nclex units 4/5

a pre-op client expresses anxiety to the nurse about upcoming surgery. which response by the nurse is most likely to stimulate further discussion between the client and the nurse?

"can you share with me what you've been told about your surgery?"

nurse has conducted pre-op teaching for a client scheduled for surgery in 1 week. the client has a history of arthritis and has been taking acetylsalicylic acid. the nurse determines that the client needs additional teaching if the client makes which statement?

"i need to continue to take the aspirin before the scheduled surgery"

nurse is providing instructions to a client and the family regarding home care after right eye cataract removal. which statement by the client would indicate an understanding of the instructions?

"i should sleep on my left side"

the nurse is teaching a client about coughing and deep breathing techniques to prevent post-op complications. which statement is most appropriate for the nurse to make to the client at this time as it relates to these techniques?

"use of an incentive spirometer will help prevent pneumonia"

nurse is caring for client following craniotomy, in which a large tumor was removed from the left side. in which position can the nurse safely place the client?

HOB 30 to 45 degrees

while performing a cardiac assessment on a client with an incompetent heart valve, the nurse auscultates a murmur. the nurse documents the finding and describes the sound as which?

a blowing or swooshing noise

a client diagnosed with conductive hearing loss asks the nurse to explain the cause of the hearing problem. the nurse plans to explain to the client that this condition is caused by which problem?

a physical obstruction to the transmission of sound waves

the nurse is performing a neuro assessment on a client and elicits a positive romberg's sign. The nurse makes this determination based on which observation?

a significant sway when the client stands erect with feet together, arms at the side, and the eyes closed.

nurse is describing Piaget's cognitive developmental theory to pediatric nursing staff. nurse should tell staff that which child behavior is characteristic of formal operations stage?

ability to think abstractly

the ED nurse receives a telephone call and is informed that a tornado has hit a local residential area and that numerous casualties have occurred. the victims will be brought to the ED. the nurse should take which initial action?

activate emergency response plan

the nurse enters clients room and finds the wastebasket is on fire. the nurse immediately assists the client out of the room. which is the next nursing action

activate the fire alarm

the nurse is instructing a client how to perform a testicular self exam. the nurse should explain that which is the best time to perform the exam?

after a shower or bath

mother of a 3 yo is concerned because her child still is insisting on a bottle at nap time and bedtime. which is most appropriate suggestion to the mother?

allow bottle if it contains water

a 16 yo client is admitted to the hospital for acute appendicitis and an appendectomy is performed. which nursing intervention is most appropriate to facilitate normal g&d post op?

allow client to interact with others in his or her age group

the maternity nurse is providing instructions to a new mother regarding the psychosocial development of the newborn infant. using erikson's psychosocial development theory, the nurse instructs the mother to take which measure?

allow newborn infant to signal a need

the nurse is caring for an older client in a long term care facility. which action contributes to encouraging autonomy in client?

allowing client to choose social activities

nurse receives phone call from PACU stating that a client is being transferred to the surgical unit. the nurse plans to take which action first on arrival of client

assess patency of airway

nursing student is presenting a clinical conference to peers regarding Freud's psychosexual stages of development, specifically the anal stage. the student explains to the group that which characteristic relates to this stage of development?

associated w/ toilet training

mother of an 8 yo child tells clinic nurse that she is concerned about child because child seems to be more attentive to friends than anything else. using erikson's psychosocial development theory, the nurse should make which response?

at this age, the child is developing his own personality

the clinic nurse prepares to perform a focused assessment on a client who is complaining of sx of a cold, a cough, and lung congestion. which should the nurse include for this type of assessment? select all.

auscultating lung sounds obtaining temperature obtaining information about clients respirations

nurse creates plan of care for client with DVT. which client position or activity in the plan of care should be included?

bed rest with elevation of affected extremity

nurse is preparing to care for a client who has returned to the nursing unit following cardiac catheterization performed through the femoral vessel. the nurse checks the HCP prescription and plans to allow which client position or activity following the procedure?

