NCLEX Nursing process

The nurse is caring for a critically ill client who informs the nurse that there is a conflict between the client's spiritual beliefs and a proposed health option. What is the nurse's role in this situation?

Assist the client in obtaining information to make an informed decision.

The nurse is administering oxygen by face mask to a client. Which action will the nurse include?

Assist the client to the semi-Fowler's position if possible.

Which nursing diagnosis takes highest priority for a client with hyperthyroidism?

Imbalanced nutrition: Less than body requirements related to thyroid hormone excess

A nurse is poviding care for a client with progressive systemic sclerosis. For a client with this disease, the nurse is most likely to formulate which nursing diagnosis?

Risk for impaired skin integrity

The nurse just started an infusion of blood on a client. A few minutes pass and the client develops a sudden fever. What are the priority interventions by the nurse? Select all that apply.

Start the normal saline infusion. Continue to monitor vital signs. Stop the blood infusion. Notify the healthcare provider.

The nurse is irrigating a client's ear due to impacted cerumen. Which nursing action is correct for this procedure?

The nurse should instill mineral oil 30 minutes before irrigation to soften the cerumen.

The client has come to the hospital emergency room reporting lethargy and vomiting. The healthcare provider makes a tentative diagnosis of Reye's syndrome. The client's history reveals a recent acute viral infection and the use of several medications. The nurse suspects which medication to be implicated in the development of Reye's syndrome?

aspirin; Aspirin is implicated in the development of Reye's syndrome in children with a history of recent acute viral infection.

Which performance improvement strategy helps prevent adverse reactions to blood products?

confirming client identification with two qualified health professionals; The client must be correctly identified to prevent a life-threatening adverse blood reaction. Obtaining vital signs, instructing the client about the signs and symptoms of a blood reaction, and priming the blood administration tubing with normal saline solution are key steps in the blood administration procedure; however, they don't prevent adverse reactions.

The nurse is planning interventions for a school-aged child hospitalized with acute poststreptococcal glomerulonephritis in need of diversional activity. Which activity should the nurse expect to include?

playing a card game with someone the same age; Generally, school-age children enjoy activities with their peers first, then family members, and lastly younger children. School-age children like to be busy but also to accomplish something. This helps to meet their task of industry versus inferiority, feeling good about what they are able to accomplish.

During a home visit the nurse observed a mother giving her infant a bath. The nurse documents "Risk for injury (fall) related to parent's knowledge deficit." Which instruction by the nurse best addresses this nursing diagnosis?

"Support the neonate's head and back with the forearm."

The client was recently diagnosed with a hiatal hernia. The healthcare provider orders an antacid that has reduced adverse effects. What should the nurse include in the client's teaching about the side effects of antacids?

"The major side effect of an antacid is diarrhea."; Major side effects of antacids include diarrhea, constipation, dry mouth, gas, nausea, and stomach pain. These should be explained to the client.

The nurse develops a plan of care for a client with a t-tube. Which nursing intervention should be included?

Inspect skin around the t-tube daily for irritation; Bile is erosive and extremely irritating to the skin. Therefore, it is essential that skin around the t-tube be kept clean and dry.T-tubes are not routinely irrigated; they are irrigated only on prescription of the health care provider.There is no need to maintain the client in a supine position; assist the client into a position of comfort.T-tubes are never clamped without a health care provider's prescription. If prescribed to be clamped, however, t-tubes are typically clamped 1 to 2 hours before and after meals.

A nurse is caring for a client who has been hospitalized with schizophrenia. The client has had this disorder for 8 years and is now displaying regression, increased disorganization and inappropriate social interactions. Which nursing intervention will best help this client meet self-care needs?

Provide client with assistance in hygiene, grooming, and dressing.

The nurse is planning with a client who has cancer to improve the client's independence in activities of daily living after radiation therapy. What should the nurse do?

Provide positive reinforcement for skills achieved.

A 10-year-old child is hospitalized for treatment of acute osteomyelitis. After assessing swelling and tenderness of the left tibia, the nurse initiates antibiotic therapy as prescribed. The child's left leg is immobilized in a splint. What is an appropriate goal at this time for this child?

The child will change position every 2 hours while awake.

Which outcome criterion is appropriate for a child diagnosed with oppositional defiant disorder?

The child will recognize responsibility for behaviors.

When a client is about to lose control, the extra staff who come to help commonly stay at a distance from the client unless asked to move closer by the nurse who is talking to the client. What statement best explains the primary rationale for staying at a distance initially?

The client is likely to perceive others as being closer than they are and feel threatened.

