nclex pass point set 7 study

A physician orders electroconvulsive therapy (ECT) for a severely depressed client who fails to respond to drug therapy. When teaching the client and family about the treatment, the nurse should include which point about ECT? An anesthetist will administer ECT. ECT can cure depression. ECT will induce a seizure. The client will remember the shock of ECT but not the pain.

ECT will induce a seizure. Explanation: Reserved for clients with acute depression who don't respond to pharmacologic or psychiatric measures, ECT is the passage of an electrical current through the brain to induce a brief seizure. According to ECT proponents, the desirable changes the seizure causes in neurotransmitters and receptor sites are similar to those caused by antidepressant drugs. ECT is administered under a general anesthetic by a physician and an anesthetist. Although ECT may reduce the severity of depression, it doesn't necessarily cure the illness. Before undergoing ECT, the client is given a medication that provides short-term amnesia of the entire event.

A client with severe acute respiratory syndrome privately informs the nurse of a desire not to be placed on a ventilator if the condition worsens. The client's partner and children have repeatedly expressed their desire that every measure be taken for the client. The most appropriate intervention by the nurse would be to: encourage the client to consider a living will or power of attorney. ask the physician to discuss the client's prognosis with the client and the family. arrange a conference to discuss the matter with all involved. assure the client that all possible measures will be taken.

encourage the client to consider a living will or power of attorney. Explanation: The nurse is obligated to act as the client's advocate. A living will or power of attorney would clearly define the client's wishes. The nurse should not discuss the issue with the client's family unless the client gives permission. Assuring the family and client that all possible measures will be taken opposes the client's wishes and does not demonstrate client advocacy.

A child with hives is prescribed diphenhydramine 5 mg/kg over 24 hours in divided doses every 6 hours. The child weighs 17.6 lb (8 kg). How many milligrams should be given with each dose? Record your answer using a whole number.

10 Explanation: Multiplying 5 mg by the child's weight (8 kg) gives the amount of milligrams for 24 hours (40 mg). Divide this by 4 (doses per day), giving 10 mg/dose. 5 mg/kg x 8 kg = 40 mg; 40 mg/4 doses = 10 mg/dose

The nurse is recording the intake and output for a client: D5NS 1,000 ml, urine 450 ml, emesis 125 ml, Jackson-Pratt drain #1 35 ml, Jackson-Pratt drain #2 32 ml, and Jackson-Pratt drain #3 12 ml. How many milliliters would the nurse document as the client's output? Record your answer using a whole number.

654 Explanation: The nurse must add all the output volumes together: 450 ml + 125 ml + 35 ml + 32 ml + 12 ml = 654 ml. D5NS 1,000 ml is considered input, not output.

A nurse is planning care with a family of a 4-year-old in preschool who is often disruptive in class, is difficult to engage, and rarely speaks. The child flaps his arms and screeches when he is upset. What would be the most appropriate responses for the nurse to make to the parents? Select all that apply. "Has your child received all his childhood immunizations? You know there is evidence that childhood immunizations play a role in the development of autism." "Has your child been evaluated by a pediatrician? He seems to have some behaviors that are abnormal for a child of his age." "How does your child behave at home? If you do not see acting out behavior at home, part of his problem may be dealing with new situations such as school." "How do you respond if he disobeys or acts out at home? If your techniques help, stop, or prevent negative behavior, perhaps the teachers can try similar measures at school." "Have you considered private school? This environment does not seem right for your child."

Correct response: "Has your child been evaluated by a pediatrician? He seems to have some behaviors that are abnormal for a child of his age." "How does your child behave at home? If you do not see acting out behavior at home, part of his problem may be dealing with new situations such as school." "How do you respond if he disobeys or acts out at home? If your techniques help, stop, or prevent negative behavior, perhaps the teachers can try similar measures at school." Explanation: The child's behavior appears to fit the criteria for autism, but suggesting the child's immunizations are causative is inaccurate according to recent research and dangerous regarding possibly convincing the mother to forego future immunizations. A better approach would be to suggest a full evaluation by a primary care provider, especially since symptoms could result from other illnesses or conditions. Inquiring about the child's behavior at home and the mother's discipline techniques would give the nurse a better idea of the home environment and could help determine whether this is a problem confined to the school setting or one that also occurs at home. Asking for the mother's input regarding discipline demonstrates a desire to involve her in problem solving. Suggesting a different school without a full evaluation does not address the problem.