bed rest with head elevation no greater than 30 degrees

the nurse is conducting a pre-op teaching with a client about the use of incentive spirometer. the nurse should include which piece of information in the discussion with the client?

best results achieved when sitting up or with HOB elevated 45 to 90 degrees

which car safety device should be used for child who is 8 yo and 4 feet tall?

booster seat

a mother calls a neighbor who is a nurse and tells the nurse that her 3 year old child has just ingested liquid furniture polish. the nurse would direct the mother to take which immediate action?

call poison control center

the nurse is assessing for correct placement of an NG tube. the nurse aspirates the stomach contents, check the gastric pH, and notes a pH of 7.35. based on this information, which action should the nurse take at this time?

call the HCP to request a prescription for a chest radiograph

the nurse caring for a client w/ a pneumothorax and who has had a chest tube inserted notes continuous gentle bubbling in the water seal chamber. what action is most appropriate?

check for air leak, because bubbling should be intermittent

The nurse is preparing to administer medication using a client NG tube. Which actions should the nurse take before administering? Select all

check residual volume aspirate stomach contents turn off suction test stomach contents for pH indicating acidity

the nurse is preparing to administer medication through an NG tube that is connected to suction. To administer the medication, the nurse should take which action?

clamp NG tube for 30 to 60 minutes following administration

a client who has had abdominal surgery complains of feeling as though "something gave way" in the incisional site. the nurse removes the dressing and notes the presence of a loop of bowel protruding through the incision. which intervention should nurse take select all that apply

contact surgeon instruct client to remain quiet prepare client for wound closure document the findings and actions taken

the nurse is preparing to initiate an intravenous line containing a high dose of potassium chloride and plans to use an IV infusion pump. the nurse brings the pump to the bedside, prepares to plug the pump cord into the wall, and notes that no receptacle is available in the wall socket. the nurse should take which action?

contact the electrical maintenance department for assistance

nurse is preparing to care for a 5 year old who has been placed in traction following a fracture of the femur. the nurse plans care, knowing that which is the most appropriate activity for this child?

crayons & coloring book

the long term care nurse is performing assessments on several residents. which are normal age related physiological changes the nurse should expect? select all

decline in visual acuity increased susceptibility to UTI increased incidence of awakening after sleep onset

home health nurse is visiting a client for the first time. while assessing clients medication hx, it is noted that there are 19 prescriptions and several OTC meds that the client has been taking. which intervention should nurse take first?

determine whether there are medication duplications

nurse is monitoring 3 m/o infant for signs of increased intracranial pressure. on palpation of the fontanels, the nurse notes that the anterior fontanel is soft and flat. on the basis of this finding, which action is most appropriate?

document finding

nurse assess the vital signs of a 12 m/o infant with respiratory infection and notes that the RR is 35 breaths/minute. what action is most appropriate?

document findings

the nurse is assessing the functioning of a chest tube drainage system in a client who has just returned from the recovery room following a thoracotomy with wedge resection. which are the expected assessment findings? select all.

drainage system maintained below the clients chest 50 mL of drainage in collection chamber occlusive dressing in place over chest tube insertion site fluctuation of water in the tube in the water seal chamber during inhalation and exhalation

nurse is caring for client with severe burn who is scheduled for an autograft to be placed on the lower extremity. the nurse creates a post-op plan of care for the client and should include which intervention?

elevate and immobilize grafted extremity

a 4 yo child diagnosed with leukemia is hospitalized for chemo. the child is fearful of the hospitalization. which nursing intervention should be implemented to alleviate fears?

encourage childs parents to stay

nurse is preparing to care for dying client and several family members are at clients bedside. which therapeutic techniques should the nurse use when communicating with the family?

encourage expression of feelings, concerns, fears touch and hold clients or family members hands be honest and let client and family know they will not be abandoned by nurse

nurse is giving report to UAP who will be caring for a client who has hand restraints. the nurse instructs the UAP to check the skin integrity for the restrained hands how frequently?

