NCLEX Exam 2

28. The nurse is reviewing the prescriptions for a client admitted to the hospital with a diagnosis of acute pancreatitis. Which interventions would the nurse expect to be prescribed for the client? Select all that apply. a. Maintain NPO status b. Encourage coughing and deep breathing c. Give small, frequent high-calorie feedings d. Maintain the client in a supine and flat position e. Give hydromorphone intravenously as prescribed for pain f. Maintain IV fluids at 10 mL/hr to keep the vein open

abe

18. A client with a diagnosis of Addisonian crisis is being admitted to the ICU. Which findings will the interprofessional health care team focus on? Select all that apply. a. Hypotension b. Leukocytosis c. Hyperkalemia d. Hypercalcemia e. Hypernatremia

ac

26. A client has just had a hemorrhoidectomy. Which nursing interventions are appropriate for this client? Select all that apply. a. Administer stool softeners as prescribed b. Instruct the client to limit fluid intake to avoid urinary retention c. Encourage a high fiber diet to promote bowel movements without straining d. Apply cold packs to the anal-rectal area over the dressing until the packing is removed e. Help the client to a Fowler's position to place pressure on the rectal area and decrease bleeding

ade

17. A client is admitted to an emergency department, and a diagnosis of myxedema coma is made. Which action should the nurse prepare to carry out initially? a. Warm the client b. Maintain a patent airway c. Administer thyroid hormone d. Administer fluid replacement

b

13. The nurse teaches a client with diabetes mellitus about differentiating between hypoglycemia and ketoacidosis. The client demonstrates an understanding of the teaching by stating that a form of glucose should be taken if which symptoms develop? Select all that apply. a. Polyuria b. Shakiness c. Palpitations d. Blurred vision e. Lightheadedness f. Fruity breath odor

bce

12. A client is brought to the emergency department in an unresponsive state, and a diagnosis of hyperosmolar hyperglycemic syndrome is made. The nurse should immediately prepare to initiate which anticipated health care provider's prescription? a. Endotracheal intubation b. 100 units of NPH insulin c. Intravenous infusion of normal saline d. Intravenous infusion of sodium bicarbonate

c

15. A client is admitted to a hospital with a diagnosis of diabetic ketoacidosis. The initial blood glucose level is 950 mg/dL. A continuous IV infusion of short acting insulin is initiated, along with IV rehydration with normal saline. The serum glucose level is now decreased to 240 mg/dL. The nurse should next prepare to administer which medication? a. An ampule of 50% dextrose b. NPH insulin subcutaneously c. IV fluids containing dextrose d. Phenytoin for the prevention of seizures

c

19. The nurse is performing an assessment on a client with pheochromocytoma. Which assessment data would indicate a potential complication associated with this disorder? a. Urinary output of 50 mL/hr b. A coagulation time of 5 minutes c. A heart rate that is 90 beats per minute and irregular d. A blood urea nitrogen level of 20 mg/dL

c

2. The mother of a 6-year-old child who has type 1 diabetes mellitus calls a clinic nurse and tells the nurse that the child has been sick. The mother reports that she checked the child's urine and it was positive for ketones. The nurse should instruct the mother to take which action? a. Hold the next dose of insulin b. Come to the clinic immediately c. Encourage the child to drink liquids d. Administer an additional dose of regular insulin

c

20. The nurse performs a physical assessment on a client with type 2 diabetes mellitus. Findings include a fasting blood glucose level of 70 mg/dL, temperature of 101 F, pulse of 82 beats per minute, respirations of 20 breaths per minute, and blood pressure of 118/68 mm Hg. Which finding would be the priority concern to the nurse? a. Pulse b. Respiration c. Temperature d. Blood pressure

c

21. The nurse is providing discharge teaching for a client newly diagnosed with type 2 diabetes mellitus who has been prescribed metformin. Which client statement indicates the need for further teaching? a. "It is okay if I skip meals once in a while." b. "I need to let my doctor know if I get unusually tired." c. "I need to constantly watch for signs of low blood sugar." d. "I will be sure not to drink alcohol excessively while on this medication."

