nclex pass point set 4

A nurse is preparing to perform a physical examination on a postpartum client. The client asks the nurse why gloves are necessary for the examination. What is the nurse's best response? "Gloves help protect you against infectious organisms." "Gloves guard you against my cold hands." "Gloves may protect me against infectious organisms." "Gloves are required for standard precautions."

"Gloves are required for standard precautions." Explanation: Wearing gloves whenever exposure to blood or body fluids is anticipated is a standard precaution recommended by the Centers for Disease Control and Prevention. Although gloves protect both the client and the nurse from infectious organisms and guard against the nurse's cold hands, the nurse wears them primarily to maintain standard precautions, which is required by the Occupational Safety and Health Administration.

A physician orders an infusion of 2,400 ml of I.V. fluid over 24 hours, with half this amount to be infused over the first 10 hours. During the first 10 hours, a client should receive how many milliliters of I.V. fluid per hour? 50 ml/hour 100 ml/hour 120 ml/hour 240 ml/hour

120 ml/hour Explanation: First, the nurse determines how many milliliters (half of the total) to administer over the first 10 hours: 2,400 ml ÷ 2 = 1,200 ml. Then the nurse determines how many of these milliliters to deliver per hour: 1,200 ml ÷ 10 hours = 120 ml/hour.

The nurse receives a physician's order to administer 1,000 mL of intravenous (I.V.) normal saline solution over 8 hours to a client who recently had a stroke. What should the drip rate be if the drop factor of the tubing is 15 gtt/mL? Record your answer using a whole number.

31 Explanation: The drip rate is calculated using the following formula: Volume of infusion (in milliliters)/Time of infusion (in minutes) × drip factor (in drops/milliliter) = drops/minute. Therefore, 1,000 mL/480 minutes × 15 drops/mL = 31 gtt/minute.

Which information is a priority for the nurse to teach the school-age client and parents newly diagnosed with type 1 diabetes? Assess feet daily. Administer oral antidiabetic medication. Assess for hypoglycemia and hyperglycemia. Avoid sports and rigorous activities.

Assess for hypoglycemia and hyperglycemia. Explanation: The school-age child should be supervised when administering insulin to prevent an error in dosage. Complications related to infection such as avoiding walking barefoot and caring for cuts and scratches are important education points to cover. The child should be monitored for dental caries and oral infections, as infectious processes may elevate glucose levels and increase the need for more insulin adjustments. The child should be allowed to play sports and live as any other child in that age group.

A 6-month-old child is taken to the pediatrician, and the parent states that the child is not growing like other children of similar age in other families. The birth weight of the child was 7 pounds 11 ounces, (3,495 g) and the current weight is 11 pounds 2 ounces (5,057 g). Based on these findings, what does the nurse tell the parent? "Your infant's weight is within the normal range based on the infant's age. No further action is required." "Your infant's weight is below the normal range based on the infant's age. Let's start with a few questions regarding your infant's eating habits." "You should not compare your infant's weight based on other infants of the same age because each child's weight gain differs. No further action is required." "Your infant's weight is above the normal range based on the infant's age. Let's start with a few questions regarding your infant's eating habits".

Correct response: "Your infant's weight is below the normal range based on the infant's age. Let's start with a few questions regarding your infant's eating habits." Explanation: Birth weight usually doubles by age 6 months and triples by age 1 year. Therefore, this infant should weigh 14 lb (6.4 kg). Watchful waiting or no action is detrimental to the infant's growth and development. Comparison to other children is not helpful. Asking about the child's eating habits will help the nurse get a better understanding of potential causes of the low birth weight. The parents should be advised that the birth weight is below normal.

A female client with which condition would be at risk for increased severity of vulvovaginal candidiasis? Select all that apply. uncontrolled diabetes immunosuppression due to cancer human immunodeficiency virus (HIV) infection hypertension asthma

Correct response: uncontrolled diabetes immunosuppression due to cancer human immunodeficiency virus (HIV) infection Explanation: Women with underlying medical conditions, such as uncontrolled diabetes and HIV infection or cancer-causing immunosuppression, correlate with an increasing severity of candidiasis. Hypertension and asthma are not related to immunosuppression or complicated candidiasis.

The nurse is preparing to initiate an enteral feeding through a percutaneous endoscopic gastrostomy (PEG) tube. What intervention will the nurse include in the client's plan of care? Ensure patency of the tube. Check residual immediately after each enteral feeding. Lay the client in prone position. Use an intravenous pump for administration of feeding formula.

Ensure patency of the tube. Explanation: Verification of patency prior to each feeding is essential to prevent aspiration; never use any equipment that is not specifically developed for enteral feeding. Residual volumes should be examined prior to starting the feeding, not after. Placing a client prone (on the stomach) is an inappropriate intervention.