every 30 minutes

contact precautions are initiated for a client with a health care associated infection caused by MRSA. the nurse prepares to provide colostomy care and should obtain which protective items to perform this procedure?

gloves, gown, goggles, mask/face shield

while changing the tapes of a newly inserted tracheostomy tube, the client coughs and the tube is dislodged. which is the initial nursing action?

grasp the retention sutures to spread the opening

the nurse is creating a plan of care for a client scheduled for surgery. the nurse should include which activity in the nursing care plan for the client on the day of surgery

have client void immediately before going into surgery

client who has undergone pre admission testing has had blood drawn for serum laboratory studies, including a CBC, coagulation studies, & electrolyte & creatinine levels. which lab result should be reported, knowing that it could cause surgery to be postponed?

hemoglobin 8.0

nurse is preparing to insert NG tube into client. the nurse should place client in which position

high fowlers

the nurse checks for residual before administering a bolus tube feeding to a client with an NG tube and obtains amount of 150 mL. what is the most appropriate action for the nurse to take?

hold the feeding and reinstill the residual amount

nurse is performing assessment on an older client who is having difficulty sleeping at night. which statement by client indicates need for further teaching

i drink hot chocolate before bed

nurse is providing medication instructions to an older client who is taking digoxin daily. the nurse explains to the client that decreased lean body mass and decreased GFR, which are age related, could place client at risk for which complication with medication therapy?

increased risk for digoxin toxicity

nurse is monitoring status of post op client in immediate post op period. the nurse would become most concerned with which sign that could indicate evolving complication?

increasing restlessness

a mother arrives at a clinic with her toddler and tells the nurse that she has a difficult time getting the child to go to bed at night. what measure is most appropriate for the nurse to suggest to mother?

inform child of bedtime a few minutes before its time for bed

the community health nurse is providing a teaching session about anthrax to members of the community and asks the participants about the methods of transmission. which answers by the participants would indicate that teaching was effective? select all.

inhalation of bacterial spores through a cut or abrasion of the skin ingestion of contaminated undercooked meat

the nurse working in the ED is assessing a client who recently returned from liberia and presented complaining of a fever at home, fatigue, muscle pain, and abdominal pain. which action should the nurse take next

isolate client in private room

nurse is administering a cleansing enema to a client with a fecal impaction. before administering the enema, the nurse should place the client in which position?

left sims

home care nurse is visiting an older client whose spouse died 6 months ago. which behaviors by client indicate effective coping. select all

looking at old snapshots of fan participating in senior citizens program visiting grave once a month decorating wall w/ spouses pics and awards

client is being prepared for thoracentesis. the nurse should assist the client to which position for the procedure?

lying in bed on unaffected side

nurse educator is preparing to conduct a teaching session for the nursing staff regarding the theories of G&D and plans to discuss kohl berg's theory of moral development. what information should the nurse include? select all.

moral development progresses in relationship to cognitive development a persons ability to make moral judgment development progresses over time theory provides framework for understanding how individuals determine a moral code to guide behavior in stage 2 the child conforms to rules to obtain rewards or have favors returned

client with gastric ulcer scheduled for surgery. the client cannot sign the operative consent form because of sedation from opioid analgesics that have been administered. the nurse should take which most appropriate action in the care of this client?

obtain a telephone consent from a family member, following agency policy

nurse is caring for client who is day 1 post op for total hip replacement. which is the best position in which the nurse should place the client?

on nonoperative side with legs abducted

a spanish speaking client arrives at the triage desk in the ED and states to the nurse, no speak english, need interpreter. Which is the best action for the nurse to take?

page an interpreter from the hospitals interpreter services

the RN is preparing to insert an NG tube in an adult client. to determine the accurate measurement of the length of the tube to be inserted, the nurse should take which action?

place the tube at the tip of the nose and measure by extending to earlobe and then xiphoid process

the nurse caring for a client with a chest tube turns the client to the side and the chest tube accidentally disconnects from the water seal chamber. which initial action should the nurse take?

place the tube in a bottle of sterile water

nurse is reviewing a plan of care for a client with internal radiation implant. which intervention, if noted in the plan, indicated the need for revision of the plan?

