Client needs NCLEX questions

A client has a newly fractured fibula that was plaster casted in the emergency department. Because the client will need to use crutches, which crutch-walking gait should the nurse teach the client before discharge? 1) two point gate 2) three point gate 3)swing through gate 4)four point alternate gait

2) three point gate

The nursing student is assigned to care for a client with a documented diagnosis of presbycusis. Which documentation on the psychosocial assessment should the nursing student expect to note? Select all that apply 1) acting out 2) manipulation 3) improvement 4) attention seeking

3) improvement

The student nurse is instructed by the registered nurse to monitor a dark-skinned client for cyanosis. The registered nurse determines that the student needs further teaching regarding physical assessment techniques for the dark-skinned client if the student states that the beterm-0st area to assess for cyanosis is where? 1) lips 2) tongue 3) nail beds 4) sclera of the eye

4) Sclera of the eye

A friend of the parents of a newborn with a diagnosis of congenital tracheoesophageal fistula contacts the home health nurse with an offer to help. Which is the best nursing action at this time to address the needs and rights of the family? 1) Inform the friend to directly contact the family and offer assistance to them. 2) Request that the friend come to the client's home during the next home health visit. 3) Report the friend's call to the nurse manager for referral to the client's social worker. 4) Assure the friend that there is no need for assistance since the nurse is visiting daily.

ans: 1 1) Inform the friend to directly contact the family and offer assistance to them.

On the cardiac monitor, the nurse notes that a client is demonstrating an irregular rhythm, with no P waves, normal QRS complex, and a rapid ventricular response at 120 beats per minute. Which cardiac rhythm is being displayed on the monitor? 1.Atrial fibrillation 2.Sinus bradycardia 3.Normal sinus rhythm 4.Ventricular fibrillation

ans: 1 1.Atrial fibrillation "A fib" is characterized by erratic or no identifiable P waves. In clients with this type of atrial dysrhythmia, the rhythm is irregular, QRS complex measurements are normal, and there can be a rapid ventricular response due to the erratic atria activity.

A client who is taking an antipsychotic medication is preparing for discharge. To facilitate health promotion for this client, what instruction should the nurse provide? 1.Avoid prolonged exposure to the sun. 2.Adhere to a strict tyramine-restricted diet. 3.Recognize the signs and symptoms of a relapse of depression. 4.Have therapeutic blood levels drawn because the medication has a narrow therapeutic range.

ans: 1 1.Avoid prolonged exposure to the sun. photosensitivity is a side effect of antipsychotic medications. Maintaining a strict tyramine-restricted diet is applicable to monoamine oxidase inhibitors (MAOIs). Antipsychotics are not used to treat depression. Lithium is a mood stabilizer that requires monitoring of medication blood levels.

The nurse is providing a client with a nonplaster (fiberglass) leg cast instructions on cast care at home. Which teaching should the nurse include in the plan of care? 1.Avoid walking on wet or slippery floors. 2.Scratch the skin under the cast only lightly. 3.Blow hot air under the cast if the cast accidentally becomes wet. 4.Keep the cast as clean as possible, because it cannot be wiped off with water.

ans: 1 1.Avoid walking on wet or slippery floors.

The nurse is caring for an intubated client on mechanical ventilation and the low-pressure alarm sounds. Which interventions should the nurse implement to determine the cause of the alarm? Select all that apply. 1) Assess the endotracheal tube for a cuff leak. 2) Look for any disconnections in the ventilator circuit. 3) Check for a kink or water in the ventilator circuit tubing. 4) Determine if the client is anxious or fighting the ventilator. 5) Check to see if the client is biting on the endotracheal tube.

ans: 1, 2 1) Assess the endotracheal tube for a cuff leak. 2) Look for any disconnections in the ventilator circuit. The low-pressure alarm sounds when there is a leak in the client's artificial airway cuff or a disconnection or leak in the ventilator circuit. The remaining options address problems with the client or ventilator that would cause the high-pressure alarm to sound.

