Questions to review mock Nclex

The toddler with nephrotic syndrome responds to treatment and is ready to go home. When helping the family plan for home care, the nurse should include which instruction in the teaching?

Keep the child away from others with an infection. A child recovering from nephrotic syndrome should be protected from infection. Therefore, the nurse would teach the parents to keep the child away from others with an infection. Because pain is not associated with this disorder, pain medication typically is not needed. The HCP should be notified if urine output decreases, not increases. In children recovering from nephrotic syndrome, there is no reason to administer acetaminophen daily.

To treat a child's atopic dermatitis, a physician orders a topical application of hydrocortisone cream twice daily. After medication instruction by the nurse, which statement by the parent indicates effective teaching?

"I will avoid using soap and water on the affected area and will apply an emollient cream on this area frequently." Avoiding the use of soap and water reflects effective teaching because such washing removes moisture from the horny layer of the skin. Applied in a thin layer, emollient cream holds moisture in the skin, provides a barrier to environmental irritants, and helps prevent infection. Spreading a thick coat of hydrocortisone cream shows ineffective teaching because topical steroid creams such as hydrocortisone should be applied sparingly as a light film; the affected area should be cleaned gently with water before the cream is applied. Scraping or abrading the skin may actually increase the risk of infection and alter drug absorption. Excessive application of steroidal creams may result in systemic absorption and Cushing's syndrome. Frequent washing dries the skin, making it more susceptible to cracking and further breakdown.

Which child most needs a developmental referral for a language delay?

4-year-old who is difficult to understand More than 90% of children have speech that is totally intelligible at 4 years of age. Having one word at 1 year is the expectation. Fifty percent of children have three words by 15 months, and 90% have three words by 18 months. Pointing to one body part at 18 months is a normal finding. Combining two words at 2 years would be a normal finding.

Which signs and symptoms would the nurse expect in a client with angina? Select all that apply.

Chest tightness, chest pressure, and jaw pain are all symptoms of angina. General muscle aching is not associated with angina. Respirations and heart rate typically increase, not decrease, with anginal attacks.

A client is preparing to undergo abdominal paracentesis. Which nursing interventions should be performed before the procedure? Select all that apply.

The nurse should explain the procedure to the client and make sure informed consent has been obtained. The nurse should instruct the client to void before the procedure to minimize the risk of accidental bladder injury from the needle or trocar and cannula. The nurse should then help the client sit up in bed, expose the client's abdomen, wash hands, and then open the paracentesis tray using sterile technique.

The nurse is caring for a client after surgery. The client has reported at least one fall in the last 3 months. The client may ambulate with assistance, has a saline lock in place, and has demonstrated appropriate use of the call light to request assistance. What intervention(s) should the nurse include in this client's plan of care? Select all that apply.

The plan of care for all clients should ensure that their necessities are readily available so they do not fall trying to obtain something out of reach; this client also has several factors that make the client a high fall risk. All clients who are high risk should be visually identified according to facility policy so that all providers are aware of increased fall risk. Assessing for and attending to pain and toileting needs regularly may help prevent a fall due to discomfort. Clients who are high fall risk should be placed closer to the nurses' station, not further away, so that they may be monitored more closely. Leaving the wheelchair next to the bed may tempt even an alert client to get up without calling for assistance and is not in the client's best safety interest. Putting all side rails up may be considered a restraint in some facilities and is not recommended; a client intent on getting out of bed may attempt to climb over the side rails, creating further risk for falling.

After a gastrectomy, the client has a nasogastric (NG) tube in place. The nurse should tell the client the tube is used for which reason?

To prevent excessive pressure on suture lines

A multigravid client is admitted at 16 weeks' gestation with a diagnosis of hyperemesis gravidarum. The nurse should explain to the client that hyperemesis gravidarum is thought to be related to high levels of which hormone?

estrogen Although the cause of hyperemesis is still unclear, it is thought to be related to high estrogen and human chorionic gonadotropin levels or to trophoblastic activity or gonadotropin production. Hyperemesis is also associated with infectious conditions such as hepatitis or encephalitis, intestinal obstruction, peptic ulcer, and hydatidiform mole. Progesterone is a relaxant used during pregnancy and would not stimulate vomiting. Somatotropin is a growth hormone used in children. Aldosterone is a male hormone.

A nurse selects a priority nursing diagnosis of Fear related to being embarrassed in the presence of others for a client who exhibits symptoms of social phobia. Which outcomes, if met, would demonstrate improvement in client's symptoms? Select all that apply.

When selecting an outcome for a nursing diagnosis, choose a statement that would demonstrate the progressing toward or achievement of the short-term or long-term goal. Improving stress management skills, verbalizing feelings, and anticipating and planning for stressful situations are adaptive responses to stress. Avoidance and denial are maladaptive defense mechanisms. Using antianxiety medication may be appropriate but does not indicate an improvement in client symptoms.

