2024 (January) Nclex Practice

A nurse is caring for a client who has acute pancreatitis. Which of the following serum laboratory values should return to the expected reference range within 72 hr of treatment beginning? a. aldolase b. lipase c. amylase d. lactic dehydrogenase

Amylase pancreatitis is the most common diagnosis for marked elevations of serum amylase. Amylase levels peak in 20-30 hours and returns to expected range within 2-3 days. - Aldolase caused by inflammation of muscle - Lipase level in pancreatitis - Lactic dehydrogenase increases in anemia, leukemia or liver damage

A nurse is reinforcing teaching about preventing engorgement to a client who is planning to use formula to feed her newborn. Which of the following instructions should the nurse include? a. apply ice packs to your breasts b. hand express milk from your breasts 3 times a day c. try to avoid wearing a bra as much as possible throughout the day d. request a prescription for medication to suppress lactation

Apply ice packs to your breasts -assists in reducing the discomfort of engorgement (when milk isn't fully removed from breasts) -hand moving causes breast stimulation of milk production -wearing a well-fitted bra for the first 72 hours after delivery assists with suppression of lactation -no medications are indicated for lactation suppression

A nurse is planning dietary teaching for a client who has diabetes mellitus. Which of the following actions should the nurse plan to take first? a. obtain sample menus from the dietitian to give to the client b. ask the client to identify the types of food she prefers c. identify the recommended range of the client's blood glucose level d. discuss long-term complications that can result from non-adherence to the dietary plan

Ask the client to identify the types of food she prefers -Nursing process: assess, diagnosis, planning, implementation and evaluation

A nurse is reviewing the laboratory reports of a client who is receiving enteral feedings. Which of the following lab values indicates a complication of enteral feeding that the nurse should report to the provider? a. sodium 143 mEq/L b. potassium 4.2 mEq/L c. BUN 25 mg/dL d. glucose 185 mg/dL

BUN 25 mg/dL - BUN level of 25 is above (10-20) indicating dehydration which is an enteral feeding complication - glucose of 185 is within expected range (<200) for casual blood glucose and does not indicate a complication of enteral feeding

A nurse is providing dietary teaching to a client who has late-stage chronic kidney disease (CKD). Which of the following nutrients should the nurse instruct the client to increase her diet? a. calcium b. phosphorus c. potassium d. sodium

Calcium -CKD can cause hypocalcemia due to reduced production of vitamin D which is needed for calcium absorption -Clients with CKD can develop hyperphosphatemia, hyperkalemia and hypernatremia

A nurse is teaching a client who is pregnant and has pregestational diabetes about dietary changes. Which of the following statements should the nurse include in the teaching? a. carbohydrates should make up to 55% of your diet b. protein should make up 70% of your diet c. fats should make up 45% of your diet d. fiber should make up 10% of your diet

Carbohydrates should make up to 55% of your diet - For client who have pregestational diabetes, intake of simple carbohydrates should be limited. The ideal diet is composed of 55% carbohydrates, 20% protein, 25% fat and less than 10% saturated fat -There is no limit on fiber, fiber should be recommended to clients to decrease constipation which is an often problem in pregnancy

A nurse is completing the admission history for a client who reports drinking 1 pint of whiskey everyday for 6 years. The clients last drink was 10 hr ago. Which of the following medications should the nurse plan to administer upon admission? a. chlordiazepoxide b. disulfiram c. naloxone d. acetaminophen

Chlordiazepoxide - benzodiazepines are the most effective medication for alcohol withdrawal - disulfiram - used to help overcome drinking problems, once detox is accomplished - naloxone - antidote for opioid overdose - acetaminophen and alcohol increases the client's risk of liver damage

A nurse is providing teaching to a client who has a new prescription for clozapine. Which of the following statement should the nurse include in the teaching? a. you should have your white blood cell count checked once per week for 6 months b. you should check yourself every 3 days for weight loss c. you might experience frequent loose stools d. you might experience ringing in your ears

You should have your white blood cell count checked once per week for 6 months - schizophrenia medication that causes a risk of neutropenia