c

33. A client with a peptic ulcer is diagnosed with a Helicobacter pylori infection. The nurse is teaching the client about the medications prescribed, including clarithromycin, esomeprazole, and amoxicillin. Which statement by the client indicates the best understanding of the medication regimen? a. "My ulcer will heal because these medications will kill the bacteria." b. "These medications are only taken when I have pain from my ulcer." c. "The medications will kill the bacteria and stop the acid production." d. "These medications will coat the ulcer and decrease the acid production in my stomach."

c

5. The nurse should implement which interventions for a child older than 2 years with type 1 diabetes mellitus who has a blood glucose level of 60 mg/dL? Select all that apply. a. Administer regular insulin b. Encourage the child to ambulate c. Give the child a teaspoon of honey d. Provide electrolyte replacement therapy intravenously e. Wait 30 minutes and confirm the blood glucose reading f. Prepare to administer glucagon subcutaneously if unconsciousness occurs

cf

1. A school-age child with type 1 diabetes mellitus has soccer practice and the school nurse provides instructions regarding how to prevent hypoglycemia during practice. What should the school nurse instruct the child to do? a. Eat twice the amount normally eaten at lunchtime b. Take half the amount of prescribed insulin on practice days c. Take the prescribed insulin at noon rather than in the morning d. Eat a small box of raisins or drink a cup of orange juice before practice

d

3. The nurse has just administered ibuprofen to a child with a temperature of 102 F. The nurse should also take which action? a. Withhold oral fluids for 8 hours b. Sponge the child with cold water c. Plan to administer salicylate in 4 hours d. Remove excess clothing and blankets from the child

d

7. The nurse provides feeding instructions to a parent of an infant diagnosed with gastroesophageal reflux disease (GERD). Which instruction should the nurse give to the parent to assist in reducing the episodes of emesis? a. Provide less frequent, larger feedings b. Burp the infant less frequently during feedings c. Thin the feedings by adding water to the formula d. Thicken the feedings by adding rice cereal to the formula

d

25. A client admitted to the hospital with a suspected diagnosis of acute pancreatitis is begin assessed by the nurse. Which assessment findings would be consistent with acute pancreatitis? Select all that apply. a. Diarrhea b. Black, tarry stools c. Hyperactive bowel sounds d. Gray-blue color at the flank e. Abdominal guarding and tenderness f. Left upper quadrant pain with radiation to the back

def

8. A child is hospitalized because of persistent vomiting. The nurse should monitor the child closely for which problem? a. Diarrhea b. Metabolic acidosis c. Metabolic alkalosis d. Hyperactive bowel sounds

c

31. A client with Crohn's disease is scheduled to receive an infusion of infliximab. What intervention by the nurse will determine the effectiveness of treatment? a. Monitoring the leukocyte count for 2 days after the infusion b. Checking the frequency and consistency of bowel movements c. Checking serum liver enzyme levels before and after infusion d. Carrying out a Hematest on gastric fluids after the infusion is completed

b

32. A client who uses nonsteroidal anti-inflammatory drugs (NSAIDs) has been taking misoprostol. The nurse determines that the misoprostol is having the intended therapeutic effect if which finding is noted? a. Resolved diarrhea b. Relief of epigastric pain c. Decreased platelet count d. Decreased white blood cell count

b

30. The nurse is monitoring a client for the early signs and symptoms of dumping syndrome. Which findings indicate this occurrence? a. Sweating and pallor b. Bradycardia and indigestion c. Double vision and chest pain d. Abdominal pain and cramping

a

23. The nurse teaches the client who is newly diagnosed with diabetes insipidus about the prescribed intranasal desmopressin. Which statements by the client indicate understanding? Select all that apply. a. "This medication will turn my urine orange." b. "I should decrease my oral fluids when I start this medication." c. "The amount of urine I make should increase if this medication is working." d. "I need to follow a low-fat diet to avoid pancreatitis when taking this medication." e. "I should report headache and drowsiness to my doctor since these symptoms could be related to my desmopressin."