The nurse is caring for a client experiencing extremely intrusive, unwanted thoughts and repetitive behaviors causing time consuming distress at work and home. The client is unable to stop the rituals and is exhausted from attempts to ignore the thoughts. Which outcome(s) is an appropriate for the nursing care plan? Select all that apply.

The client verbalizes the relationship between stress and ritualistic behaviors. The client refrains from performing rituals during stress. The client verbalizes "thought-stopping" procedures when necessary.

A nurse is caring for a client with a nursing diagnosis of fluid volume deficit related to impaired thirst mechanism. Which outcome would the nurse determine as most appropriate for this client?

The client's intake and output are balanced.

An adolescent is brought to the emergency department (ED) after accidentally taking an overdose of heroin. The adolescent is semiconscious, unable to respond appropriately to questions, slurs words, and has constricted pupils; the client's vital signs are blood pressure 60/50 mm Hg, pulse 50 beats/min, and respirations 8 breaths/min. Naloxone is administered to temporarily reverse the effects of the heroin. Which finding would first indicate that the naloxone administration has been effective?

The client's respirations improve to 12/min.

A client is diagnosed with dependent personality disorder. Which behavior is most likely to be evidence of ineffective coping?

inability to make choices and decisions without advice

For a client with rib fractures and a pneumothorax, the health care provider (HCP) prescribes morphine sulfate, 1 to 2 mg/h, given IV as needed for pain. The nursing care goal is to provide adequate pain control so that the client can breathe effectively. Which finding indicates the goal has been met?

pain rating of 0 on a scale of 0 to 10 by the client

A nurse is reviewing arterial blood gas results on an assigned client. The pH is 7.32 with PCO2 of 49 mm Hg and a HCO3−of 28 mEq/L. The nurse reports to the physician which finding?

respiratory acidosis

A nurse is caring for a client with bronchogenic carcinoma. Which nursing intervention takes highest priority?

Maintaining a patent airway is the first concern in a client with a condition that may compromise the airway. Therefore, adequate removal of pulmonary secretions is a priority. Although clients may exhibit fatigue, anxiety, or appetite loss, these need to be addressed, but are not the priority.

A nurse works with a client diagnosed with bulimia. What is the most appropriate long-term client goal for this client?

Manage stresses in life without binging or purging.

The nurse is admitting a 12-year-old child diagnosed with osteomyelitis of the left femur. What will be the nurse's first action for the child's care?

Draw blood for cultures as ordered.

The nurse is teaching an unlicensed assistive personnel (UAP) about the care of clients with self-mutilation. Which statement by the UAP would indicate teaching about self-mutilation has been effective?

"It's a way to express anger and rage."

A nurse is developing a drug therapy regimen that won't interfere with a client's lifestyle. When doing this, the nurse must consider the drug's

adverse effects

A client is recovering from a gastric resection for peptic ulcer disease. Which outcome indicates that the goal of adequate nutritional intake is being achieved 3 weeks following surgery? The client:

increases food intake and tolerance gradually.

A client experienced a pelvic fracture in a motor vehicle collision several months ago. Recovery has been slow. Among the challenges presented by this event is that sexual activity causes a dull ache in the pelvis. What client problem is the priority?

pain

An outpatient client who has been receiving haloperidol for two days develops muscular rigidity, altered consciousness, a temperature of 103° F (39.4° C), and trouble breathing on day 3. The nurse interprets these findings as indicating which complication?

neuroleptic malignant syndrome

A nurse is caring for a client immediately following an appendectomy. The nurse should assign which nursing diagnosis the highest priority?

Acute pain

When caring for a client with nonresectable colon cancer, which nursing diagnosis requires the nurse to function collaboratively to achieve the best outcome related to client comfort?

Acute pain

Which action(s) should the nurse take prior to administering an oral medication to an infant? Select all that apply.

Ensure that it is the correct medication. Verify that it is the correct dose. Verify the infant's name; The nurse should first ensure that the medication is the correct medication, is the correct dose, the correct route, and the correct client. The infant's pulse would only need to be checked if the medication being administered impacted the pulse. After these steps, the nurse should hold the infant securely in the crook of her arm and raise the infant's head to about a 45° angle. Then, the nurse should place the dropper at the corner of the infant's mouth so the drug runs into the pocket between the infant's cheek and gum. Doing this keeps him from spitting out the drug and reduces the risk of aspiration. After administering the medication, the nurse should document that the medication was given.

When administering flumazenil intravenously for reversal of sedation, what should the nurse do? Select all that apply.