A nurse is providing teaching about disease-management strategies to a 9-year-old client who has cystic fibrosis. Which of the following statements should the nurse include? a. thorough and effective pulmonary clearance can help prevent the need for a lung transplant when you get older b. you should eat these kinds of foods because they will help you grow big and strong c. you're mucus is thick because cystic fibrosis interferes with how you're glands work d. you're medication follows a certain schedule to help you sleep better

You're mucus is thick because cystic fibrosis interferes with how you're glands work

A nurse on an oncology unit is providing discharge teaching to an adolescent female client who received a bone marrow transplant for leukemia. Which of the following pieces of information should the nuse include in the teaching? (select all) a. take your temperature twice each day b. you may return to school if you feel strong enough c. it is important to wear shoes always d. clean your toothbrush weekly with isopropyl alcohol e. avoid using tampons

a. Take your temperature twice each day c. It is important to wear shoes always e. Avoid using tampons - avoid infection, patient is extremely immunosuppressed -note alcohol on toothbrush can cause trauma and irritation to gums and tissues

A nurse is planning care for a client who has AIDS and has developed stomatitis. Which of the following interventions should the nurse include in the plan of care. a. rinse the mouth with chlorhexidine solution every 2 hr b. limit fluid intake with meals c. provide oral hygiene with a firm-bristled toothbrush after each meal d. avoid salty foods

Avoid salty foods - stomatitis is an inflammation of the mucosa of the mouth, usually with ulcerations - spicy and acidic or salty food should be avoided for preventing further irritation

A nurse is caring for a client with a pseudomonas infection who has a new prescription for ticarcillin clavulanate. Which of the following data should the nurse collect before administering this medication? a. indications of super infection b. peak and through medication levels c. baseline BUN and creatinine d. history of allergy to aminoglycoside antibiotics

Baseline BUN and creatinine Ticarcillin-clavulanate is a penicillin antibiotic and is excreted by the kidneys. Therefore renal impairment could result, so checking BUN and creatinine levels are important while giving this medication

A nurse cares for a client receiving chemotherapy. The latest blood work shows: platelet count 18,000/mm3 WBC count of 5,000/mm3 Which intervention does the nurse implement? a. respiratory transmission precautions b. contact transmission precautions c. bleeding precautions d. neutropenic precautions

Bleeding precautions -normal platelet count is 150,000-400,000/mm3 bleeding precautions should be implemented with a platelet count less than

A nurse is caring for a 2-year-old child who has cystic fibrosis. The nurse is planning to take the child to the playroom. Which of the following activities would be appropriate for the child? a. cutting figures from colored paper b. drawing stick figures using crayons c. riding a tricycle d. building towers with blocks

Building towers with blocks - 3 year-olds work with scissors - 4 year-olds draw stick figures - 3 year-olds ride tricycle.

While performing passive range of motion (PROM), the client reports discomfort with an abduction exercise. After stopping the exercise, which action does the nurse take next? a. complete a focused pain assessment b. ask the client if heat or ice to the area is preferred c. offer a dose of PRN analgesia to the client d. report the pain to the healthcare provider

Complete a focused pain assessment -the nurse should perform an assessment as the next step to guide further actions

A nurse is caring for a child who had her spleen removed following a bicycle accident. The child's parent asks the nurse about the role of the spleen in the body. The nurse should explain that the spleen performs which of the following functions? a. maintains fluid balance b. regulates calcium in the blood c. destroys old blood cells d. produces prothrombin

Destroys old blood cells - the spleen destroys old blood cells, filters antigens, stores platelets (client without spleen is at risk of infection and sepsis due to reduced immune function) - fluid balance is maintained by a variety of regulators: renal and endocrine - parathyroid glands regulate calcium levels - prothrombin is a clotting factor produced in the liver

A nurse in an emergency department is caring for a 4 year old who has burns to the neck and face following a house fire. Which action should the nurse take first? a. cover the child's wounds with a clean, dry cloth b. establish IV access with a large-bore catheter c. provide reassurance to the child's parents d. determine the child's breathing pattern

Determine the child's breathing pattern (ABCs)

A nurse is caring for a client from the Middle East who has celiac disease. Which of the following actions should the nurse perform regarding the client's diet? a. provide foods prepared according to kosher dietary law b. ask the kitchen to prepare grits to meet the client's dietary need for grains c. determine the client's dietary preferences d. prepare the diet tray and include vegetable and barley soup