The nurse is providing information to the client about the causes of Addisonian crisis. Which causes of this acute state should be included? Select all that apply. 1.Infection 2.Adrenal surgery 3.Circulatory collapse 4.Increased consumption of fat 5.Sudden discontinuation of corticosteroids

ans: 1, 2, 3, 5 1.Infection 2.Adrenal surgery 3.Circulatory collapse 5.Sudden discontinuation of corticosteroids Addisonian crisis is a life-threatening situation caused by insufficient adrenocortical hormones. Causes include infection, adrenal surgery, circulatory collapse, periods of increased stress, sudden discontinuation of corticosteroids, trauma, or psychological distress. Dietary intake is not a major factor.

The clinic nurse provides home care instructions to an adult client diagnosed with influenza. Which instructions should the nurse provide to the client? Select all that apply. 1.Practice frequent hand washing. 2.Remain at home until feeling better. 3.Sneeze or cough into the upper sleeve. 4.Return in 1 week for an influenza vaccine. 5.Take acetaminophen for myalgia. 6.Completely isolate self in a room from other family members and use a separate bathroom until feeling better.

ans: 1, 2, 3, 5 1.Practice frequent hand washing. 2.Remain at home until feeling better. 3.Sneeze or cough into the upper sleeve. 5.Take acetaminophen for myalgia.

The nursing student is assigned to care for a client with a documented diagnosis of presbycusis. Which documentation on the psychosocial assessment should the nursing student expect to note? Select all that apply. 1) The client may isolate herself or himself. 2)The client has a sensorineural hearing loss. 3) The client has difficulty with communication. 4) The client may demonstrate signs and symptoms of depression. 5) The client has positive Rinne and Webber test with lateralization to the left ear.

ans: 1, 3, 4 1) The client may isolate herself or himself. 3) The client has difficulty with communication. 4) The client may demonstrate signs and symptoms of depression.

The nurse is assigned to the care of a client who is dying. In planning care, which interventions would be helpful for this client? Select all that apply. 1.Spend time with the client. 2.Make referrals to other disciplines based on client's stated needs. 3.Offer to contact clergy to support the spiritual needs of the client. 4.Plan to balance the client's need for assistance with the need for independence. 5.Provide extremely thorough answers to each question asked by client or family.

ans: 1,2,3,4 1.Spend time with the client. 2.Make referrals to other disciplines based on client's stated needs. 3.Offer to contact clergy to support the spiritual needs of the client. 4.Plan to balance the client's need for assistance with the need for independence.

The nurse is measuring the head circumference of an infant on the fifth postoperative day after surgical placement of a ventricular peritoneal shunt for the correction of hydrocephalus. The nurse notes that the head circumference measurement has increased by 1 cm over the past 24 hours. The nurse analyzes this assessment data as which finding after this surgical procedure? 1) Normal for this postoperative period 2) A complication related to the functioning of the shunt 3) Subcutaneous tissue swelling as a result of the surgical procedure 4) Insignificant and unrelated to the patency of the ventricular peritoneal shunt

ans: 2 2) A complication related to the functioning of the shunt The head circumference should decrease slightly every day as the superficial tissue fluid is reabsorbed after the surgical trauma. An increase in the head circumference indicates a lack of proper shunting of cerebrospinal fluid caused by either a blockage or a defect in the ventricular peritoneal shunt apparatus. Medical or surgical intervention is required. Options 1, 3, and 4 are incorrect interpretations.

The nurse recognizes which signs as indications that a client who recently experienced a myocardial infarction (MI) may be developing cardiogenic shock? 1) Oliguria, bradypnea, and warm dry skin 2) Tachycardia, confusion, and hypotension 3) Bradycardia, hypertension, and a pale appearance 4) Peripheral edema, distended neck veins, and hepatic engorgement

ans: 2 2) Tachycardia, confusion, and hypotension classical s/s of cardiogenic shock include: tachycardia, confusion, hypotension, tachypnea, oliguria, and cold/clammy/cyanotic skin.