Give the medication undiluted in incremental doses. Be alert for shivering and hypotension. Use only a free-flowing IV line in a large vein. Monitor the client's level of consciousness; Flumazenil should be administered in small quantities such as 0.2 mg over 15 to 30 seconds but never as a bolus. Flumazenil may be given undiluted in incremental doses. Adverse effects of flumazenil may include shivering and hypotension. The nurse should monitor the client's level of consciousness while recovering from sedation. Flumazenil should be administered through a free-flowing IV line in a large vein because extravasation causes local irritation.

A 6-year-old client is diagnosed with attention deficit hyperactivity disorder (ADHD). When asking this client to complete a task, what techniques should the nurse use to communicate most effectively with him?

Obtain eye contact before speaking, use simple language, and have him repeat what was said. Praise him if he completes the task.

Which intervention should the nurse include in the plan of care to ensure adequate nutrition for a very active, talkative, and easily distractible client who is unable to sit through meals?

Offer the client nutritious finger foods.

A client with a cerebellar brain tumor is admitted to an acute care facility. The nurse formulates a nursing diagnosis of Risk for injury. Which "related-to" phrase should the nurse add to complete the nursing diagnosis statement?

Related to impaired balance; A client with a cerebellar brain tumor may suffer injury from impaired balance as well as disturbed gait and incoordination.

A postmenopausal client is scheduled for a bone density scan. What should the nurse instruct the client to do?

Remove all metal objects on the day of the scan; Metal will interfere with the test. Metallic objects within the examination field, such as jewelry, earrings, and dental amalgams, may inhibit organ visualization and can produce unclear images.

The nurse is preparing a client for a thoracentesis. How should the nurse position the client for the procedure?

Sitting forward with the arms supported on the bedside table.

The client is suspicious of staff members and other clients. To help establish a therapeutic relationship with the client, which plan would be best?

Spend brief intervals with the client each day.

The nurse is caring for a client with a blood pressure of 210/94 mm Hg. The health care provider prescribes enalapril 20 mg b.i.d. Which nursing action is best when instructing on the new medication regimen?

State the new medication, including name, use, and reason for the new medication.

One month following a subtotal gastrectomy for cancer, the nurse is evaluating the nursing care goal related to nutrition. What indicates that the client has attained the goal? The client has:

The client has achieved adequate nutritional status through oral or parenteral feedings.

Which outcome should the nurse include in the initial plan of care for a client who is exhibiting psychomotor deficits, withdrawal, minimal eye contact, and unresponsiveness to the nurse's questions?

The client will interact with the nurse.

The client is in preterm labor and is ordered magnesium sulfate to help stop labor. The nurse asks the student, "What adverse effects should we be watching for?" What is the most appropriate response made by the student nurse? Select all that apply.

respiratory depression loss of deep tendon reflexes (DTR) slurred speech; Signs of magnesium sulfate toxicity include deep tendon reflexes, paralysis, respiratory depression, drowsiness, lethargy, blurred vision, slurred speech, and confusion.

At birth, a neonate weighs 7 lb, 3 oz (3,267 g). When assessing the neonate 1 day later, the nurse obtains a weight of 7 lb (3,182 g) and an axillary temperature of 98° F (36.7° C) and notes that the sclerae are slightly yellow. The neonate has been breast-feeding once every 2 to 3 hours. Based on these findings, the nurse should add which nursing diagnosis to the care plan?

risk for injury related to hyperbilirubinemia

A nurse is caring for a client with schizotypal personality disorder with impaired verbal communication. Which nursing intervention is the priority?

establishing a one-on-one relationship with the client; By establishing a one-on-one relationship, the nurse helps the client learn how to interact with people in new situations. Helping the client participate in social interactions, establishing alternative forms of communication, and allowing the client to decide when to communicate are appropriate but should take place only after the nurse-client relationship has been established.

A client is admitted with multiple pressure ulcers. When developing the client's diet plan, the nurse should include

ground beef patties

A client is admitted to an inpatient psychiatric unit. After the assessment and admission procedures have been completed, the nurse states, "I'll try to be available to talk with you when needed and will spend time with you each morning from 10:00 until 10:30 in the corner of the dayroom." What is the rationale for communicating these planned nursing interventions?

To attempt to establish a trusting relationship; Availability, reliability, and consistency are critical factors in establishing trust with a client. Being specific about the time and place of meetings helps establish trust, which is initially the main objective. Although important, structuring the environment and instilling hope aren't the primary tasks at this time. Arranging a regular meeting with the client allows the nurse to plan the workload but isn't the major reason for such scheduling.