The nurse manager is developing an assessment guide for clients on the urology unit. Which client is at the highest risk for catheter-associated urinary tract infection (CAUTI)?

client with diabetes mellitus Clients who are immunosuppressed, have diabetes mellitus, or have undergone multiple courses of antibiotic therapy are prone to bacterial, fungal, and parasitic infections. Taking one course of antibiotic therapy or having a family history of UTIs does not place a client at high risk for the development of a CAUTI. A predisposing factor for a UTI is ongoing problems of urinary calculi; one calculus would not place a client at high risk.

The nurse is performing a complete neurological assessment on an older adult client. Which question by the nurse would best assess cerebral function?

"Have you noticed a change in your memory?" Explanation: To assess cerebral function, the nurse should ask about the client's level of consciousness, orientation, memory, and other aspects of mental status. Questions about muscle strength help evaluate the client's motor system. Questions about coordination help assess cerebellar function. Questions about eyesight help evaluate the cranial nerves associated with vision.

A physician orders metaproterenol/orciprenaline by metered-dose inhalation four times daily for a client with acute bronchitis. Which statement by the client indicates effective teaching about this medication?

"I need to hold my breath as long as possible after I take a deep inhalation." Explanation: The client demonstrates effective teaching if they state that they'll hold their breath for as long as possible after inhaling the drug. Holding the breath increases the absorption of the drug into the alveoli. Metaproterenol needs to be used over an extended period for maximum effect. The client shouldn't use the inhaler whenever they feel out of breath because dependency can develop if the drug is used excessively. The client should adhere to the prescribed dosage. Tachycardia is an expected adverse reaction to metaproterenol. The client should be taught how to monitor their heart rate and contact the physician only if the heart rate exceeds 130 beats/minute.

A client diagnosed with acquired immunodeficiency syndrome (AIDS) is experiencing end-stage Kaposi's sarcoma. Concerned that the healthcare team is investing too much energy in keeping them alive, the client asks that they not attempt any more interventions. How should a nurse respond to this client?

"We have to make sure you've signed an advance directive." Explanation: The nurse should tell the client that they must sign an advance directive to prevent future healthcare interventions. This client has lived with AIDS for many years; suggesting that the client talk with a therapist or reconsider this decision is disrespectful and disregards the client's experience of the disease. An advance directive doesn't require a physician's order.

Which client, diagnosed with pneumonia, is most likely to have community-acquired pneumonia?

A client newly admitted to a long-term care facility Explanation: The client who is a new resident in a long term care facility is at high risk for community-acquired infections. Traveling is not likely to cause community-acquired pneumonia. Legionnaires' disease is a risk if traveling on a confined cruise ship. Receiving family visits and the death of a spouse are not typically causative factors associated with developing community-acquired pneumonia.

While caring for the neonate of an HIV-positive birth parent, the nurse prepares to administer a prescribed vitamin K intramuscular injection at 1 hour after birth. Which action should the nurse take first?

Bathe the neonate. Newborns are typically bathed 2 to 4 hours after birth when their temperatures have had time to stabilize, but early/immediate bathing is recommended for the infants of HIV-positive birth parents to decrease blood exposure. Placing the neonate under the radiant warmer for the vitamin K injection is not necessary unless the neonate's temperature is subnormal. Washing the injection site with povidone-iodine is not recommended and may increase the risk for possible allergy to iodine preparations. The first dose of zidovudine is given when the newborn is 6 to 12 hours old, but vitamin K is recommended to be given within an hour of birth to be most effective. Therefore, administering vitamin K should not be delayed.

A nurse is caring for a 4-year-old child with end-stage leukemia. The child's physician has ordered a lumbar puncture. His mother, who has legal custody, has refused to give consent for the child to undergo the procedure. However, the child's father is demanding that the procedure be performed. What should the nurse do first?

Inform the father that the procedure won't be performed because the mother didn't consent. The parent who has legal custody of a child has medical decision-making rights for that child. The other parent could contest the decision but would need to seek legal counsel. After informing the father that the procedure won't be performed at this time, the nurse should make the physician and social services aware of the situation in case additional problems arise.

The nurse is caring for a senior citizen who lives alone. When evaluating the effectiveness of adding fluticasone propionate and salmeterol to the chronic obstructive airway disease (COPD) client's medication regimen, which client statements would support symptom improvement? Select all that apply.

Fluticasone propionate and salmeterol is a combination of steroid and bronchodilator used in the treatment of chronic asthma and chronic obstructive airway disease. The medication is intended to be used daily. It is not a rescue inhaler, and additional doses do not improve respiratory function. Evaluation of effectiveness includes improvement in respiratory status and ability to perform activities of daily living/quality of life activities such as walking and playing. Side effects of the medication include an increase in cough and sputum production. Nervous system side effects include tremors and nervousness.