A client received a dose of regular insulin (Humulin R) this morning at 7:00 a.m. At what approximate time would the nurse likely anticipate the potential for a hypoglycemic reaction to occur? 1. 8:00 a.m. 2. 10:00 a.m. 3. 12:00 p.m. 4. 2:00 p.m.

ans: 2 2. 10:00 a.m. Humulin R is a rapid-acting insulin with a peak action of 2 to 4 hours after injection. Hypoglycemic reactions are most likely to occur during the peak action of insulin.

A client diagnosed with a personality disorder will begin recreational therapy as a component of the treatment plan. The nurse provides information to the client regarding the therapy, knowing that this modality is helpful for clients who demonstrate which behavior? 1.Anger 2.Difficulty socializing 3.Violent tendencies toward others 4."Numbness" when experiencing intense feelings

ans: 2 2.Difficulty socializing Recreational therapy helps clients with personality disorders explore ways to enjoy themselves without the use of self-destructive behaviors, such as abusing alcohol or drugs. This modality is helpful to clients who have difficulty socializing because recreation strengthens social skills. Art therapy may be helpful for the client who is angry. The client who is exhibiting violent behavior may require medication therapy. Movement therapy may be helpful for clients who become "numb" when experiencing intense feelings.

A client has cirrhosis complicated by ascites. Which expected but adverse laboratory result should the nurse monitor for? 1.High urine sodium 2.Low serum albumin 3.High serum calcium 4.Low urine specific gravity

ans: 2 2.Low serum albumin The client with ascites as a complication of cirrhosis loses plasma proteins into the ascitic fluid. Over time, this causes the client's serum albumin and total protein levels to decrease. This problem also is aggravated by decreased protein synthesis by the cirrhotic liver

The home care nurse visits a child diagnosed with scarlet fever who is being treated with penicillin G potassium. The mother tells the nurse that the child has only voided a small amount of tea-colored urine since the previous day. The mother also reports that the child's appetite has decreased and that the child's face was swollen this morning. How should the nurse interpret these new signs/symptoms? 1.Nothing to be concerned about 2.Signs/symptoms of acute glomerulonephritis 3.Signs/symptoms of the normal progression of scarlet fever 4.Symptoms of an allergic reaction to penicillin G potassium

ans: 2 2.Signs/symptoms of acute glomerulonephritis nephrotoxicity!!

A client is suspected of having pulmonary tuberculosis (TB). The nurse assesses the client for which manifestations of this communicable disease? Select all that apply. 1) Hematuria 2) Chest pain 3) Hemoptysis 4) Night sweats 5) High fever at night

ans: 2, 3, 4 2) Chest pain 3) Hemoptysis 4) Night sweats The client with pulmonary TB generally has a productive or nonproductive cough, anorexia and weight loss, fatigue, low-grade fever, chills and night sweats, dyspnea, hemoptysis, and chest pain. Breath sounds may reveal crackles.

A client regularly takes nonsteroidal antiinflammatory drugs (NSAIDs) and misoprostol has been added to the medication regimen. The nurse should monitor the client for the relief of which sign/symptom? 1.Diarrhea 2.Bleeding 3.Infection 4.Epigastric pain

ans: 4 4.Epigastric pain The client who regularly takes NSAIDs is prone to gastric mucosal injury, which gives the client epigastric pain as a symptom. Misoprostol is administered to prevent this occurrence.

The nurse is developing an educational session on client advocacy for the nursing staff. The nurse should include which interventions as examples of the nurse acting as a client advocate? Select all that apply. 1) Obtaining an informed consent for a surgical procedure 2) Providing information necessary for a client to make informed decisions 3) Providing assistance in asserting the client's human and legal rights if the need arises 4) Including the client's religious or cultural beliefs when assisting the client in making an informed decision 5) Defending the client's rights by speaking out against policies or actions that might endanger the client's well-being

ans: 2, 3, 4, 5 2) Providing information necessary for a client to make informed decisions 3) Providing assistance in asserting the client's human and legal rights if the need arises 4) Including the client's religious or cultural beliefs when assisting the client in making an informed decision 5) Defending the client's rights by speaking out against policies or actions that might endanger the client's well-being

Which questions should the nurse ask the client when assessing for indicators of possible cataract development? Select all that apply. 1."Do you wear contact lenses?" 2."How old were you on your last birthday?" 3."Have you ever been prescribed corticosteroids?" 4."Do you wear sunglasses regularly when you are outdoors?" 5."Have you ever experienced any injury to either of your eyes?"

ans: 2, 3, 4, 5 2."How old were you on your last birthday?" 3."Have you ever been prescribed corticosteroids?" 4."Do you wear sunglasses regularly when you are outdoors?" 5."Have you ever experienced any injury to either of your eyes?"