Determine the client's dietary preferences - the nurse should assess the client's dietary habits before planning to meet dietary needs

A nurse is preparing a client who has a brain tumor for computed tomography (CT). Which of the following factors affects the manner in which the nurse will prepare the client for the scan? a. no food or fluids consumed for 4hr b. difficulty recalling recent events c. development of hives when eating shrimp d. paresthesias in both hands

Development of hives when eating shrimp -allergy to shellfish is a contraindication for the use of contrast media

A nurse is caring for a client who smokes cigarettes and has a new diagnosis of emphysema. How should the nurse assist the client with smoking cessation? a. discuss ways the client can reduce the number of cigarettes smoked per day b. suggest the client switch from smoking cigarettes to smoking a pipe c. inform the client that treatment will be ineffective if smoking continues d. discourage the use of nicotine gum

Discuss ways the client can reduce the number of cigarettes smoked per day - this will create a realistic goal to decrease smoking gradually

A nurse is caring for a client with alcohol use disorder who has undergone detoxification. Which of the following medications should the nurse expect the provider to prescribe to assist the client with maintaining sobriety? a. varenicline b. clonidine c. buprenorphine d. disulfiram

Disulfiram -helps clients abstain from alcohol - Varenicline = reduce nicotine craving - Clonidine = treat heroin withdrawal - Buprenorphine = treat opioid withdrawal

The nurse assesses a client who has new onset atrial fibrillation. The ventricular rate is 145 beats/min. What does the nurse expect to observe? a. head and neck pain b. bilateral lower extremity swelling c. distended jugular veins d. dizziness and dyspnea

Dizziness and dyspnea -uncontrolled atrial fibrillation can result in acute drop in cardiac output. s/s are dizziness and shortness of breath -bilateral lower swelling = high salt, stay in position too long, heart failure, kidney failure, etc -distended jugular signs of chronic heart failure, fluid overload, pulmonary hypertension, cardiac tamponade

A nurse is providing teaching to a client who has constipation. Which of the following instruction should the nurse include? a. use bismuth subsalicylate regularly b. consume a low-fiber diet c. eat yogurt with live cultures d. use bisacodyl suppositories regularly

Eat yogurt with live cultures - bismuth subsalicylate (antidiarrheal) - use bisacodyl suppositories regularly can result in decreased defecation reflexes

A nurse at a pediatric clinic is assessing a 5-month-old infant during a well-child visit. Which of the following findings should the nurse report to the provider? a. head lagging when the infant is pulled from a lying to a sitting position b. absence of startle and crawl reflexes c. inability to pick up a rattle after dropping it d. rolling from back to side

Head lagging when the infant is pulled from a lying to a sitting position - at 5 months = infant should hav eno head lag - startle reflex disappears by the age of 4 months - the crawl reflex disappears around 6 weeks - at 5 months the infant can follow a dropped object but can't pick it up until 6 months - at 4 months the infant should be able to roll form back to side

A nurse is assessing a client who is receiving hemodialysis for the first time. Which of the following findings indicates that the client is developing dialysis disequilibrium syndrome (DDS)? a. elevated BUN b. bradycardia c. headache d. temperature 39.2 C (102.5 F)

Headache (DDS is a CNS disorder that can develop in clients who are new to dialysis due to rapid removal of solutes and changes in blood pH - causes headaches, nausea, voming, decreased LOC, seizures, restlessness, coma, death -elevated BUN increases DDS risk -client would have tachycardia, not bradycardia -temperature indicates infection

A nurse is preparing to administer digoxin to a client. Which of the following findings should the nurse identify as a contraindication to the client receiving this medication? a. blood pressure 180/70 mmHg b. oxygen saturation rate 94% c. heart rate 51/min d. respiratory rate 21/min

Heart rate 51/min -digoxin slows down the heart rate

A nurse is administering a rubella immunization to a client who is 2 days postpartum. Which of the following client statements indicates a need for further instruction? a. I can continue to breastfeed b. I still need to have my provider perform a rubella titer check during my next pregnancy c. I cannot receive the rubella immunization during pregnancy d. I can conceive anytime I want after 10 days

