Saunders NCLEX-PN Review 1

A client is admitted to the hospital with a diagnosis of carbon dioxide narcosis. In addition to respiratory failure, the nurse plans to monitor the client for which complication of this disorder?

Increased intracranial pressure

A nursing student is assisting the clinic nurse with the administration of immunizations in the well-baby clinic. The student is asked to administer a measles, mumps, and rubella (MMR) vaccine to a child and prepares to administer the vaccine in which way?

Subcutaneously in the upper arm

Which equipment should the nurse plan to have at the bedside when initiating a clear liquid diet in a postoperative client who has had general anesthesia?

Suction equipment

The nurse is reinforcing instructions to an adolescent with type 1 diabetes mellitus regarding insulin administration and rotation sites. Which statement made by the adolescent would indicate an understanding of the instructions?

"I need to use one major site for the morning injection and another major site for the evening injection for 2 to 3 weeks before changing major sites."

A concerned mother of a newborn with a cleft lip asks the nurse when the surgical repair will occur. Which is an appropriate nursing response?

"Surgical repair is usually around 6 to 12 weeks of age."

Which symptoms would validate the diagnosis of a cluster headache? Select all that apply.

-A runny nose -Burning sensation in the eye -Tearing on the affected eye

The nurse develops a plan of care for a client following a lumbar puncture. Which interventions should be included in the plan? Select all that apply.

-Monitor the client's ability to void. -Maintain the client in a flat position -Monitor the client's ability to move the extremities. -Inspect the puncture site for swelling, redness, and drainage.

The nurse is reading the health care provider's documentation regarding a pregnant client and notes that the health care provider has documented that the client has an android pelvic shape. Which terms apply to an android pelvis? Select all that apply.

-Narrow wedge shape -Unfavorable for a vaginal birth

A client is at risk for developing disseminated intravascular coagulopathy (DIC). The nurse should become concerned with which fibrinogen level?

90 mg/dL

An assessment of a woman at 32 weeks of gestation indicates moderate fetal distress. Which intervention is the nurse's priority?

Administer oxygen with a face mask at 7 to 10 L/min.

The nurse in the labor room is assisting in caring for a client in the active stage of labor. The nurse is told that the fetal patterns show a late deceleration on the monitor strip. Based on this finding, the nurse prepares for which appropriate nursing action?

Administering oxygen via face mask

A client with acquired immunodeficiency syndrome and Pneumocystis jiroveci infection has been receiving pentamidine isethionate (Pentam 300). The nurse assisting in caring for the client monitors the client most closely for which adverse effect?

Anemia

Which conditions places the client at risk for developing acute postrenal failure?

Hydronephrosis

An infant returns to the nursing unit following surgery for an esophageal atresia with tracheoesophageal fistula (TEF). The infant is receiving intravenous (IV) fluids, and a gastrostomy tube is in place. The nurse assisting in caring for the infant should ensure that which action is done to the gastrostomy tube?

Elevated

A client with carcinoma is admitted to the hospital for a chemotherapy treatment with intravenous bleomycin sulfate. The plan of care mentions observing for interstitial pneumonitis as the priority of care. Which finding most closely correlates to symptoms of interstitial pneumonitis, requires reporting?

Lung wheezing and shortness of breath

A client newly diagnosed with renal failure will be receiving peritoneal dialysis. During the infusion of the dialysate, the client complains of abdominal pain. Which action by the nurse is appropriate?

Explain that the pain will subside after the first few exchanges.

The nurse is reinforcing dietary instructions to a client with tuberculosis. The nurse should specifically instruct the client to increase intake of which food items in the daily diet?

Meats and citrus fruits

The nurse is assisting in preparing to administer acetylcysteine to a client with an overdose of acetaminophen (Tylenol). How should the nurse administer the medication?

Mix the medication in a flavored ice drink, and allow the client to drink the medication through a straw.

The nurse is providing instructions to a client beginning medication therapy with divalproex sodium (Depakote ER) for the treatment of absence seizures. The nurse instructs the client that which is the most frequent side effect of this medication?

Nausea and vomiting

The nurse is assisting the health care provider in performing a caloric test on a client. Following instillation of cool water into the ear, the nurse observes the presence of nystagmus. The nurse should document the findings of this test as indicative of which result?

Normal

The nurse is caring for a hospitalized child with a diagnosis of rubella (German measles). The nurse reviews the health care provider's progress notes and reads that the child has developed Forchheimer sign. Based on this documentation, which should the nurse expect to note in the child?

Petechiae spots located on the palate

After a routine eye examination, a client has been told there are refractive errors in both eyes. The nurse explains to the client that this problem is primarily treated with which intervention?