A client who has been using benzodiazepines for anxiety wants to add an alternative therapy. The nurse suggests biofeedback. How will the nurse best describe biofeedback to the client? It is a way to concentrate on the body's response during a stressful situation. It is used to assist with controlling feelings and emotions toward others. It is most helpful when used in conjunction with antianxiety medications. It can balance the positive and negative energies emitted from the anxiety.

It is a way to concentrate on the body's response during a stressful situation. Explanation: Biofeedback uses the senses such as heart rate and respiratory rate to sensitize the client to ways to find calm. The client uses the responses of the body to relax. This therapy can assist the client in finding alternative ways to deal with stressors. Rather than controlling emotions, biofeedback allows the person to recognize and respond to physical signs of emotional stress before the emotions are fully formed. When biofeedback is not effective or is still being learned, antianxiety medications are useful; however, biofeedback works well alone. This therapy does not balance energies.

Bone resorption is a possible complication of Cushing's disease. To help the client prevent this complication, what should the nurse recommend to the client? Increase the amount of potassium in the diet. Maintain a regular program of weight-bearing exercise. Limit dietary vitamin D intake. Perform isometric exercises.

Maintain a regular program of weight-bearing exercise. Explanation: Osteoporosis is a serious outcome of prolonged cortisol excess because calcium is resorbed out of the bone. Regular daily weight-bearing exercise (e.g., brisk walking) is an effective way to drive calcium back into the bones. The client should also be instructed to have a dietary or supplemental intake of calcium of 1,500 mg daily. Potassium levels are not relevant to prevention of bone resorption. Vitamin D is needed to aid in the absorption of calcium. Isometric exercises condition muscle tone but do not build bones.

A mother of a 5-year-old child who was admitted to the hospital has a Protection from Abuse order for the child against his father. A copy of the order is kept on the pediatric medical surgical unit where the child is being treated. The order prohibits the father from having any contact with the child. One night, the father approaches the nurse at the nurses' station, politely but insistently demanding to see his child, and refusing to leave until he does so. What should the nurse do first? Firmly tell the father he must leave. Notify the nursing coordinator on duty. Notify the nurse-manager. Notify hospital security or the local authorities.

Notify hospital security or the local authorities. Explanation: The Protection from Abuse order legally prohibits the father from seeing the child. In this situation, the nurse should notify hospital security or the local authorities of this attempt to breach the order, and allow them to escort the father out of the building. The father could be jailed or fined if he violates the order. The nurse shouldn't argue or continue explaining to the father that he must leave because it could place the nurse and the child at risk if the father becomes angry or agitated. The nursing coordinator and nurse-manager should be notified of the incident; the nurse's first priority, however, should be contacting security or the authorities.

An older infant who has been injured in an automobile accident is to wear a splint on the injured leg. The mother reports that the infant has become mobile even while wearing the splint. What should the nurse advise the mother to do? Notify the health care provider (HCP) immediately to adjust the treatment plan. Confine the infant to one room in the apartment. Keep the infant in the splint at night, removing it during the day. Remove any unsafe items from the area in which the infant is mobile.

Remove any unsafe items from the area in which the infant is mobile. Explanation: Safety is the priority in caring for this infant. Infants adapt easily, increasing mobility even with a splint in place. Therefore, the mother needs to ensure that the area in which the infant is mobile is safe. There is no need to contact the HCP to alter the treatment plan. Confining the infant to one room may not allow the child to achieve normal development. The child needs different environments for maximum development. The infant needs to wear the splint as prescribed by the HCP to ensure optimal healing.

A nurse is conducting a physical assessment on an adolescent who does not want her parents informed that she had an abortion in the past. Which statement best describes the information security measures the nurse would implement in this situation? Respect the adolescent's wishes and maintain her confidentiality. Because the adolescent is a minor, inform her parents about her medical history. Discussing the adolescent's medical history with her parents and thoroughly document it in the medical record. Before agreeing to maintain confidentiality, determine whether the adolescent is an emancipated minor.

Respect the adolescent's wishes and maintain her confidentiality. Explanation: The nurse should respect the rights of minors who do not want parents informed of medical situations; the nurse should not tell parents about an adolescent's past procedures. Many states have laws that emancipate minors for healthcare visits involving pregnancy, abortion, or sexually transmitted diseases.

A client was admitted with a diagnosis of schizophrenia and exhibiting behaviors of hostility, paranoia, and isolation. The student nurse discussed with the nurse what the most therapeutic approach to take with the client would be. Which would indicate to the nurse that the student understands the best approach? Inform the client that they need to receive care and that you will assist them. Greet the client by gently touching their arm and telling the client that they can trust you. Respect the client's need for personal space and avoid physical contact with the client. Tell the client that if they do not comply with the rules, you will inform the physician.