b

24. A client with diabetes mellitus visits a health care clinic. The client's diabetes mellitus previously had been well controlled with glyburide daily, but recently the fasting glucose level has been 180-200 mg/dL. Which medication, if added to the client's regimen, may have contributed to the hyperglycemia? a. Atenolol b. Prednisone c. Phenelzine d. Allopurinol

b

29. The nurse is providing care for a client with a recent transverse colostomy. Which observation requires immediate notification of the health care provider? a. Stoma is beefy red and shiny b. Purple discoloration of the stoma c. Skin excoriation around the stoma d. Semi-formed stool noted in the ostomy pouch

b

10. The nurse provides home care instructions to the parents of a child with celiac disease. The nurse should teach the parents to include which food item in the child's diet? a. Rice b. Oatmeal c. Rye toast d. Wheat bread

a

22. The nurse is teaching the client about his prescribed prednisone. Which statement, if made by the client indicates that further teaching is necessary? a. "I can take aspirin or my antihistamine if I need it." b. "I need to take the medication every day at the same time." c. "I need to avoid coffee, tea, cola, and chocolate in my diet." d. "If I gain 5 pounds or more in a week, I will call my doctor."

a

11. Which interventions should the nurse include when creating a care plan for a child with hepatitis? Select all that apply. a. Providing a low-fat, well-balanced diet b. Teaching the child effective hand washing techniques c. Scheduling playtime in the playroom with other children d. Notifying the health care provider if jaundice is present e. Instructing the parents to avoid administering medications unless prescribed f. Arranging for indefinite home schooling because the child will not be able to return to school

abe

4. A child has fluid volume deficit. The nurse performs an assessment and determines that the child is improving and the deficit is resolving if which finding is noted? a. The child has no tears b. Urine specific gravity is 1.035 c. Capillary refill is less than 2 seconds d. Urine output is less than 1 mL/kg/hr

c

9. The nurse admits a child to the hospital with a diagnosis of pyloric stenosis. On assessment, which data should the nurse expect to obtain when asking the parents about the child's symptoms? a. Watery diarrhea b. Projectile vomiting c. Increased urine output d. Vomiting large amounts of bile

b

14. The nurse provides instructions to a client newly diagnosed with type 1 diabetes mellitus. The nurse recognizes accurate understanding of measures to prevent diabetic ketoacidosis when the client makes which statement? a. "I will stop taking my insulin if I'm too sick to eat." b. "I will decrease my insulin dose during times of illness." c. "I will adjust my insulin dose according to the level of glucose in my urine." d. "I will notify my primary care provider if my blood glucose level is higher than 250 mg/dL."

d

6. The clinic nurse reviews the record of an infant and notes that the primary health care provider has documented a diagnosis of suspected Hirschsprung's disease. The nurse reviews the assessment findings documented in the record, knowing that which sign most likely led the mother to seek health care for the infant? a. Diarrhea b. Projectile vomiting c. Regurgitation of feedings d. Foul-smelling ribbon-like stools

d

16. The nurse is admitting a client who is diagnosed with syndrome of inappropriate antidiuretic hormone secretion and has a serum sodium of 118 mEq/L. Which health care provider prescriptions should the nurse anticipate receiving? Select all that apply. a. Initiate an infusion of 3% NaCl b. Administer intravenous furosemide c. Restrict fluids to 800 mL over 24 hours d. Elevate the head of the bed to high-Fowler's e. Administer a vasopressin antagonist as prescribed

ace

27. The nurse is assessing a client 24 hours following a cholecystectomy. The nurse notes that the T-tube has drained 750 mL of green-brown drainage since the surgery. Which nursing intervention is most appropriate? a. Clamp the T-tube b. Irrigate the T-tube c. Document the findings d. Notify the health care provider

c