Prescription of corrective lenses

The nurse is caring for a postoperative client who has been NPO and the health care provider has prescribed a clear liquid diet. In planning to initiate this diet, which priority item should the nurse place at the client's bedside?

Suction equipment

A client presents to the urgent care center with complaints of abdominal pain. Suddenly the client vomits bright red blood. The nurse takes which immediate action?

Takes the client's vital signs.

The nurse is reviewing the postoperative prescriptions for a client who has just returned from surgery and notes that the surgeon has prescribed lepirudin (Refludan). Which is this medication prescribed to prevent?

Thromboembolic complications

Megestrol acetate (Megace), an antineoplastic medication, is prescribed for the client with metastatic endometrial carcinoma. The nurse reviews the client's history and contacts the registered nurse if which diagnosis is documented in the client's history?

Thrombophlebitis

The nurse is preparing a client for an emergency cesarean delivery. Which information regarding the client has priority?

When was the last time the client ate or drank?

The nurse is caring for a hospitalized infant with a diagnosis of bronchiolitis. The nurse places the infant in which position?

With the head and chest at a 30-degree angle, with the neck slightly extended

The nurse is caring for a client who has been admitted for alcohol abuse and knows that which medications may be prescribed in the treatment of this disorder? Select all that apply.

-Diazepam (Valium) -Disulfiram (Antabuse) -Chlordiazepoxide (Librium)

The nurse is caring for a client diagnosed with Paget's disease. The nurse understands that this condition usually affects which bones?

Axial skeleton including vertebrae

Which car safety device should be used for a child who is 8 years old and is 4 feet tall?

Booster seat

The nurse is monitoring a postoperative client on an hourly basis. The nurse notes that the client's hourly urine output is 25 mL. Based on this finding, what should be the nurse's first action?

Check the client's overall intake and output record.

The nurse is caring for a newborn following circumcision and notes that the circumcised area is red with a small amount of bloody drainage. Which nursing action would be appropriate?

Document the findings.

A client has been diagnosed with open-angle glaucoma and asks the nurse to repeat the health care provider's explanation of the disorder. The nurse should offer the client which explanation?

The pressure increases within the eye from excess fluid or blocking of drainage.

The nurse is providing instructions to a client with a diagnosis of scabies regarding the administration of crotamiton (Eurax). Which statement by the client indicates an understanding regarding the application of this medication?

"I will massage the medication into the skin from my chin downward and apply a second application in 24 hours, followed by a cleansing bath 48 hours after the second application."

The nurse is caring for a client diagnosed with tuberculosis (TB). Rifampin (Rifadin), 600 mg by mouth daily is prescribed for the client. The nurse reinforces instructions to the client regarding the administration of this medication. Which statement by the client indicates an understanding of the instructions?

"I will need to take the medication for months."

The licensed practical nurse is assisting the registered nurse (RN) in the care of a child who is receiving a blood transfusion and notifies the RN if the child displays which signs/symptoms of fluid overload? Select all that apply.

-Dry cough -Distended neck veins

The nurse is assigned to care for an adult client who had a stroke and is aphasic. Which interventions should the nurse use for communicating with the client? Select all that apply.

-Face the client when talking. -Speak slowly and maintain eye contact. -Use gestures when talking to enhance words. -Give the client directions using short phrases and simple terms.

The nurse is caring for a client with a permanent pacemaker. The nurse knows that which three primary problems can occur when cardiac pacemakers malfunction? Select all that apply.

-Failure to sense -Failure to capture -Failure to pace or fire

Which observations by the nurse caring for clients on a hospital medical-surgical unit should be immediately reported to the health care provider? Select all that apply.

-New confused mental state and pulse rate of 106 beats per minute in a 72-year-old client -A volume of 105 mL of urine over 4 hours in the collection bag of a 1-day postoperative client

A client has been diagnosed with metabolic alkalosis. Which laboratory value(s) is most important for the nurse to monitor for this client?

Arterial blood gases (ABGs)

A client received 20 units of NPH insulin subcutaneously at 8:00 am. The nurse should check the client for a potential hypoglycemic reaction at which time?

5:00 pm

Why should the nurse who is focusing on facilitating positive outcomes regarding health care services become familiar with the cultural beliefs and practices of a childbearing woman?

A culturally diverse woman may have beliefs that impact the delivery of health care services.

A cardiac monitor alarm sounds, and the nurse notes a straight line on the monitor screen. What is the nurse's immediate nursing action?

Assess the client.

The nurse is caring for a client within the first 24 hours following a total gastrectomy for gastric cancer. During this time frame, on which intervention should the nurse focus?