A client is prescribed furosemide to manage heart failure. What laboratory values should the nurse monitor while the client receives this medication? Select all that apply. complete blood count serum potassium prothrombin time (PT) thrombin time international normalized ratio

Correct response: complete blood count serum potassium Explanation: Complete blood count should be monitored, because furosemide can cause agranulocytosis, anemia, leukopenia, and thrombocytopenia. Because loop diuretics such as furosemide promote excretion of potassium, the nurse should also monitor serum potassium levels. Potassium replacement therapy may be necessary to prevent hypokalemia. Thrombin time, PT, and INR do not have to be monitored in a client receiving furosemide.

The nurse is assessing an infant with neonatal bronchopulmonary dysplasia (chronic lung disease). Which symptoms would the nurse expect to find? Select all that apply. tachypnea bradypnea hyperexpansion on chest X-ray rapid weight gain wheezing

Correct response: tachypnea hyperexpansion on chest X-ray wheezing Explanation: The physical exam of an infant with neonatal chronic lung disease often reveals tachypnea and wheezing. The chest X-ray shows hyperinflation as the disease becomes more severe. Infants often fail to gain weight.

A client is using patient-controlled analgesia (PCA) to manage postoperative pain. What should the nurse do when assisting the client with the PCA? Reassure the client that pain will be relieved. Document the client's response to pain medication. Instruct the client to continue pressing the system's button whenever pain occurs. Titrate pain medication until the client is free from pain.

Document the client's response to pain medication. Explanation: It is essential that the nurse document the client's response to pain medication on a routine, systematic basis. Reassuring the client that pain will be relieved is often not realistic. A client who continually presses the PCA button may not be getting adequate pain relief, but through careful assessment and documentation, the effectiveness of pain relief interventions can be evaluated and modified. Pain medication is not titrated until the client is free from pain but rather until an acceptable level of pain management is reached.

What action should the nurse take first when a client is coughing up pink, frothy sputum? Place the client in high-Fowlers position Plan to administer a diuretic Start an IV line Apply supplemental oxygen

Place the client in high-Fowlers position Explanation: Production of pink, frothy sputum is a classic sign of acute pulmonary edema. Pulmonary edema requires immediate emergency treatment. The priority action is to place the client placed in high-Fowler's position to facilitate air exchange and improve oxygenation. After positioning the client, application of supplemental oxygen, IV access, and drug therapy can be performed. The goal of treatment is to reduce the amount of fluid in the lungs, improve gas exchange and heart function, and, if possible, correct the underlying disease. Because this client is at high risk for decompensation, the nurse should call for help without leaving the room.

A client who had a splenectomy is being discharged. What should the nurse teach the client to do? Refrain from driving a car for 6 weeks. Alternate rest and activity. Make an appointment for the staples to be removed. Report early signs of infection.

Report early signs of infection. Explanation: Clients who have had a splenectomy are especially prone to infection. The reduction of immunoglobulin M leaves the client especially at risk for immunologic deficiency infections. All clients who have had major abdominal surgery usually receive discharge instructions not to drive because the stomach muscles are not strong enough to brake hard or quickly after the abdominal muscles have been separated. All clients need to pace activity and rest when going home after major surgery. Rest and sleep allow the growth hormone to repair the tissue, and activity allows the energy and strength to build endurance and muscle strength. An appointment is usually made to see the surgeon in the office 1 week after discharge for follow-up and to remove sutures or staples if this has not already been done.

A 4-year-old child is brought to the emergency department in cardiac arrest. The staff performs cardiopulmonary resuscitation (CPR). Identify the area where the child's pulse would be checked. Click to select the correct part of the image.

The carotid artery would be used to check for a pulse when performing CPR on children and adults. The brachial pulse would be used when performing CPR on an infant.

A client at term arrives in the labor and delivery unit experiencing contractions every 4 minutes. After a brief assessment, the client is admitted, and an electronic fetal monitor is applied. Which assessment finding would be most concerning to the nurse? total weight gain of 30 lb (13.6 kg) maternal age of 32 years blood pressure of 146/90 mm Hg treatment for syphilis at 15 weeks' gestation

blood pressure of 146/90 mm Hg Explanation: A blood pressure of 146/90 mm Hg may indicate gestational hypertension. Over time, gestational hypertension reduces blood flow to the placenta and can cause intrauterine growth restriction, and other problems that reduce the fetus's ability to tolerate the stress of labor. A weight gain of 30 lb (13.6 kg) is within expected parameters for a healthy pregnancy. A woman over age 30 doesn't have a greater risk of complications if her general condition is healthy before pregnancy. Syphilis that has been treated does not pose an additional risk.