A client with antisocial personality disorder smokes in prohibited areas and refuses to follow other unit and facility rules. The client persuades others to do the client's laundry and other personal chores, splits the staff, and will work only with certain nurses. The care plan for this client should focus primarily on:

consistently enforcing unit rules and facility policy.

A nurse is assigned to a client who, after a medication teaching session, began receiving amitriptyline hydrochloride to treat depression. One week after starting this drug, the client refuses to take the medication, reporting that it has caused blurred vision, dry mouth, and constipation, but it hasn't improved the client's mood. Which nursing diagnosis is appropriate for this client?

deficient knowledge (treatment regimen) related to inadequate understanding of teaching; The nurse should understand that this client doesn't have the information necessary to make an informed decision about using the medication. The therapeutic effects of amitriptyline aren't seen for 2 to 3 weeks after starting therapy, and the client may develop a tolerance to the adverse effects of the medication if the client continues taking it.

A nurse is conducting a spiritual assessment on a client admitted for surgery and developing a plan of care based on this assessment. To help ensure that the nurse is most successful in meeting the client's spiritual needs and promote a comfortable working relationship with the client, which aspect would be most important initially for the nurse?

developing an awareness of one's own beliefs about the connection between spirituality and health

A nurse is caring for a client newly diagnosed with primary hypertension. Which activity best reflects the implementation phase of the nursing process?

providing education about documenting blood pressure readings

A client is admitted with increased ascites related to cirrhosis. The client has a large round and firm abdomen. The client is not able to lie flat in bed and requests to be placed in a high Fowler's position to sleep. Which nursing diagnosis should receive top priority?

ineffective breathing pattern; In ascites, accumulation of large amounts of fluid causes extreme abdominal distention, which may put pressure on the diaphragm and interfere with respiration. If uncorrected, this problem may lead to atelectasis or pneumonia. Although fluid volume excess is present, the diagnosis ineffective breathing pattern takes precedence because it can lead more quickly to life-threatening consequences.

A child with sickle cell anemia is admitted to the healthcare facility in vaso-occlusive crisis after developing a fever and joint pain. What is the nurse's highest priority when caring for this child?

providing fluids; During a vaso-occlusive crisis, sickle-shaped red blood cells (RBCs) clump together and obstruct blood vessels, causing ischemia and tissue damage. Therefore, the highest priority is providing I.V. and oral fluids, which promotes hemodilution and aids the free flow of RBCs through blood vessels. The client must be kept away from known infection sources but doesn't require protective isolation. Warm compresses may be applied to painful joints to promote comfort; cool compresses would cause vasoconstriction, which exacerbates sickling. Antipyretics may be administered to reduce fever but don't play a crucial role in resolving the crisis.

A client brought to the clinic after being arrested for harassing and stalking his ex-wife denies any other symptoms or problems except anger about being arrested. The ex-wife reports to the police, "He's fine except for this irrational belief that we'll remarry." When collaborating with the health care provider about a plan of care, which intervention would be most effective for the client at this time?

referral to an outpatient therapist

A nurse is preparing for the discharge of a neonate born 7 weeks premature. The neonate has had several apneic episodes and will need a home apnea monitor but will require no other specialized care. Which nursing diagnosis is most appropriate for the neonate's parents?

Deficient knowledge related to lack of exposure to apnea monitor.

For the past 24 hours, a client with dry skin and dry mucous membranes has had a urine output of 600 ml and a fluid intake of 800 ml. The client's urine is dark amber. These assessments indicate which nursing diagnosis?

Deficient fluid volume

What short-term goal for a client hospitalized with a stress related disorder is most realistic?

The client will write a list of strengths and needs; Writing a list of strengths and needs is short-term, achievable, and measurable. Achieving positive self-esteem would occur over the long term. Going to school involves complex future steps to a long-term goal. Using skills is likely to be stressful and is best attempted after the client has done a self-assessment.

A client experienced the loss of home and beloved family dog in flood waters 4 months ago. The client states that since the loss, the client finds it hard to "feel anything." The client says they can't concentrate on simple tasks, thinks about the flood incessantly, and fears losing control. The client reports becoming extremely anxious whenever the flood is mentioned and must leave the room if people talk about it. The admitting nurse suspects the client has post-traumatic stress disorder (PTSD). Which nursing goal would be most appropriate for this client?

The client will demonstrate progress in dealing with the grief of losing their home and dog.

The client with hepatitis A is experiencing fatigue, weakness, and a general feeling of malaise. The client tires rapidly during morning care. What is the most appropriate goal for this client?

Gradually increase activity tolerance.