I can conceive anytime I want after 10 days - a client who receives a rubella immunization (for mumps and measles, usually given 12-15 months and second dose at 4-6 yrs) should not conceive for at least 1 month after receiving the immunization to prevent injury to fetus - the client can continue to breastfeed, and should have a rubella titer check with each pregnancy, and should not receive the rubella immunization during a pregnancy because it is a live virus

A nurse is completing dietary teaching with a client who has heart failure and is presribed a 2g sodium diet. Which of the following statements by the client indicates an understanding of the teaching? a. I should use salt sparingly while cooking b. I can have yogurt as a dessert c. I should use baking soda when I bake d. I should use canned vegetables instead of frozen

I can have yogurt as a dessert -yogurt is low in fat and sodium and is a good source of calcium and protein

A nurse is interviewing a client who is seeking help from intimate partner violence. Which of the following client statements should the nurse identify as an indication that the client is in the tension-building phase of the cycle of violence? a. last night my partner beat me worse than ever before b. it'll be easier just to make my partner mad and get the violence over with c. I believe my partner is remorseful and won't hurt me again d. I only get shoved a little bit, and it was my fault for coming home late

I only get shoved a little bit, and it was my fault for coming home late -during tension-building phase violence is often minor and the recipient might rationalize it

A nurse is teaching a client who has a new prescription for sucralfate for a duodenal ulcer. Which of the following client statements indicates an understanding of teaching? a. I should only take this medication with my meals and at bedtime b. I should only have to take this medication for about 2 weeks c. I should wait at least 30 minutes before taking this medication after I take an antacid d. I should swallow these tablets whole

I should wait at least 30 minutes before taking this medication after I take an antacid -antacids can raise the gastric pH above 4 and can interfere with sucralfate, so these interactions should be taking 30 minutes apart from antacids -should also be taken 1 hour before meals and at bedtime

A nurse is providing teaching to a client who has COPD about maintaining proper nutrition. Which of the following statements by the client indicates an understanding of the teching? a. I will increase my fluid intake when I eat a meal b. I will eat more cold foods at meals rather than hot foods c. I will avoid high-fat foods like butter and gravies d. I will cook my meals instead of eating convenience foods

I will eat more cold foods at meals rather than hot foods - cold foods provide a decreased feeling of fullness compared to hot foods (remember we want to increase nutrition)

The nurse provides education to the breastfeeding patient of a 4-month-old infant who plans to return to work soon. Which parental statement indicates to the nurse the need for additional teaching regarding infant nutrition? a. I will thaw my pumped milk in a warm cup of water b. I will heat up my baby's bottle of breastmilk in the microwave c. I will store my pumped milk in the freezer d. I plant to start rice cereal when my baby is 6 months old

I will heat up my baby's bottle of breastmilk in the microwave - To prevent oral burns from uneven warming of the milk, breastmilk must never be thawed or warmed in a microwave oven note: rice cereal and other solid foods can be introduced at 5-6 months of age

A nurse is discussing exercise activities with an acute care client who has schizophrenia and is overweight due to psychotropic medications. The client refuses to participate in an aerobic exercise class and instead requests to walk in the facility's gym. Which of the following responses should the nurse make? a. can you tell me why you do not want to participate in the planned group activity? b. do you understand that psychotropic medications cause weight gain? c. the aerobic class will be more effective at burning calories than walking d. it sounds like you have come up with an alternative exercise that works for you

It sounds like you have come up with an alternative exercise that works for you

A nurse is providing discharge teaching to a client who has been hospitalized for major depressive disorder and has a prescription for amitriptyline. Which of the following statements by the client indicates an understanding of the teaching? a. I will take amitriptyline in the morning because i'll likely have trouble falling asleep if I take it in the evening b. I will move slowly when I stand up because amitriptyline can cause my blood pressure to decrease c. I can drink a glass of beer or wine with my evening meal because amitriptyline doesn't interact with alcohol d. I will avoid foods that are high in fiber because amitriptyline can cause diarrhea

I will move slowly when I stand up because amitriptyline can cause my blood pressure to decrease - Amitriptyline can cause orthostatic hypotension (it also has a sedative effect, often prescribed 3 times daily and usually prescribed at bedtime to help client sleep)