Respect the client's need for personal space and avoid physical contact with the client. Explanation: A newly-admitted client with a diagnosis of schizophrenia accompanied by paranoia needs to have a sense of trust before the nurse attempts to touch the client. Using statements of veiled threats will only increase the client's anxiety and lead to increased potential for hostility and anger.

A nurse is caring for a client with the visual field deficit depicted above. What is the most important information for the nurse to teach this client? Scan the environment on the affected side. Use memory aids such as pictures. Plan for adequate rest. Make simple, non-risky decisions.

Scan the environment on the affected side. Explanation: Scanning the environment can help a client with homonymous hemianopia overcome a loss in visual perception and prevent injury. Clients with other types of perceptual or memory loss may benefit from the interventions, nonspecific for a visual field loss, in the remaining answer choices.

Which nursing approach is most helpful to a client with Parkinson disease who is experiencing a freezing of gait with difficulty initiating movement? Pull the client forward to initiate walking. Instruct the client to use a wheelchair. Have the client remain still. Tell the client to march in place.

Tell the client to march in place. Explanation: When a freezing gait occurs, having the client march in place or step over actual lines, imaginary lines, or objects on the floor can promote walking. Instructing the client to take one step backward and two steps forward may also stimulate walking. Pulling the client forward can cause imbalance. The nurse does not instruct the client to use a wheelchair. The client obtains much exercise as possible; having the client remain still does not help the client obtain the momentum needed to walk.

A 36-month-old child weighing 20 kg (44 lb) is to receive ceftriaxone 2 g IV every 12 hours. The recommended dose of ceftriaxone is 50 to 75 mg/kg per day in divided doses. How should the nurse proceed? Administer the medication as prescribed. Administer half the prescribed dose. Call the laboratory to check the therapeutic serum level of ceftriaxone. Withhold administering the ceftriaxone, and notify the child's health care provider (HCP).

Withhold administering the ceftriaxone, and notify the child's health care provider (HCP). Explanation: The child's HCP should be notified because the maximum daily recommended dosage for ceftriaxone for this child's weight would be 1,500 g/day, and giving this dose would administer 4 g/day. The nurse cannot administer a different dose than that prescribed. There is no therapeutic serum level of ceftriaxone.

An experienced nurse is precepting a new nurse in a psychiatric emergency room and is discussing criteria for involuntary commitment. Which client would signal to the experienced nurse that the new nurse understands the criteria? the parent who leaves their minor children unattended and stays out all night snorting cocaine a client with schizophrenia who can manage activities of daily living but has grandiose delusions a person who threatens to kill their spouse of 38 years a person with depression who says they are tired of living and does not have a suicidal plan

a person who threatens to kill their spouse of 38 years Explanation: One of the criteria for involuntary commitment is an emergency in which the client is a threat to themself or others. A parent might have a child removed from the home because of neglect but that doesn't meet the criteria for involuntary commitment. Many individuals with schizophrenia can learn to live with hallucinations and delusions and don't require hospitalization. To meet criteria for involuntary commitment, a depressed individual must have a suicide plan and be a direct threat to themself.

When prioritizing a client's care plan based on Maslow's hierarchy of needs, a nurse's first priority would be allowing family members to visit a newly admitted client. ambulating the client in the hallway. administering pain medication. placing wrist restraints on the client.

administering pain medication. Explanation: In Maslow's hierarchy of needs, pain relief is on the first layer. Love and belonging, as in allowing family members to visit, are on the third layer. Activity, as in ambulation, is on the fifth layer. Safety, as in placing wrist restraints on the client, is on the second layer.

The third stage of labor ends with the birth of the neonate. when the client is fully dilated. after the delivery of the placenta. when the client is transferred to her postpartum bed.

after the delivery of the placenta. Explanation: The definition of the third stage of labor is the delivery of the placenta. The first stage of labor ends with complete cervical dilation and effacement. The second stage of labor ends with the birth of the neonate. The fourth stage of labor includes the first 4 hours after birth.

A client has been admitted to the emergency department. The client's family tells the nurse that the client has suddenly become lethargic and is "not making sense." The client has not had anything to eat or drink for the last 8 hours. The nurse further assesses the client using the Confusion Assessment Method (CAM). The client's responses to questions are rambling, and the client is not able to focus clearly to answer the nurse's questions. Based on these findings, the nurse should report that the client has which problem? dementia depression delirium dehydration

delirium Explanation: Based on CAM's assessment tool, the client has an acute onset of behaviors, is inattentive, has disorganized thinking, and is lethargic (decreased level of consciousness). This cluster of behaviors constitutes delirium. Dementia has a slow onset, the client's level of consciousness is usually normal, and the client can focus attention. Clients who are depressed are alert and oriented and able to focus attention, although they may be easily distracted. Further assessment is needed to determine if the client also is dehydrated.

