NCLEX- pass point comprehensive

The nurse is caring for a client in labor and notes late decelerations on the external fetal monitoring strip. Which actions will the nurse include in the client's plan of care? Select all that apply.

Contact the healthcare provider. Administer oxygen to the client. Change the client's position.

When auscultating the heart sounds of a client who's 34 weeks pregnant, the nurse detects a systolic ejection murmur. Which action should the nurse take?

Document the finding, which is normal during pregnancy.

When explaining to parents how to reduce the risk of sudden infant death syndrome (SIDS) the nurse should teach about which measures? Select all that apply.

Maintain a smoke-free environment. Breastfeed the baby. Place the baby on his back to sleep.

Before assisting a client to ambulate after surgery, the nurse helps the client to dangle the feet over the side of the bed. Which action will best prepare the client to dangle the feet over the side of the bed?

Place the client in a high Fowler's position.

The nurse is caring for a frail, older adult client who is experiencing pain. At the client care meeting, the family asks if it is safe for the client to receive narcotics. The nurse is aware that the client is receiving hydromorphone hydrochloride for pain. What is the nurse's most appropriate response to this family?

The narcotic is safe because it does not accumulate in the body.

A primigravid client at 35 weeks gestation is scheduled for a biophysical profile. After instructing the client about the test, which client statement indicates effective teaching about what the test measures?

amniotic fluid volume

A client is being treated for dilated cardiomyopathy. Which medication would this client most likely receive?

beta-adrenergic blockers

Three days after admission of a neonate born at 30 weeks' gestation, the neonatologist plans to assess the neonate for intraventricular hemorrhage (IVH). The nurse should plan to assist the neonatologist by preparing the neonate for which test?

cranial ultrasonography

A child with heart failure is taking captopril. What are the desired effects of this medication? Select all that apply.

decreased preload decreased blood pressure increased urine output

A nurse is teaching a client with a left fractured tibia how to walk with crutches. Which instruction is appropriate?

"All weight should be on the hands."

An adolescent girl with severe malnutrition is admitted to an acute care facility. After a thorough examination, the physician diagnoses anorexia nervosa. When developing the care plan for this client, the nurse is most likely to include which nursing diagnosis?

Chronic low self-esteem

The nurse is caring for a client with nephropathy. The health care provider orders a 24-hour urine collection. Which actions are necessary to ensure proper collection of the specimen? Select all that apply.

Collect the urine in a preservative-free container and keep on ice. Encourage daily amounts of fluids. Discard the initial voiding but save all others for 24 hours.

The nurse is caring for a client in labor. The client wishes to have a "nonmedicated" labor and birth. During the early stages of labor, the client becomes frustrated with the use of music and imagery. Which of the following would the nurse include in the client's plan of care? Select all that apply.

Encourage ambulation. Suggest a shower or bath. Offer the use of a yoga ball.

A client has been diagnosed with hypothyroidism. Which statement by the client would demonstrate appropriate teaching by the nurse?

I will increase fiber and fluids in my diet.

A nurse is caring for a child with leukemia. Which goal is a priority?

Remain fever free.

The client asks the nurse what the main benefits are for prescribing pentazocine, an agonist-antagonist opioid, over morphine, a strong opioid agonist, for mild to moderate pain. What is the nurse's best response?

Respiratory depression is limited and abuse liability is low with the use of pentazocine, whereas both are major concerns for clients taking morphine.

Twenty minutes after a transfusion of packed red blood cells is initiated, a client reports shivering, headache, and lower back pain. The vital signs show a normal temperature and increased pulse and respiratory rate. What should be the first nursing actions?

Stop the transfusion, continue with saline infusion, and notify the physician regarding a suspected hemolytic reaction.

An older adult client seeks help for chronic constipation. Which recommendation would be most beneficial for the nurse to suggest?

Try eating an apple each day with peanut butter.

The nurse should establish baseline data on a client who is starting on long-term gentamicin sulfate therapy. Which of the following is least important for assessment screening in this client?

Visual acuity.

After the acute stage following an ingestion of drain cleaner by a child, the nurse should be alert for the development of which likely complication?

esophageal strictures

Before a cancer client receiving total parenteral nutrition resumes a normal diet, the nurse teaches them about dietary sources of minerals. Which foods are good sources of zinc?

whole grains and meats

In an initial screening for lead poisoning, a toddler is found to have a minimally elevated lead level. What is the most important action the nurse should take?

Educate parents on ways to reduce lead in the environment.

The client was diagnosed with hypertension 7 years ago. In the last 6 months, after diet and exercise, the client's blood pressure has consistently ranged around 160/95. What should the nurse include in the client's teaching about the side effects of clonidine? Select all that apply.

"Clonidine may cause low blood pressure when you stand up." "Clonidine may cause dry mouth." "Clonidine may cause fatigue."