A nurse is teaching a client who is postpartum about keeping the newborn safe. Which of the following statements should the nurse identify as an indication that the client understands the instructions? a. i will put bumper pads in the crib b. i will warm my baby's formula in the microwave on a low setting c. i will place my baby on his stomach to sleep d. i will purchase a firm mattress for the crib

I will purchase a firm mattress for the crib - a firm mattress leaves no gaps between it and the crib rails help prevent suffocation

A nurse is teaching about secondary prevention actions for colorectal cancer for a health fair for adults in the community. Which of the following topics should the nurse include? a. smoking cessation b. benefits of a diet high in cruciferous vegetables c. new types of ostomy appliances d. importance of colonoscopy screening starting at age 50 years old

Importance of colonoscopy screening starting at age 50 years old -Primary (action that prevents the development of a disease) smoking cessation and benefits of diet in cruciferous vegetables -Secondary (actions that promotes early detection of disease) screening -Tertiary (action that minimizes the effects of long-term disease or disability) ostomy appliances

A charge nurse is observing a newly licensed nurse irrigate a client's ear, which is impacted with cerumen. Which of the following actions requires the charge nurse to intervene? a. visualizing the eardrum before irrigating b. instilling 50 mL of fluid with each irrigation c. using frim, continuous pressure while irrigating d. warming the irrigation fluid to at least 37 C (98 F)

Instilling 50 mL of fluid with each irrigation - should use no more than 5 to 10 mL of irrigating fluid at a time to decrease the chance of stimulating the vestibular nerve of the inner ear

The nurse in the emergency room cares for a client who has a traumatic brain injury (TBI). THe healthcare provider has prescribed 100 mL of 3% saline to infuse at 45 mL/hr via a central line. What is the purpose of this infusion for this client? a. it is prescribed to reduce the risk of serum sodium imbalances b. this solution will rapidly decrease the vascualr and cerebral fluid volume c. this solution will maintain a serum sodium level greater than 160 mmol/L (136-145 mmol/L) d. it is a hypertonic solution that is used to decrease intracranial pressure (ICP)

It is a hypertonic solution that is used to decrease intracranial pressure (ICP) - 3% saline draws fluid out of edematous cerebral tissues because of its higher concentration of sodium and a lower concentration of water than blood - serum sodium should be 145 mmol/L or less (135-145)

A nurse is determining the total score for a client's Alcohol Use Disorders Identification Test (AUDIT) by assigning a score of 0 to 4 for each answer. For which of the following self-reported findings should the nurse assign the client a score of 4? a. the frequency of alcohol intake is typically 3 times per week b. the client misses work once a month because of alcohol intake c. alcohol intake does not cause the client to have feelings of guilt d. last month, the provider suggested the client should reduce alcohol intake

Last month, the provider suggested the client should reduce alcohol intake - for AUDIT the nurse should assign a score of 4 if the client indicates that a friend, relative or healthcare provider has recommended decreasing alcohol consumption during 12 months - drinking 2-3 times per week = score of 3 - missing work or failing to fulfill obligations once a month = score of 2 - client denies feelings of guilt because of alcohol intake = score of 0

A nurse in a provider's office is assessing a client who is crying and states "It's my child's first day of school." The nurse should recognize that the child is experiencing which of the following types of loss? a. actual loss b. maturational loss c. perceived loss d. situational loss

Maturational loss - loss is tied to normal, expected life change - situational loss is sudden and unpredictable (losing job) - perceived loss is less obvious to those around an individual (being shunned by a friend)

A nurse is caring for an 18 year old adolescent who is up to date on immunizations and is planning to attend college. The nurse should recommend which immunization prior to moving into the dormitory? a. pneumococcal polysaccharide b. meningococcal polysaccharide c. rotavirus d. herpes zoster

Meningococcal polysaccharide -immunization to prevention meningococcal bacteria (which can cause meningitis and meningococcemia)

A nurse is working in a mental health facility is admitting a client with opioid use disorder who is experiencing withdrawal. The nurse should anticipate a prescription for which of the following medications from the provider? a. methylnaltrexone b. methadone c. naloxone d. hydromorphone

Methadone -opioid medication used for pain management and treatment of withdrawl manifestations in clients with opioid use disorder -Methylnaltrexone = treat opioid-induced constipation -Naloxone = treat opioid overdose