Maintaining a patent nasogastric (NG) tube

Dantrolene sodium (Dantrium) is prescribed for a client experiencing flexor spasms, and the client asks the nurse about the action of the medication. The nurse responds knowing that which is the therapeutic action of this medication?

Acts directly on the skeletal muscle to relieve spasticity

During admission data collection, the nurse asks the client to run the heel of one foot down the lower anterior surface of the other leg. The nurse notices rhythmic tremors of the leg being tested and concludes that the client has interference in which area?

Balance and coordination

A client is being treated for heart failure and is receiving digoxin (Lanoxin). The client's vital signs are blood pressure 85/50 mm Hg, pulse 96 beats per minute, respirations 26 breaths per minute. To evaluate therapeutic effectiveness of this medication, the nurse should expect which change in the client's vital signs?

Blood pressure 98/60 mm Hg, pulse 80 beats per minute, respirations 24 breaths per minute

The nurse is reviewing the laboratory results of a client who is receiving chemotherapy and notes that the platelet count is 10,000 cells/mm3. On the basis of this laboratory value, the nurse should collect which data as a priority?

Level of consciousness

The nurse is assigned to assist in caring for a client who is receiving parenteral nutrition with fat emulsion. The nurse is instructed to monitor the client for signs of fat overload. The nurse monitors for which signs and symptoms of this complication?

Fever and pruritic urticaria

The nurse is caring for a client who has been taking acetazolamide (Diamox) for glaucoma. The nurse reviews the assessment data documented in the client's medical record and determines that an adverse effect of the medication may be occurring if which result is noted?

Jaundice

After receiving furosemide (Lasix) 40 mg slow intravenous push for chest pain related to shortness of breath and generalized edema, the client responds poorly. The client has no relief of the chest pain, shortness of breath, or edema and only minimal urine output (less than 40 mL of urine). The health care provider is notified, and after reviewing the chart, suspects the client has syndrome of inappropriate antidiuretic hormone (SIADH). Which findings would lead to this specific diagnosis?

Minimal responsiveness to furosemide (Lasix) and small cell lung cancer

The nurse is caring for a client who is receiving an intravenous (IV) infusion of an antineoplastic medication. During the infusion, the client complains of pain at the insertion site. During an inspection of the site, the nurse notes redness and swelling. The nurse should take which appropriate action?

Notify the registered nurse.

A client who sustained an eye injury arrives at the emergency department. Which is the initial nursing action?

Obtain a history regarding the cause of the injury.

The nurse in the recovery room area is preparing to care for a client following cataract extraction of the right eye. Which position does the nurse prepare to place the client?

On the left side with the head of the bed elevated

The nurse is caring for a client with a resolved intestinal obstruction who has a nasogastric tube in place. The health care provider has now prescribed the nasogastric tube to be discontinued. To determine the client's readiness for discontinuation of the nasogastric tube, which measure should the nurse check?

Presence of bowel sounds in all four quadrants

An anxious client is experiencing respiratory alkalosis from hyperventilation as a result of anxiety. The nurse should do which action to help the client experiencing this acid-base disorder?

Provide emotional support and reassurance.

According to Kohlberg's theory of moral development, at the preconventional level, moral development is thought to be motivated by which factor?

Punishment and reward

A client is in metabolic acidosis caused by diabetic ketoacidosis (DKA). The nurse prepares for the administration of which medication as a primary treatment for this problem?

Regular insulin

A client has a serum sodium level of 129 mEq/L because of hypervolemia. The nurse consults with the health care provider to determine whether which measure should be instituted?

Restricting fluid intake

The nurse is caring for a client with a diagnosis of chronic kidney disease who is receiving dialysis. Epoetin alfa (Epogen) has been prescribed for the client. How should the nurse prepare to administer the medication?

The subcutaneous route

The client has been on treatment for rheumatoid arthritis for 3 weeks. Which is most important for the nurse to check during the administration of etanercept (Enbrel)?

The white blood cell counts and platelet counts

The nurse is explaining the concept of time-out in the perioperative area to a group of nursing students. What is the purpose of a time-out?

To allow the surgical team a chance to verbally verify their agreement on the client's name, surgical procedure, and site

The nurse is preparing to set up a sterile field using the principles of aseptic technique to perform a dressing change. Which should the nurse include in the preparations? Select all that apply.

-Open the distal flap of a sterile package first. -Prepare the sterile field just before the planned procedure. -Avoid placing items within 1 inch of any area surrounding the outer edge of the sterile field.