placing the client in a semiprivate room at the end of the hallway

nurse is reviewing surgeons prescription sheet for a preoperative client that states that the client must be NPO after midnight. the nurse should call the surgeon to clarify that which medication should be given to the client and not withheld?

prednisone

the nurse is caring for a client with meningitis and implements which transmission based precautions for this client?

private room or cohort client

the nurse is inserting an NG tube in an adult client. during the procedure, the client begins to cough and has difficulty breathing. what is the most appropriate action?

pull back on tube and wait until distress subsides

clinic nurse is preparing to explain the concepts of Kohlberg's theory of moral development with a parent. the nurse should tell the parent that which factor motivates good and bad actions for the child at the pre conventional level?

punishment and reward

the nurse notes that a 6 yo child does not recognize that objects exist even when the objects are outside of the visual field. based on this observation, which action should the nurse take?

report to HCP

the nurse notes documentation that a client is exhibiting cheyne-stokes respirations. on assessment of the client, the nurse should expect to note which finding?

rhythmic respirations with periods of apnea

the nurse obtains a prescription from a health care provider to restrain a client and instructs a UAP to apply the safety device. which observation of unsafe application of the safety device would indicate that further instruction is required by the UAP?

safely securing the safety device straps to the side rails

the nurse assesses a clients surgical incision for signs of infection. which finding by the nurse would be interpreted as a normal finding at the surgical site?

serous drainage

a parent of a 3 yo tells a clinic nurse that the child is rebelling constantly and having tantrums. which instructions should nurse provide. select all

set limits to behavior provide simply explanation of why behavior is unacceptable

the nurse is caring for a client immediately after removal of the endotracheal tube. the nurse should report which sign immediately if experienced by the client?

stridor

the visiting nurse observes that the older male client is confined by his daughter in law to his room. nurse suggests he walk to den and join family he says "I'm in everyones way, my daughter needs me to stay here." which is most important action for nurse to take?

suggest appropriate resources to client and daughter in law, such as respite care and senior center

client has just returned to nursing unit after an above knee amputation of right leg. the nurse should place client in which position?

supine, with residual limb supported with pillows

which interventions are appropriate for care of infant? select all

swaddling hang mobiles w/ black & white contrast caress infant while bathing or during diaper change

the nurse is testing the extra ocular movements in a client to assess for muscle weakness in the eyes. the nurse should implement which assessment technique to assess for muscle weakness in the eye?

test the 6 cardinal positions of gaze

the nurse is assessing a client for meningeal irritation and elicits a positive brudzinski's sign. which finding did the nurse observe?

the client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column

nurse is providing instructions to UAP regarding care of older client with hearing loss. what should nurse tell UAP?

they respond to low pitched tones

the nurse has just reassessed the condition of a post-op client who was admitted 1 hour ago to the surgical unit. the nurse plans to monitor which parameter most carefully during the next hour?

urinary output of 20 ml/hour

the nurse is evaluating the developmental level of a 2 yo. which does the nurse expect to observe?

uses cup to drink

the nurse is assisting a HCP with removal of chest tube. the nurse should instruct the client to take which action?

valsalva maneuver

the mother of a 3 yo asks clinic nurse about appropriate and safe toys for the child. the nurse should tell the mother that the most appropriate toy is

wagon

a 2 yo child is treated in ED for burn to chest and abdomen. the child sustained the burn by grabbing a cup of hot coffee that was left on the kitchen counter. the nurse reviews safety principles w. the parents before discharge. which statement by parents indicates an understanding of measures to provide safety in the home?

we will be sure not to leave hot liquids unattended

a client with a diagnosis of asthma is admitted to the hospital with respiratory distress. which type of adventitious lung sounds should the nurse expect to hear when performing a respiratory assessment on this client?

wheezes

nurse is providing educational session to new employees, and the topic is abuse of the older client. the nurse helps the employees identify which client as most typically a victim of abuse?

woman who has advanced parkinsons disease