A nurse is caring for a client who has encephalitis due to West Nile virus. Which of the following actions should the nurse take? (select all that apply) a. place the client in respiratory isolation b. monitor vital signs every 2 hours c. assess neurological status every 4 hours d. maintain the client in a modified Trendelenburg position e. keep the client's room darkened

Monitor vital signs every 2 hours Assess neurological status every 4 hours Keep the client's room darkened - West Nile virus is transmitted to a person after being bitten by an infected organism (ex: mosquito). Standard precautions with this patient. Encephalitis is inflammation of active tissues of the brain caused by an infection, causes the brain to swell, which can lead to headache, stiff neck, sensitivity to light, mental confusion and seizures.

A nurse is providing teaching about baclofen to the guardian of a toddler who has cerebral palsy. Which of the following adverse effects should the nurse include? a. bradycardia b. muscle weakness c. diarrhea d. dry skin

Muscle weakness - and dizziness, drowsiness and nausea

A nurse is caring for a clinet who has multiple sclerosis and is receiving interferon beta-1a. The nurse should identify that which of the following client statements indicates a potential adverse effect of the medication? a. my body aches all over b. i have abdominal cramping c. my hair seems to be thinning d. it hurts when i urinate

My body aches all over -adverse effects of interferon beta-1a include flu-like symptoms

A nurse is caring for a client who has a depressed skull fracture of the bone that makes up the larger part of the upper and side wall of the cranium. This fracture is located on which of the following bones? a. sphenoid b. occipital c. parietal d. frontal

Parietal -sphenoid forms part of face -occipital is the back of the skull -frontal is the front of the skull

A nurse is caring for a client who is receiving peritoneal dialysis. The nurse should monitor the client for which of the following adverse effects? a. diarrhea b. increased serum albumin c. hypoglycemia d. peritonitis

Peritonitis (when the thin layer of tissue inside abdomen becomes inflamed) -note peritoneal dialysis can cause decreased serum albumin

A nurse is conducting a risk assessment for clients who are prescribed medications that can cause orthostatic hypotention. Which of the following medications requires a follow-up by the nurse? a. phenelzine b. escitalopram oxalate c. galantamine d. naltrexone

Phenelzine -MAOI for depression and mental health = lightheaded, dizzy and orthostatic hypotension are common side effects - Escitalopram oxalate = SSRI for depression - Galantamine = cholinergic for improved cognition, Alzheimer's - Naltrexone = decrease alcohol craving

A nurse is caring for a client whose wounds are covered with heterograft dressing. In response to the client's questions about the dressing, the nurse explains that it is obtained from which of the following sources? a. Cadaver skin b. Pig skin c. Amniotic membranes d. Beef collagen

Pig skin - heterografts are obtained from an animal, usually pig - homographs = cadaver skin - amniotic membranes are used to treat burns - artificial skin = beef collagen used to treat burns

A nurse is planning care for a client following a total hip arthroplasty. Which of the following interventions should the nurse include in the plan? a. position the client with her legs adducted b. internally rotate the client's affected hip c. place a pillow between the client's legs d. instruct the client to avoid flexing her hip more than 95 degrees

Place a pillow between the client's legs - The nurse should plan to place a pillow or a wedge between the client's legs to reduce the risk of hip dislocation - the nurse should place the client with her legs abducted - the nurse should avoid internal rotation - the nurse should instruct the client to avoid flexing her hip more than 90 degrees (all of this is done to reduce hip dislocation)

A nurse is caring for a client who is at 38 weeks of gestation and is receiving an oxytocin IV for labor augmentation. The nurse notes variable decelerations on the FHR tracing. Which of the following actions should the nurse take first? a. place the client in a side-lying position b. discontinue the oxytocin infusion c. apply oxygen to the client via a face mask d. check for umbilical cord prolapse

Place the client in a side-lying position - the nurse should act quick to restore the oxygen supply to the fetus. Variable decelerations reflect an umbilical cord prolapse; therefore, the nurse should act immediately to help shift the pressure of the presenting part off the cord (moving patient on side is always first action!) - the nurse should discontinue oxytocin since proceeding birth should be stopped at this time (just not first action) - the nurse should administer oxygen to prevent fetal hypoxia however this is not first action - the nurse should perform or assist with vaginal examination of umbilical cord prolapse because this can cause variable decelerations however this is not first action

