Nclex

A client is admitting to the health care facility after 3 days of nausea, vomiting and fever. Which nursing diagnosis takes highest priority for this client? A. excessive fluid volume related to intracellular fluid shift B. imbalanced nutrition; less than body requirements related to decreased intake C. Deficient fluid volume related to nausea and vomiting D. Ineffective cardiopulmonary tissue perfusion related to hyperventilation

C. Deficient fluid volume related to nausea and vomiting

A client seeks medical attention after developing acute abdominal pain. which action by the nurse would help ensure accurate auscultation of the clients bowel sounds A. listening with the bell of the stethoscope B. make sure the clients bladder is empty before auscultating C. listen for 1 minute in each quadrant to confirm absence of bowel sounds D. pressing the stethoscope gently and deeply into the abdomen

make sure the clients bladder is empty before auscultating Listen for 5 minutes lightly not deeply

A client taking atopic dermatitis is prescribed medication for photochemotherapy. The client needs to protect eye from the ultraviolet light before drug is administered and protect them for 8 hours. After taking the photochemotherapy drug, the client must protect the eyes for?? A. 4 hours B.8 hours C. 24 hours D. 48 hours

48 hours

The nurse may use one of many nursing theories to guide client care. What are the four keys concepts of most nursing theories? A. Man , health illness, health care B. health, illness, health restoration, and caring c. Man, environment, health and nursing D. Health, environment, disease, and treatment

Man, environment, health and nursing

The nurse is teaching an elderly client about good bowel habits. Which statement would indicate a need for furthering teaching? A. I should eate a fiber rich diet with raw, leafy veggies, unpeeled fruit, and whole grain bread B. i need to use laxatives regularly to prevent constipation C. I need to drink 2 to 3 liters of fluid every day D. i should exercise four times per week

"I need to use laxatives regularly to prevent constipation" Laxatives can have the opposite effect.

A female client is diagnosed with primary herpes genitalis. which instruction should the nurse provide? "Apply one applicator of terconazole intravaginally at bedtime for 7 days" B. "Apply one applicator of tioconazole intravaginally at bedtime for 7 days" C. "Apply acyclovir ointment to the lesions every 3 hours 6 times per day for 7 days" D. "Apply sulconazole nitrate twice daily by massaging it gently into the lesions"

C. "Apply acyclovir ointment to the lesions every 3 hours 6 times per day for 7 days" Terconazole and tioconazole are used to treat vulvovaginal candidiasis Sulconazole is used to treat tinea versicolor

During clindamycin (Cleocin) therapy, the nurse monitors a client for pseudomembranous colitis. This serious adverse reaction to clindamycin results from superinfection with which organism? 1. Staphylococcus aureus 2. Bacteroides fragilis 3. Escherichia coli 4. Clostridium difficile

Clostridium difficile

An xray of the left femur shows a facture that extends through the midshaft of the bone and multiple splinter fragments. What is this type of fracture called? A. Compression fracture B. Green stick C. Comminuted fracture D. Impacted fracture

Comminuted fracture

Which findings are common in neonate born with esophageal atresia? A. decreased production of salvia B. Cyanosis C. coughing D. Inadequate swallow E. choking F. inability to cough

Cyanosis coughing choking

A client with shock brought on by hemorrage has a temperature of 97.6, a heart rate of 140 beats/minute, a respiratory rate of 28 breaths/ minute, and a blood pressure of 60/30. for this client the nurse should question which physician order? A. Monitor urine output every hour B. Infuse I.V. fluids at 83 ml/hour C. Administer oxygen by nasal cannula at 3 L/minute D. Draw samples for HGB and HCT every 6 hours

Infuse I.V. fluids at 83 ml/hour Because shock signals a severe fluid volume loss, its treatment includes rapid I.V. fluid replacement to sustain homeostasis and prevent death.

During chemotherapy, a boy, age 10, loses his appetite. When teaching the parents about his food intake, the nurse should include which instruction? 1. "Offer dry toast and crackers." 2. "Withhold all food and fluids." 3. "Ignore your child's lack of food intake." 4. "Let your child eat any food he wants."

Let you child eat any food he wants

A client is in the manic phase of bipolar disorder. To help the client effectively maintain adequate nutrition, the nurse should plan to: A. provide large attractive meals B. offer finger foods and sandwiches C. provide a stimulating mealtime environment D. let the client choose favorite foods

Offer finger food and sandwiches A client in manic phase can not sit still for large meals They need a quiet place They have a short attention span

A nurse is providing dietary teaching for the parents of a child with celiac disease. the child should avoid: A. Vegetables B. fruits C. Prepared puddings D. Rice

Prepared puddings Celiac patient should consume food containing gluten

When teaching a client with cushing syndrome about dietary changes. The nurse should instruct the client to increase intake of: A. fresh fruits B. Dairy products C. processed meats D. cereals and grains

fresh fruits Cushing's syndrome causes sodium retention, which increases urinary potassium loss. encourage potassium rich foods.