A client who can't tolerate oral feedings begins receiving intermittent enteral feedings. When monitoring for evidence of intolerance to these feedings, the nurse must remain alert for

diaphoresis, vomiting, and diarrhea. Explanation: The nurse must monitor for diaphoresis, vomiting, and diarrhea because these signs suggest an intolerance to the ordered enteral feeding solution. Other signs and symptoms of feeding intolerance include abdominal cramps, nausea, aspiration, and glycosuria. Electrolyte disturbances, constipation, dehydration, and hypercapnia are complications of enteral feedings, not signs of intolerance. Hyperglycemia, not hypoglycemia, is a potential complication of enteral feedings.

A school-age child is admitted to the hospital with acute rheumatic fever with chorea-like movements. Which eating utensil should the nurse remove from the meal tray? fork spoon plastic cup drinking straw

fork Explanation: For a child with chorea-like movements, safety is of prime importance. Feeding the child may be difficult. Forks should be avoided because of the danger of injury to the mouth and face with the tines.

A nurse is planning postoperative care for a client who has received a general anesthetic. During the immediate postoperative period, which nursing assessment should the nurse be most concerned about? dressing saturated with a moderate amount of bloody drainage, and blood pressure of 130/70 mm Hg urinary output of 190 milliliters and dark amber urine in 6 hours reports of pain and an occasional premature ventricular contraction (PVC) heart rate of 130 bpm, blood pressure of 98/56 mm Hg, and inspirations of 24

heart rate of 130 bpm, blood pressure of 98/56 mm Hg, and inspirations of 24 Explanation: The nurse should check for bleeding, monitor the vital signs, and promote urine output after airway patency has been established. Heart rate of 130 bpm, blood pressure of 98/56 mm Hg, and inspirations of 24 indicates the early signs and symptoms of shock and the nurse should be most concerned about these.

A nurse is performing a sterile dressing change. Which action contaminates the sterile field? holding sterile objects above the waist pouring solution onto a sterile field cloth leaving a 1″ (2.5-cm) edge around the sterile field opening the outermost flap of a sterile package away from the body

pouring solution onto a sterile field cloth Explanation: Pouring solution onto a sterile field cloth contaminates the sterile field because moisture penetrating the cloth can carry microorganisms to the sterile field via capillary action. Holding sterile objects above the waist, leaving a 1″ edge around the sterile field, and opening the outermost flap of a sterile package away from the body maintain the sterile field.

A female client reports to a nurse that she experiences a loss of urine when she jogs. The nurse's assessment reveals no nocturia, burning, discomfort when voiding, or urine leakage before reaching the bathroom. The nurse explains to the client that this type of problem is called: functional incontinence. reflex incontinence. stress incontinence. total incontinence.

stress incontinence. Explanation: Stress incontinence is a small loss of urine with activities that increase intra-abdominal pressure, such as running, laughing, sneezing, jumping, coughing, and bending. These symptoms occur only in the daytime. Functional incontinence is the inability of a usually continent client to reach the toilet in time to avoid unintentional loss of urine. Reflex incontinence is an involuntary loss of urine at predictable intervals when a specific bladder volume is reached. Total incontinence occurs when a client experiences a continuous and unpredictable loss of urine.

The nurse receives an order to administer morphine to a client with an acute myocardial infarction. What is the purpose of this medication? to decrease cardiac output to increase preload and afterload to increase myocardial oxygen demand to decrease myocardial oxygen demand

to decrease myocardial oxygen demand Explanation: Morphine will calm and relax the client and decrease respiratory rate, anxiety, and stress, thus decreasing myocardial oxygen demand. It doesn't have any effect on cardiac output or preload or afterload.

The nurse is encouraging an unlicensed assistive personnel (UAP) to interact with a dying client and family. The nurse should help the UAP understand that: the family members who are present can provide essential care. when health care personnel do not understand their own feelings about death and dying, they often avoid the client. the dying person requires minimal physical care to be comfortable, and it is not necessary to provide daily care. to protect a person's right to die with dignity, it is best to avoid interrupting the client.

when health care personnel do not understand their own feelings about death and dying, they often avoid the client. Explanation: Health care personnel may avoid the terminally ill client because they are uncomfortable about death and do not understand their own feelings about dying. Family members should not be expected to assume responsibility for the client's care, but they should be involved in the client's care to the extent they desire. Skilled and knowledgeable nursing care is required to make a dying person comfortable. Interrupting the client does not necessarily interfere with the right to die with dignity.