A nurse is caring for a newborn immediately following delivery. Which of the following actions should the nurse perform first? a. perform a detailed physical assessment b. place the newborn directly on the client's chest c. give the newborn IM vitamin K d. administer erythromycin ophthalmic ointment

Place the newborn directly on the client's chest

A nurse is teaching a client who has type 1 diabetes mellitus about a new subcutaneous insulin infusion pump. Which of the following pieces of information should the nurse include in the teaching? a. plan to use a type of short-duration insulin in the infusion pump b. replace the infusion pump set every 4 days c. turn off the infusion pump for at least 3 hours each day d. move the infusion pump catheter 1.27 cm (0.5 in) away from the old site

Plan to use a type of short-duration insulin in the infusion pump - this subcutaneous insulin infusion pump should be replaced every 1 to 3 days, there should be constant infusion and the catheter infusion site should be moved at lease 2.54 cm (1 in) away from old site to maintain tissue integrity

A nurse is caring for an older adlut client who has chronic obstructive pulmonary disease (COPD) with pneumonia. The nurse should monitor the client for which of the following acid-base imbalances? a. respiratory alkalosis b. respiratory acidosis c. metabolic alkalosis d. metabolic acidosis

Respiratory acidosis -common COPD complication occurs because clients are unable to exhale carbon dioxide due to a loss of elastic recoil in the lungs

A nurse is caring for a client with asthma who has been taking an inhaled glucocorticoid and long-acting beta2-agonist combination dry-powedered inhaler (DPI) for maintenance therapy. The nurse should identify that which of the following is a disadvantage of this medication? a. restricted dosage flexibility b. complicated delivery device c. serious systemic effects d. limited efficacy over time

Restricted dosage flexibility - glucocorticoid and a long acting beta2-agonist being combined is fixed dosage, meaning dose cannot be adjusted - DPI is an easy-to-use device allowing the client to self-administer medication -DPI is delivered locally to lungs - systemic effects usually don't occur - DPI is effective for long-term use for clients with asthma

A client with emphysema is short of breath. The nurse assists the client into which position? a. supine with pillows under the legs b. lying to the left side c. leaning back in a recliner d. sitting upright and leaning forward

Sitting upright and leaning forward -emphysema is a lung disease that causes breathlessness (usually caused by cigarette smoking, no cure)

What is the primary dietary alteration for a client who has heart failure?

Sodium Restriction ex: turkey sandwich with whole-wheat bread

A nurse in an emergency department is assessing a school-aged child who is experiencing an acute asthma exacerbation. Which of the following findings is the priority for the nurse to report to the provider? a. excessively prolonged expiration b. increased diaphoresis c. increased production of frothy sputum d. sudden decrease in wheezing

Sudden decrease in wheezing - indicates child is experiencing decreased air movement and

A nurse is assessing a client who is receiving a transfusion of packed red blood cells (RBCs). Which of the following findings should the nurse identify as an indication of an acute intravascular hemolytic reaction? a. severe hypertension b. low body temperature c. sudden oliguria d. decreased respirations

Sudden oliguria -acute intravascular hemolytic reaction causes acute kidney injury resulting in oliguria and hemoglobinuria (blood in urine)

A nurse is caring for a 4-year-old child who has superficial partial thickness burns over 50% of his body. To meet the nutritional needs of the child, which of the following actions should the nurse plant to take? a. administer pancrelipase to the child prior to each meal b. supplement the child's feedings with enteral feedings c. provide the child with a low-protein meal d. perform dressing changes 10 min prior to the child's meals

Supplement the child's feedings with enteral feedings -pancrelipase is for children with cystic fibrosis - pancreatic enzyme to aid in digestion

A nurse is planning care for a client who has a physical dependence on alprazolam and must discontinue the medication. Which of the following actions should the nurse include in the plan? a. taper the medication gradually over several weeks b. encourage participation in stimulating physical activity c. monitor the client for a return of anxiety for up to 72 hr following discontinuation of the medication d. implement restraints and seclusion as needed

Taper the medication gradually over several weeks -Alprazolam (Xanax) - benzodiazepines = anti anxiety

