NCLEX Flashcards Unit 3
The nurse is providing instructions to a new parent regarding the psychosocial development of the infant. Using Erikson's psychosocial development theory, which instruction should the nurse reinforce to the parents?
Allow the infant to signal a need.
The nursing instructor asks a nursing student to describe the procedure for relieving an airway obstruction on an unconscious pregnant woman at 8 months' gestation. How should the student describe the procedure correctly?
Place a rolled blanket under the right abdominal flank and hip area.
The parents of a 16-year-old child tell the nurse that they are concerned because the child sleeps until noon every weekend. Which is the most appropriate nursing response?
"adolescents love to sleep late in the morning."
The nurse is monitoring an adult client for postoperative complications. Which is most indicative of a potential postoperative complication that requires further observation?
1. A urinary output of 20 mL/hour 2. A temperature of 37.6° C (99.6° F) 3. A blood pressure of 100/70 mm Hg 4. Serous drainage on the surgical dressing Correct answer: 1. urinary output of 20 ml/hr
The nurse is performing cardiopulmonary resuscitation (CPR) on an adult. The nurse should deliver how many breaths per minute to the client?
10
The nurse is performing cardiopulmonary resuscitation (CPR) on an infant. When performing chest compressions, which is the compression rate for an infant?
100 times per minute
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
The nurse is assigned to assist with caring for a client with esophageal varices who had a Sengstaken-Blakemore tube inserted because other treatment measures were unsuccessful. The nurse should check the client's room to ensure that which priority item is at the bedside?
A pair of scissors
The nurse is preparing to administer an intermittent tube feeding to a client. The nurse aspirates 90 mL of residual from the tube. What should the nurse do with the aspirated residual?
Reinstill the residual and administer the feeding
An older client has been prescribed digoxin (Lanoxin). The nurse understands that which age-related change would place the client at risk for digoxin toxicity?
Decreased lean body mass and glomerular filtration rate
The parent of a 4-year-old child expresses concern because her hospitalized child has started sucking his thumb. The mother states that this behavior began 2 days after hospital admission. Which is the appropriate nursing response?
It is best to ignore the behavior
The nurse witnesses a neighbor's husband sustain a fall from the roof of his house. The nurse rushes to the victim and determines the need to open the airway. The nurse opens the airway in this victim with the use of which method?
Jaw thrust maneuver
The nurse is administering a cleansing enema to a client with a fecal impaction. Before administering the enema, the nurse should assist the client to which position?
Left Sims' position, with the head of the bed flat.
The nurse checks the client's surgical incision for signs of infection. Which is indicative of a potential infection?
The presence of purulent drainage.
The medication prescription states to administer acetaminophen (Tylenol), 650 mg orally for a temperature of more than 38° C. The medication bottle states Tylenol (acetaminophen), 325 mg tablets. The nurse takes the client's temperature and notes that it is 101° F. The nurse plans to take which action?
administer two Tylenol tablets. C= (101-32)=69, divided by 1.8= 38.3 degrees Fahrenheit.
Which is the most appropriate location for assessing the pulse of an infant who is less than 1 year old?
brachial
The nurse is turning a postoperative client who had extensive spinal surgery on the previous day. Which turning intervention or position would be best for repositioning this client?
logrolling
The nurse monitors the postoperative client frequently, knowing that accumulated secretions can lead to which problem?
pneumonia
Which statement by a nursing student about Kohlberg's theory of moral development indicates the need for further teaching about the theory
"Individuals move through all six stages in a sequential fashion."
The nursing instructor asks a nursing student to describe the formal operations stage of Piaget's cognitive developmental theory. The appropriate response by the nursing student is which?
"The child has the ability to think abstractly."
