidents? select all that apply ROM is limited peripheral vision is decreased client denies complaints of nocturia transmission of hot impulses is delayed high-frequency hearing tones are perceptible voluntary and autonomic reflexes are slowed

ROM is limited peripheral vision is decreased transmission of hot impulses is delayed voluntary and autonomic reflexes are slowed

A nurse is admitting a client to the nursing unit who sustained an extensive burn injury. The nurse reviews the physician's prescriptions and questions which of the following? adm morphine sulfate IM q3h PRN for pain maintain NGT to intermittent suction monitor UOP hourly monitor wt daily

adm morphine sulfate IM q3h PRN for pain rationale: PO, SQ, IM routes for adm of meds are contraindicated for burn pts b/c of poor tissue absorption; when fluid balance is stabilized, PO opioid analgesics may be Rx

A nurse is preparing to institute IV heparin therapy for a client. The nurse should question the physician's prescription b/c of which of the following active problems listed in the client's medical record? DVT degenerative arthritis cerebral aneurysm COPD

cerebral aneurysm rationale: heparin is contraindicated w/ preexisting health conditions such as threatened abortion, active hemorrhage, cerebrovascular hemorrhage, cerebral or aortic aneurysm, severe HTN, hemophilia, thrombocytopenia, pericarditis, and recent or upcoming ophthalamic or neurosurgery; caution should be used if risk of hemorrhage is present such as w/ recent childbirth, severe DM, vasculitis or trauma, significant renal impairment, active lesions of respiratory, GI, GU tract

A nurse is reviewing the physician's prescriptions written for a client admitted to the hospital w/ a dx of acute cellulitis of the lower leg. The nurse contacts the physician and questions which of the following prescriptions? IV ATBs cold compresses to the affected area obtaining blood cultures APAP for fever

cold compresses to the affected area rationale: warm compresses may be used to decrease discomfort, erythema, and edema; after tissue and blood cultures are obtained ATBs will be initiated; the nurse should provide supportive care as prescribed to manage symptoms of fatigue, fever, chills, HA, and myalgia; cold compresses would not be a component of the tx for cellulitis b/c they may increase discomfort and would not promote tissue healing

Nurse is caring for a term small for gestational age (SGA) infant immediately after delivery. The nurse's initial plan of care in the delivery room to prevent heat loss to the infant would include which of the following? placing the infant in a prewarmed transport unit drying the infant with a warm blanket submerging the infant's body into a warm-water bath allowing the mother to hold the infant immediately after delivery

drying the infant with a warm blanket

A client who is hospitalized on an outpatient psychiatric unit w/ a dx of schizophrenia tells thenurst that voices in his head are telling him that he is worthless and doesn't deserve to be alive. The nurse IDs which problem as the priority for this client? demonstrating inability to cope exhibiting behavior that indicates a problem w/ sensory perception verbally expressing feelings of low self-esteem exhibiting behavior that indicates violence toward self

exhibiting behavior that indicates violence toward self rationale: altered perceptions and the cognitive distortions experienced by client w/ schizophrenia put the client at risk for self harm; a responsibility of the nurse is to provide a safe environment for this client and others

A nurse is developing a nursing care plan for a client with diabetic retinopathy secondary to T2DM. Which of the following is a priority concern for this client? - verbalizing negative statements regarding body image - demonstrating inability to provide self care b/w of altered vision - stating feelings that reflect low self-esteem as a recent loss of independence - exhibiting behaviors that indicate a possible risk for injury

exhibiting behaviors that indicate a possible risk for injury rationale: individuals w/ retinopathy have varying degrees of visual impairment; thus falls are a major concern

Fat emulsions (lipids) is prescribed for a client receiving parenteral nutrition. Which of the following, if noted during the inspection of the solution before hanging, prompts the nurse to obtain a new solution for adm? the solution is in a glass bottle fat globules are in the solution the solution is white the solution is cool in temperature

fat globules are in the solution rationale: do not use if fat globules are visible in lipids, or visible "ring" is noted

an intravenous dose of lorazepam (ativan) is prescribed for a client. which of the following notes from the client's history indicates the need to consult with the physician before administering the medication? hx of glaucoma hx of hypothyroidism hx of diabetes mellitus hx of CAD

hx of glaucoma

A clinic nurse is developing a plan of care for a client w/ AIDS. The nurse determines that which of the following is the priority concern for this client? risk of constipation disturbed sensory perception risk of infection fatigue

risk of infection

A nurse is completing the preprocedure checklist before a client is sent for a bronchoscopy procedure. The nurse determines that the client needs additional preparation for the procedure is which of the following is noted? the client has not signed informed consent the client has had been NPO since midnight the client has received a sedative the client's dentures have been removed

the client has not signed informed consent