A nurse is assessing an infant who develops respiratory distress, absence of breath sounds on one side, and deviation of the trachea away from the affected side. Based on these manifestations, which of the following conditions is the infant experiencing? a. tension pneumothorax b. flail chest c. pulmonary contusion d. fractured rib

Tension pneumothorax - the infant may also become cyanotic and show asymmetry of the thorax - Flail chest = pulling of traumatized rib area inward during inspiration and outward during expiration - Pulmonary contusion = decreased breath sounds, tachycardia, tachypnea, and blood-tinged secretions - Fractured rib = pain and ecchymosis (bruise) in area of trauma, swelling and muscle spasms

A nurse is conducting discharge teaching about foot care for a client who has diabetes mellitus. Which of the following instructions should the nurse include? a. wear nylon socks with shoes every day b. trim toenails by rounding the edges of the nail c. apply lotion between the toes after bathing d. test water temperature with the wrist

Test water temperature with the wrist - test water temperature with the wrist to detect if the water is too hot or cold (diabetes causes peripheral nerve damage, making temperature difficult) - client should wear COTTON socks to let feet breathe and prevent moisture - client should trim toenails straight across and not round the edges

A nurse is performing a nonstress test (NST) on a client who is at 41 weeks of gestation. The client asks what the purpse of the test is/ Which of the following responses should the nurse provide? a. this test will determine if you are likely to deliver within the next week b. this test will help determine if your baby is healthy c. this test can see how you baby responds when you have contractions d. this test will determine if you're baby's lungs are mature

This test will help determine if your baby is healthy - This NST is used as a prenatal fetal assessment, it tracks fetal heart rate patterns expected with fetal movement and can help identify fetal distress

A nurse cares for an adult client who is on the organ transplant waiting list. Which factor is most important for selecting a donor-recipient match? a. age of client b. tissue compatibility c. immediate need d. gender

Tissue compatibility - compatible tissue and blood types are the most important factors when matching a donor to a recipient

A nurse is teaching a client with cystic fibrosis about daily chest physiotherapy. Which of the following is the purpose of these treatments? a. to encourage deep breaths b. to mobilize secretions in the airways c. to dilate the bronchioles d. to stimulate the cough reflex

To mobilize secretions in the airways - the purpose is to loosen and promote the drainage of secretions from the lungs

A nurse is accepting a transfer from the postanesthesia care unit (PACU) of a client who has had a subtotal thyroidectomy. Which of the following pieces of equipment should the nurse have available at the bedside for this client? a. cardiac monitor b. defibrillator c. thoracotomy tray d. tracheostomy tray

Tracheostomy tray -laryngeal edema is common after thyroidectomy, which can result in airway obstruction and emergency intubation can be difficult due to the swelling so a nurse should have this tray -thoracotomy = for chest tube insertion

A nurse is caring for a child who has glomerulonephritis. Which of the following actions should the nurse take? a. monitor the child's blood pressure twice per day b. maintain the child on bed rest for 3 days c. weigh the child once each day d. increase the child's daily intake of sodium

Weigh the child once each day (to monitor fluid balance) - Glomerulonephritis = inflammation and damage to the filtering part of the kidneys (can cause hypertension, should have regular diet with moderate sodium restriction)

A nurse is teaching a female client who has pyelonephritis about the disorder. Which of the following pieces of information should the nurse include to help the client prevent a recurrence? a. douche after vaginal intercourse b. wipe from front to back after defecation c. avoid foods that are high in phosphate d. add yogurt to your diet regularly

Wipe from front to back after defecation -pyelonephritis (renal infection) -phosphate can help kidney stones -yogurt helps with genital tract infections

A home health nurse is talking with the partner of a client who has dementia. Which of the following statements by the partner indicates that the client is displaying signs of apraxia? a. yesterday, my partner put on a jacket upside down b. my partner has trouble reading the newspaper c. my partner often repeats words d. last week, my partner did not recognize the sound of the alarm clock

Yesterday, my partner put on a jacket upside down (apraxia - lack of ability to accomplish once known tasks) - agraphia = decrease ability to read or write - perseveration - repetition of word or phrase - agnosia - loss of the ability to recognize objects, this loss can be auditory, visual or tactile