The nurse is reinforcing discharge teaching to the parents of an infant diagnosed with tetralogy of Fallot. Which statements made by the parents indicate a need for further teaching? Select all that apply.

-Our child will eventually grow out of this condition. -It is not necessary to avoid individuals with the common cold.

The nurse in the pediatric clinic is planning care for a 2-month-old client who has been brought to the clinic for a well-child exam and 2-month immunizations. The infant is afebrile and does not exhibit signs of a respiratory infection. The mother tells the nurse that the child developed a rash and difficulty breathing after the mother applied Neosporin ointment to a scrape on the baby's leg. The nurse knows which vaccines are safe to administer to the child? Select all that apply

-Rotavirus -Hepatitis B -Pneumococcal -Diphtheria, tetanus, pertussis -Haemophilus influenza type b

A student nurse is assigned to assist in caring for a client with acute pulmonary edema who is receiving digoxin (Lanoxin) and heparin therapy. The nursing instructor reviews the plan of care formulated by the student and tells the student that which intervention is unsafe?

Restricting the client's potassium intake

The nurse is assisting a health care provider with an assessment of a child with a diagnosis of suspected appendicitis. In assessing the intensity and progression of the pain, the health care provider palpates the child at McBurney's point. The nurse understands that McBurney's point is located midway between which body landmarks?

Right anterior superior iliac crest and the umbilicus

The nurse is reviewing the record of a child with increased intracranial pressure and notes that the child has exhibited signs of decerebrate posturing. On data collection of the child, the nurse expects to note which characteristic of this type of posturing?

Rigid extension and pronation of the arms and legs

An oral hypoglycemic medication, a sulfonylurea, is prescribed for a client with type 2 diabetes mellitus. The nurse plans to administer the medication, knowing that what is the primary action of this medication?

To promote insulin secretion by the pancreas

A hospitalized client is dyspneic and has been diagnosed with left pneumothorax by chest x-ray. Which sign or symptom observed by the nurse clearly indicates that the pneumothorax is rapidly worsening?

Tracheal deviation to the right

The nurse is preparing for the admission of a client with a prescription for seizure precautions. Which supplies will the nurse make available to this client? Select all that apply.

-Suction machine -Oxygen administration -Padding for the side rails -Prescribed diazepam (Valium)

The nurse is told in report that a client has a positive Chvostek's sign. Which other data should the nurse expect to find on data collection? Select all that apply.

-Tetany -Diarrhea -Possible seizure activity -Positive Trousseau's sign

The health care provider writes a prescription for the nurse to obtain a consent for a colonoscopy. Which are the nurse's responsibilities to obtain an informed consent? Select all that apply.

-To ensure the client is the age of consent -To ensure the client is signing voluntarily

The nurse is assigned to care for a pregnant client being admitted to the nursing unit. Laboratory and diagnostic studies have confirmed a diagnosis of gestational trophoblastic disease (hydatidiform mole). The nurse collects data on the client and reviews the results of the laboratory and diagnostic studies, knowing that which findings are associated with this diagnosis? Select all that apply.

-Vaginal bleeding -Excessive vomiting -No fetal heart activity -Larger than normal fetus size for gestational age -Elevated levels of human chorionic gonadotropin (HCG)

The nurse is collecting data from a client, and the client's spouse reports that the client is taking donepezil hydrochloride (Aricept). Which disorder should the nurse suspect that this client may have based on the use of this medication?

Dementia

Lispro (Humalog) insulin is prescribed three times a day, with the amount based on blood glucose levels. The nurse determines that the client understands teaching regarding lispro insulin if which statement is made?

"I will take the lispro 10 to 15 minutes before I eat breakfast, lunch, and dinner."

The nurse on a telemetry unit checks a client's chart and notes that the potassium level is 6.3 mEq/L. Based on the laboratory result, which signs/symptoms should the nurse anticipate? Select all that apply.

-Anxiety -Electrocardiogram (ECG) changes

Which guidelines should the nurse follow when performing narrative documentation? Select all that apply.

-Date and time entries. -Sign and title each entry. -Avoid judgmental and evaluative statements. -Do not leave blank spaces on documentation forms.

The nurse is monitoring a client who sustained a head injury and suspects that the client has a skull fracture. This conclusion is based on which findings? Select all that apply.

-Drainage from ear -Bruising around the eyes -Pink-tinged drainage from the nose

The nurse is collecting data from a child suspected of having juvenile idiopathic arthritis (JIA). Which findings should the nurse expect to note if JIA were present? Select all that apply.

-Malaise, fatigue, and lethargy -Painful, stiff, and swollen joints -Limited range of motion of the joints -History of late afternoon temperature, with temperature spiking up to 105° F