After suffering an acute myocardial infarction (MI), a client with a history of type 1 diabetes is prescribed metoprolol intravenously. Which nursing interventions are associated with intravenous administration of metoprolol? Select all that apply.

Metoprolol masks the common signs of hypoglycemia; therefore, glucose levels would be monitored closely in diabetic clients. When used to treat an MI, metoprolol is contraindicated in clients with heart rates less than 45 beats/minute and any degree of heart block, so the nurse would monitor the client for bradycardia and heart block. Metoprolol masks common signs and symptoms of shock, such as decreased blood pressure, so blood pressure would also be monitored closely. The nurse would give the drug undiluted by direct injection. Although metoprolol would not be mixed with other drugs, studies have shown that it is compatible when mixed with morphine sulfate or when administered with alteplase infusion at a Y-site connection.

The therapeutic team has identified the need to formulate strategies to maintain a safe environment for a client with schizophrenia displaying inappropriate behavior. Which strategy must be initiated immediately?

Monitor the client's behavior. The unit must be maintained as a safe environment for the client and the other clients; therefore, the client should never have unsupervised time on the unit. The nurse never attempts to do psychotherapy to delve into why a client exhibits behavior. Teaching interpersonal skills such as ways to communicate and interact with others is not the priority at this early stage.

After the administration of t-PA, the assessment priority is to:

Observe the client for chest pain. Although monitoring the 12-lead ECG and monitoring breath sounds are important, observing the client for chest pain is the nursing assessment priority because closure of the previously obstructed coronary artery may recur. Clients who receive t-PA frequently receive heparin to prevent closure of the artery after administration of t-PA. Careful assessment for signs of bleeding and monitoring of partial thromboplastin time are essential to detect complications. Administration of t-PA should not cause fever.

What are important nursing care measures for a client with diabetes who is admitted with end-stage renal failure?

Restrict sodium and potassium and restrict fluids as ordered. In renal failure, there is retention of sodium and potassium, so these are restricted. Important care measures will also include fluid restrictions. The client will require permanent dialysis, not temporary as with acute renal failure. The diet will be restricted in protein to decrease waste products. Hypertension is associated with chronic renal failure.

A home health nurse is providing care to a palliative care client with liver cancer. Which classifications of medications are anticipated on the medication administration record? Select all that apply.

The client with liver cancer who is also a palliative care client has decided to focus on quality of life and symptom management instead of curative treatment. Narcotics for pain relief, stool softeners to maintain a bowel regiment in light of narcotic use, and antiemetics to control nausea and vomiting all assist the client to meet these goals. Chemotherapeutic agents are aggressive therapy to kill liver cancer cells. Antidepressants are used for symptoms of depression.

A nurse is caring for four clients who gave birth 12 hours ago. Which client is at greatest risk for complications?

gravida 2 para 2002, cesarean birth, incision site intact, hemoglobin level 9.8 g/dl Explanation: Women who have anemia during pregnancy (defined as a hemoglobin less than 10 g/dl) may experience more complications such as poor wound healing and inability to tolerate activity. An intact incision site and a pulse of 84 beats/minute after a cesarean birth and a temperature of 99.8° F (37.7° C) after a vaginal delivery with episiotomy are findings within normal limits. Dehydration can cause a slightly elevated temperature. Although women whose membranes are ruptured more than 24 hours before birth are more prone to developing chorioamnionitis, the client with anemia is at greater risk for complications.

Which diagnostic test is used first to evaluate a client with upper GI bleeding?

hemoglobin levels and hematocrit Hemoglobin and hematocrit are typically performed first in clients with upper GI bleeding to evaluate the extent of blood loss. Endoscopy is then performed to directly visualize the upper GI tract and locate the source of bleeding. An upper GI series, or barium study, usually isn't the diagnostic method of choice, especially in a client with acute active bleeding who's vomiting and unstable. An upper GI series is also less accurate than endoscopy. Although an upper GI series might confirm the presence of a lesion, it wouldn't necessarily reveal whether the lesion is bleeding. Arteriography is an invasive study associated with life-threatening complications and wouldn't be used for an initial evaluation.

The nurse is aware that clients who are Christian Scientists may not approve of

immunizations Some groups, such as Christian Scientists and Amish, have been legally exempted from immunizations; however, many medical decisions are reviewed on a case-by-case basis depending on the client's age and imminence of death.

The nurse develops the discharge teaching plan for the parents of a child who has undergone a cardiac catheterization for a ventricular septal defect. Which information should the nurse expect to include?

use of prophylactic antibiotics before receiving any dental work Prophylactic antibiotics are suggested for children with heart defects before dental work is done to reduce the risk for bacterial infection. Typically, activities are not restricted after a cardiac catheterization. A percutaneous approach is used to insert the catheter, so stitches are not necessary. Showering or bathing is allowed as usual. The pressure dressing will be removed before the child is discharged.