When preparing for the discharge of a newborn after surgery to correct tracheoesophageal fistula (TEF), the nurse teaches the parents about the need for long-term health care because their child has a high probability of developing which complication? recurrent mild diarrhea with dehydration esophageal stricture speech problems gastric ulcers

esophageal stricture Explanation: Dilatation at the anastomosis site is needed during the first years of childhood in about 50% of children who have had corrective surgery for TEF. Recurrent mild diarrhea with dehydration is not likely to develop with this surgery. Speech problems can occur if other abnormalities are present to produce them; the larynx and structures of speech are not affected by TEF. Dysphagia and strictures may decrease food intake, and poor weight gain may be noted, but gastric ulcers should not develop from surgery to repair TEF.

After an eye examination, a client is diagnosed with open-angle glaucoma. The physician orders pilocarpine ophthalmic solution, 0.25% gtt i, OU q.i.d. Based on this prescription, the nurse should teach the client or a family member to administer the drug by instilling one drop of pilocarpine 0.25% into both eyes daily. instilling one drop of pilocarpine 0.25% into both eyes four times daily. instilling one drop of pilocarpine 0.25% into the right eye daily. instilling one drop of pilocarpine 0.25% into the left eye four times daily.

instilling one drop of pilocarpine 0.25% into both eyes four times daily. Explanation: The abbreviation "gtt" stands for drop, "i" is the apothecary symbol for the number 1, "OU" signifies both eyes, and "q.i.d." means four times per day. Therefore, one drop of pilocarpine 0.25% should be instilled into both eyes four times daily.

The nurse is assessing a client with superficial thrombophlebitis in the greater saphenous vein of the left leg. The client has "aching" in the leg. Which finding indicates the nurse should contact the health care provider (HCP) to request a prescription to improve the client's comfort? brown discoloration of the skin with edema in the lower left leg dark, protruding veins of both legs that are uncomfortable when standing absence of pain or swelling when the client dorsiflexes the left foot red, warm, palpable linear cord along the vein that is painful on palpation

red, warm, palpable linear cord along the vein that is painful on palpation Explanation: Superficial thrombophlebitis is associated with pain, warmth, and erythema. The nurse can request a prescription for warm packs to relieve the pain. Venous insufficiency causes edema and a brown discoloration of the lower leg. Varicose veins are dark, protruding veins, and symptoms of discomfort increase with standing. Pain on dorsiflexion of the foot indicates deep vein thrombosis; the client does not indicate having this pain.

A charge nurse is preparing client care assignments for the next shift. A client who underwent femoral-popliteal bypass surgery is scheduled to return from the postanesthesia care unit. Which staff member would best receive this client? registered nurse (RN) with 2 years of experience registered practical nurse/licensed practical or vocational nurse with 5 years of experience registered nurse who just completed orientation charge nurse with 10 years of experience

registered nurse (RN) with 2 years of experience Explanation: Because this client requires frequent neurovascular assessments, an RN with experience would best receive the client. A registered practical nurse/licensed practical or vocational nurse, although experienced and capable of collecting data, would not be receiving the client and report from the operating room as skilled assessments are necessary. The registered nurse who just finished orientation would best assist the registered nurse and be assigned a more stable client at this time. The charge nurse needs to be available to direct the care of other clients and management of unit.

A nurse is caring for an infant who requires intravenous therapy. The nurse notes that the only available IV pump is in a toddler's room. In which order should the nurse complete the following actions?1. Remove pump from toddler's room.2. Clean the pump.3. Take pump into infant's room.4. Use the pump. 1, 2, 3, 4 1, 3, 2, 4 2, 1, 3, 4 2, 3, 1, 4

1, 2, 3, 4 Explanation: Properly cleaning the monitoring equipment is the correct infection control process. Best practices would include removing the pump from the toddler's room, cleaning the pump, taking the pump into the infant's room, and using the pump.