Chemical cardioversion is prescribed for the client diagnosed with atrial fibrillation. The nurse who is assisting in preparing the client should expect that which medication specific for chemical cardioversion would be prescribed? 1.Lidocaine 2.Nifedipine 3.Amiodarone 4.Nitroglycerin

ans: 3 3.Amiodarone Amiodarone is an antidysrhythmic that is useful in restoring normal sinus rhythm for the client experiencing atrial fibrillation. Lidocaine is used for control of ventricular dysrhythmias. Both nifedipine and nitroglycerin are vasodilators and are prescribed for the restoration of a normal sinus rhythm.

Which medication should the nurse ensure is available to treat a client experiencing signs/symptoms of acute iron intoxication? 1.Folic acid 2.Dirithromycin 3.Deferoxamine 4.Ferrous sulfate

ans: 3 3.Deferoxamine The antidote to iron dextran is deferoxamine, which is a heavy metal antagonist

Which baseline laboratory test should the nurse expect to monitor for the client prescribed atorvastatin? 1.Basic metabolic panel 2.Renal function studies 3.Hepatic function studies 4.Glycosylated hemoglobin

ans: 3 3.Hepatic function studies Atorvastatin is an antihyperlipidemic, and it acts by decreasing (LDL) and triglyceride levels and increasing (HDL) levels. As part of a baseline assessment, the nurse should assess hepatic function studies and cholesterol and triglyceride levels. The nurse must also determine whether the client is pregnant or whether there is a possibility of pregnancy. This medication is contraindicated in active hepatic disease and pregnancy.

The nurse is caring for a client who has returned from the postanesthesia care unit after prostatectomy. The client has a three-way Foley catheter with an infusion of continuous bladder irrigation (CBI). Which color description of the urinary drainage should lead the nurse to determine that the flow rate is adequate? 1.Dark cherry 2.Clear as water 3.Pale yellow or slightly pink 4.Concentrated yellow with small clots

ans: 3 3.Pale yellow or slightly pink The infusion of bladder irrigant is not at a preset rate; rather, it is increased or decreased to maintain urine that is a clear, pale yellow color or has just a slight pink tinge. The infusion rate should be increased if the drainage is cherry colored or if clots are seen. Alternatively, the rate can be slowed down slightly if the returns are as clear as water.

A client has decreased pulmonary perfusion associated with obstruction of pulmonary arterial blood flow. The nurse determines that the client's condition is improved if which data are obtained on assessment of the client? 1) Dyspnea while ambulating to the bathroom is reduced. 2) Presence of fine bibasilar lung crackles on auscultation is noted. 3) Oxygen saturation is increased from 82% to 88% by pulse oximeter. 4) O2 level is increased to 90 mm Hg from 76 mm Hg, and CO2 level is decreased to 43 mm Hg from 54 mm Hg.

ans: 4 4) O2 level is increased to 90 mm Hg from 76 mm Hg, and CO2 level is decreased to 43 mm Hg from 54 mm Hg. Signs and symptoms that correlate with decreased pulmonary perfusion include dyspnea and hypoxia, making options 1 and 3 incorrect. Crackles indicate fluid in the alveoli, which impairs gas exchange at the alveolar level, making option 2 incorrect.

The nurse is monitoring for the presence of pitting edema in the prenatal client. The nurse presses the fingertips of the middle and index fingers against the shin in 4 different locations and holds pressure for 2 to 3 seconds. The nurse notes that the indentation is approximately 1-inch deep. The nurse should document that the client has which level of pitting edema? 1.+1 2.+2 3.+3 4.+4

ans: 4 4. +4 A slight indentation would indicate +1 edema. an indent of approx. ¼-inch deep indicates +2 edema. an indent approx. ½-inch deep indicates +3 edema. An indent of approx. 1-inch deep would be indicative of +4 edema.