When a client has an acute attack of diverticulitis, what should the nurse do first?

"I can pass stool without cramping."

An elderly client becomes confused and combative. The client's nurse receives an order for soft wrist restraints. When the client's family insists that the client not be restrained, the nurse informs the family that the family must provide an around-the-clock attendant for the client to avoid use of restraints. The family spokesman replies, "You find the attendant; that is your responsibility." Which would be the best response by the nurse?

"I recommend family members arrange to stay with the client."

Parents ask why they should not give their 10-month-old child ibuprofen after receiving vaccinations. What is the best response by the nurse?

"Ibuprofen and other NSAIDs blunt the effect of the vaccination by decreasing the production of antibodies necessary to mount the immune response desired by the vaccination."

A nurse is conducting a teaching session with a group of parents on infant care and safety to assist parents in appropriately preparing to take their neonates home. Which statement about automobile restraints made by one of the parents would indicate to the nurse that learning has taken place?

"Infants should ride in a rear-facing car seat until they have reached the maximum weight allowed by the car seat manufacturer or are 2 years old."

A nurse has been caring for an adolescent client in a residential facility. The child has been through a series of foster placements since infancy with no success in any placement until the age of 7 when placed with a middle-aged single woman. The client thrived there until the woman was killed in a car accident. The client attempted suicide after her foster mother died in response to the loss and the child was placed in the residential facility. The nurse has become close to this client and wants to help her address her issues and move on with her life. Which comment to the manager demonstrates that the nurse understands the client's issues and is able to respond appropriately to the client's needs?

"It's difficult for her to love and trust again after her losses. In this facility, she can learn to deal with her loss in a less emotionally charged environment than a foster home."

A nurse is caring for a 16-year-old girl who isn't sexually active. The girl asks if she needs a Papanicolaou (Pap) test. How should the nurse respond?

"No, it isn't necessary because you aren't sexually active."

A child admitted to the hospital with a serum sodium level of 160 mEq/L (160mmol/L) is receiving 5% dextrose with 0.45 normal saline solution. The mother asks the child's nurse why the child is receiving sodium. What is the nurse's best reply?

"Your child's sodium is high; but if the serum sodium level is decreased too rapidly, it may cause seizures."

The nurse is caring for a very ill child with a large extended family. Members of the family repeatedly ask the same questions of the nurse and other healthcare team members. To effectively manage the accurate dissemination of information, which of the following should be the priority action by the nurse?

Ask the family to identify a spokesperson to be the communicator with the team.

The client with peripheral vascular disease and a history of hypertension is to be discharged on a low-fat, low-cholesterol, low-sodium diet. Which should be the nurse's first step in planning the dietary instructions?

Assess the family's food preferences.

A 67-year-old client will be discharged to home with imipramine. Which information would be most important for the nurse to include when instructing the client and spouse about the medication?

Avoid alcohol.

A client has been prescribed valproic acid for the treatment of bipolar disorder. The client tells the nurse, "I know that vitamin B can help with depressive episodes, so I am going to give that a try." What is the nurse's best response?

Be sure to dialogue with your care provider before you start taking vitamin B supplements.

The nurse is using home telehealth monitoring to manage care for an 80-year-old who is home bound. The client spends most of the day in bed. Two months ago, the nurse detected sacral redness from friction and shearing force of being in bed. Last month, the client had increased sacral redness, and the area was classified as a stage I pressure ulcer. On this visit, the nurse is assessing the sacral area using a video camera. The nurse compares the site from a visit made 1 month ago (see figure part A) to the assessment made at this visit (see figure part B). Upon comparing the change of the pressure ulcer from this visit to the previous visit, what should the nurse do next?

Contact the health care practitioner (HCP) to request a hydrocolloid dressing.

The nurse is caring for a client receiving digoxin who has begun vomiting and reports seeing colorful halos around the lights in the room. Which actions should the nurse implement? Select all that apply.

Determine serum digoxin and electrolyte levels. Begin continuous electrocardiographic monitoring. Discontinue administration of digoxin.

The nurse has asked the unlicensed assistive personnel (UAP) to ambulate a client with Parkinson's disease. The nurse observes the UAP pulling on the client's arms to get the client to walk forward. What should the nurse do?

Explain how to overcome a freezing gait by telling the client to march in place

A client who has been diagnosed with type 1 diabetes has an insulin drip to aid in lowering the serum blood glucose level of 600 mg/dL (33.3 mmol/L). The client is also receiving ciprofloxacin IV. The health care provider (HCP) prescribes discontinuation of the insulin drip. What should the nurse do next?

Inform the HCP that the client has not received any subcutaneous insulin yet.

Which action should the nurse include in the plan of care for a child with leukemia who has an absolute neutrophil count of 400/mm3 (0.4 X 109/L)?

Restrict staff and visitors with active infections.