A client with Rh isoimmunization gives birth to a neonate with an enlarged heart and severe, generalized edema. The neonate is immediately transferred to the neonatal intensive care unit. Which nursing diagnosis is most appropriate for the client?

impaired parenting related to the neonate's transfer to the intensive care unit Explanation: Because the neonate is severely ill and needs to be placed in the neonatal intensive care unit, the client may have a nursing diagnosis of impaired parenting related to the neonate's transfer to the neonatal intensive care unit. (Another pertinent nursing diagnosis may be compromised family coping related to lack of opportunity for bonding.) Rh isoimmunization isn't a socially unacceptable infection. This condition causes an excess fluid volume (not deficient) related to cardiac problems. Rh isoimmunization doesn't lead to loss of the neonate by statute.

A nurse caring for a client with a fecal impaction should watch for

liquid or semiliquid stools. Passage of liquid or semiliquid stools results from seepage of unformed bowel contents around the impacted stool in the rectum. Clients with fecal impaction don't pass hard, brown, formed stools because the feces can't move past the impaction. These clients typically report the urge to defecate (although they can't pass stool) and decreased appetite.

The nurse encourages client evaluation of their own behavior. Which probe should the nurse use?

"What did you do differently with your coworker this time?" Explanation: Asking for descriptions of changes in behavior (what the client did differently) encourages evaluation. Conveying empathy, such as stating that it is still hard for the client to talk about it, encourages data collection. Asking for meaning helps with the nursing diagnosis. Asking the client about what it will take to follow a plan is part of planning.

The nurse reviews the nurse's note of an older adult client and implements which intervention to help with the maintenance of skin integrity?

Administer the ordered pain medication. The client needs to be encouraged to assist with turning once pain medication is administered. While the client could be turned first, having the pain medication will make it more likely that the client will be successful with movement. Providing a blanket will help with comfort, but is not related to the maintenance of skin integrity. While the surgical dressing would be changed daily and as needed, it would not be more important to the maintenance of skin integrity since there is no indication of a need for this as a priority with the dressing being clean and dry.

What is the priority nursing intervention for a client experiencing a myocardial infarction (MI)?

Administering oxygen Administering supplemental oxygen to the client is the priority of care. The myocardium is deprived of oxygen during an infarction, so additional oxygen is administered to assist in oxygenation and prevent further damage. Morphine and sublingual nitroglycerin are also used to treat MI, but are commonly administered after oxygen. An ECG is the most common diagnostic tool used to evaluate MI.

During nursing rounds, a nurse checks on a client on bed rest who reports an itchy rash. The nurse assesses the client's skin for erythematous, slightly edematous areas on the client's back, posterior lower legs, and posterior elbows. The health care provider's diagnosis is an allergic contact dermatitis. Which teaching points about contact dermatitis are correct? Select all that apply.

Contact dermatitis is classified as a reaction to an allergen and can appear when skin, especially if it's moist from perspiring or other reasons, remains in contact with an irritant for an extended time. It is a hypersensitivity reaction but usually requires extended contact. This client has a presentation often seen when clients remain in bed, perspiring on detergent-cleansed bed linens or gowns. This type of sensitivity to detergents may not have produced a reaction with a shorter time contact. The rash is not contagious or infectious, although areas may become exudative and crusted. Treatment varies according to the intensity of the skin reaction and other factors, but oatmeal (Aveeno) baths are frequently prescribed.

When instructing a pregnant client diagnosed with a chlamydial infection at 28 weeks' gestation, what should the nurse include about this infection during pregnancy?

The client will likely receive a 5-day course of azithromycin. Explanation: Chlamydial infection during pregnancy has been associated with preterm labor (resulting in a low-birth-weight infant) and with preterm rupture of the membranes. Chlamydial infection is usually treated with azithromycin or doxycycline. Central nervous system disorders in the fetus are not associated with the infection. Neonatal complications include conjunctivitis, pneumonitis, chronic otitis media, and asthma. Although the neonate can be infected during passage through the birth canal, there is no evidence to suggest that the client will require a cesarean birth. Fetal demise from this infection during pregnancy is rare.

A healthcare provider writes a prescription for "digoxin .125mg PO once daily" and "nitroglycerin patch 0.4 mg/hour topically to be worn 0800-2000 daily." What does the nurse clarify with the healthcare provider?

the dose of digoxin The prescription for digoxin is improperly written because there is no zero (0) before the decimal point. The nurse clarifies this order to ensure it is not meant to be 1.25mg. The other aspects of proper prescription are addressed, including route and frequency. The nitroglycerin patch prescription includes route (topical), dose, and frequency and does not require clarification.