A client diagnosed with gastric cancer is being sent home from the hospital and will be receiving total parenteral nutrition (TPN). As part of the discharge teaching, the client and family members have been taught the aspects of home care for TPN. What comment by the client indicates a need for further teaching? 1."This therapy gives me needed calories." 2."I have to monitor my weight every day." 3."I need to document my fluid intake and output while I'm on this nutrition." 4."My doctor will check my calcium level because it can drop too low while I am on this nutrition."

ans: 4 4."My doctor will check my calcium level because it can drop too low while I am on this nutrition." Calcium imbalances, particularly hypercalcemia, are associated with TPN.

A client seen in the health care clinic is scheduled for several diagnostic procedures. An abdominal aorta sonogram, a barium enema, an upper gastrointestinal (GI) series, and a small bowel series are prescribed. What should the nurse schedule first? 1.Barium enema 2.Upper GI series 3.Small bowel series 4.Abdominal aorta sonogram

ans: 4 4.Abdominal aorta sonogram The abdominal aorta sonogram should be performed before intestinal barium tests or after the barium is cleared from the system. The barium will obstruct the view when the abdominal aorta sonogram is obtained. The tests identified in the other procedures use barium for the visualization of these organs during diagnostic study.

The nurse is preparing a client for elective cardioversion. The nurse determines that a need for further preparation for the procedure is necessary if which condition is present? 1.The client's digoxin was withheld for the last 48 hours. 2.The client received a dose of midazolam intravenously. 3.The defibrillator has the synchronizer turned on and is set at 50 joules. 4.The client is wearing a nasal cannula delivering oxygen at 2 L per minute.

ans: 4 4.The client is wearing a nasal cannula delivering oxygen at 2 L per minute. During the procedure, any oxygen is removed temporarily, because oxygen supports combustion and a fire could result from electrical arcing.

The nurse is performing a physical assessment of the respiratory system of a client with a history of recurrent respiratory infections, but who has no active disease. Which normal assessment finding should the nurse assess for in this client? 1.Egophony 2.Consolidation 3.Whispered pectoriloquy 4.Vesicular breath sounds

ans: 4 4.Vesicular breath sounds Vesicular breath sounds are normal sounds that are heard over peripheral lung fields where the air enters the alveoli. Egophony occurs when the sound of the letter "e" is heard as an "a" with auscultation and also indicates lung consolidation. Whispered pectoriloquy is present if the nurse hears the client when "one-two-three" is whispered. This is an abnormal finding, again heard over an area of consolidation. Consolidation typically occurs with pneumonia but consolidation is a condition, not a breath sound.

A nursing student is assigned to care for a child who has been placed in Crutchfield tongs to stabilize a fracture in the cervical area. The registered nurse reviews the plan of care created by the student and decides there is a need for further teaching if which intervention is included? 1) Monitor neurological status. 2) Perform pin care every shift. 3) Logroll the child when positioning. 4) Check the tongs every 24 hours for displacement and looseness.

ans: 4 4) Check the tongs every 24 hours for displacement and looseness. The purpose of Crutchfield tongs is to stabilize fractures or displaced vertebrae in the cervical and thoracic areas. Tongs are inserted on the sides of the scalp through drill holes. Traction pull is always along the axis of the spine. The nurse should check the tongs at least every 8 hours and as needed (PRN) for displacement and looseness. Neurological status should be checked frequently, because spinal cord injury frequently accompanies a cervical injury. Pin care is done every shift. The child can be repositioned by logrolling or turned as a unit.

characteristics of sinus bradycardia

heart rate below 60 beats per minute. The PR and QRS measurements are normal, measuring 0.12 to 0.2 second and 0.04 to 0.1 second, respectively.

characteristics of ventricular fibrillation

life-threatening cardiac rhythm where there is no blood circulation. There are no P waves and the rhythm is chaotic.

characteristics of normal sinus rhythm

regular rhythm with an overall rate of 60 to 100 beats per minute.