The nurse is providing follow-up care to a client 10 days after the birth. The nurse would anticipate what outcomes from the new mother? Select all that apply.

The client feels tired but can care for herself and her new infant. The family has adequate support from one another and others. Lochia is changing from red to pink and is smaller in amount. The client has positive comments about her new infant.

A nurse is administering atropine sulfate to a client about to undergo electroconvulsive therapy (ECT). Which assessment indicates that the medication is effective?

The client reports having a dry mout

The nurse is beginning the shift and is planning care for six clients on the postpartum unit. Three of the clients have immediate needs, and three of the clients are listed as "stable." For the best utilization of time and client safety, the nurse should make rounds on which client first?

a mother who had a spontaneous vaginal birth and received carboprost 1 hour ago for increased bleeding

The nurse is evaluating an infant for auditory ability. What is the expected response in an infant with normal hearing?

blinking and stopping body movements when sound is introduced

A nurse must monitor a client receiving chloramphenicol for adverse drug reactions. What is a toxic reaction to chloramphenicol?

bone marrow suppression

When developing a teaching plan for the parents of a child with Down syndrome, the nurse focuses on activities to increase which factor for the parents?

confidence in their ability to care for their child

A client who speaks little English has emergency gallbladder surgery. During discharge preparation, which nursing action would best help this client understand wound care instructions?

demonstrating the procedure and having the client return the demonstration

A client comes to the emergency department complaining of chest pain. An electrocardiogram (ECG) reveals myocardial ischemia and an anterior-wall myocardial infarction (MI). Which ECG characteristic does the nurse expect to see?

elevated ST segment

Immediately after a birth, a nurse assesses the neonate's head for signs of molding. Which factors determine the type of molding?

fetal body flexion or extension

A nurse on the labor-and-birth unit transfers a primiparous client and her term neonate to the mother-baby unit 2 hours after the client gave vaginal birth to the neonate. Which information is a priority for the nurse to report to the nurse receiving the client on the mother-baby unit?

firm fundus when gentle massage is used

A client is admitted with peritonitis. The priority of nursing care for this client is:

fluid and electrolyte balance.

A client with bipolar disorder has been receiving lithium for two weeks. The client also takes chemotherapeutic drugs that cause them to feel nauseated and anorexic. It is most important for the nurse to assess this client for

hypotonic reflexes with muscle weakness.

A client requests medication at 9 p.m. (2100) instead of 10 p.m. (2200) so that the client can go to sleep earlier. Which type of nursing intervention is required?

independent Nursing interventions are classified as independent, interdependent, or dependent. Altering the drug schedule to coincide with the client's daily routine represents an independent intervention, whereas consulting with the physician and pharmacist to change a client's medication because of adverse reactions represents an interdependent intervention. Administering an already ordered drug on time is a dependent intervention. There's no such thing as an intradependent nursing intervention.

A nurse caring for a client who has just received chemotherapy infusion is wearing a disposable gown, gloves, and goggles for protection. The nurse knows that accidental exposure to chemotherapy agents can occur through

inhalation of aerosols.

A client recovering from a closed head injury is restless and agitated. The client still has a central venous catheter in place for antibiotic therapy. The nurse doesn't want to sedate the client, but needs to protect the catheter and other less-restrictive measures have failed. Which method of restraint is best for this client?

mitt restraints applied to both hands

The nurse is caring for a client receiving digoxin. Which symptoms would the nurse anticipate with a digoxin level of 2.3 ng/dl (0.08 nmol/l)? Select all that apply.

nausea drowsiness photophobia seeing halos around bright objects

A pregnant client is diagnosed with group B streptococcus chorioamnionitis. The nurse should expect to administer which medication to prevent fetal transmission?

penicillin G potassium I.V. to the client

The primary goal in the plan of care for the client after cataract removal surgery is to:

promote safety at home.

The nurse assigns an unlicensed assistive personnel (UAP) to provide care for a client with peptic ulcer disease. Concerned about possible ulcer perforation, the nurse should instruct the UAP to report to the nurse immediately if the client has:

severe abdominal pain.

Which type of medication order might read "Vitamin K 10 mg I.M. daily × 3 days?"

standing order

The nurse is caring for a 19-year-old client recently diagnosed with multiple sclerosis (MS). What interventions would be important for the nurse to include when teaching this client ways to prevent the exacerbation of symptoms? Select all that apply.

suggesting a support group or meditation to decrease stress planning activities to avoid fatigue promoting daily exercise

A client with schizophrenia is withdrawn and suspicious of others, and projects blame. The client's behavior reflects problems in which stage of development as identified by Erikson?

trust versus mistrust

A client is diagnosed with shigellosis. The nurse teaches the client and family how the disease is transmitted and treated and discusses the need for enteric precautions. The nurse should explain that enteric precautions must be maintained:

until three fecal cultures are negative for Shigella.