NCLEX-passpoint ?s
The breastfeeding mother of a 1-month-old diagnosed with cow's milk sensitivity asks the nurse what she should do about feeding her infant. Which recommendation would be most appropriate?
Continue to breastfeed, but eliminate all milk products from your own diet.
how does oxytocin affect contractions?
Contractions will be stronger and more uncomfortable and will peak more abruptly.
The nurse is caring for a client with Clostridium difficile infection. Prior to entering the room, which step would the nurse take?
Put on a gown.
What med treats hyperkalemia?
Sodium polystyrene
A nurse is instructing an unlicensed assistive personnel (UAP) on the proper care of a client in Buck's extension traction following a fracture of the left fibula. Which observation would indicate that teaching has been effective?
The weights are allowed to hang freely over the end of the bed.
Therapeutic response to chlorpromazine & benztropine?
benztropine is an anti cholinergic med, administer t decrease adverse effects of anti psychotic meds **pt experiences less psychosis & a decrease in ESP s/s
how is hep c spread?
blood
A client is 12 hours post abdominal inguinal hernia repair done under general anesthesia. The practitioner orders to progress diet as tolerated. Which tray should the nurse choose for this client?
broth, gelatin cubes, and tea -clear liquid diet first, THEN try a full liquid diet
The nurse is taking care of a client with neutropenia. Which nursing action is most important in preventing cross-contamination?
changing gloves immediately after use
purpose of indomethacin?
closes the patent ductus arteriosus!!
Which findings indicate that a client has developed water intoxication secondary to treatment for diabetes insipidus?
confusion and seizures
After administering an I.M. injection, a nurse should
discard the uncapped needle and syringe in a puncture-proof container.
When examining a client who has abdominal pain, a nurse should assess the symptomatic quadrant when?
last
The nurse should instruct the client to report which possible sign of cervical cancer?
light bleeding or watery vaginal discharge
A nurse is caring for a client after a hemorrhoidectomy. Which order would the nurse question on the medical record?
low-fiber diet -want a high fiber diet to prevent constipation!
Best way to prevent spread of impetigo?
teach importance of hand washing!! this is a direct contact illness
ideal site to administer insulin for a runner?
the abdomen!! (then rotate to butt cheeks)
What is functional incontinence?
the inability of a usually continent client to reach the toilet in time to avoid unintentional loss of urine.
normal range for lithium?
0.6-1.2 If pt in active mania, 1-1.5 is theraputic TOXIC= anything about 1.5 mild toxic: 1.5-2 moderate toxic: 2-3.5 severe toxicity: >3.5
How long should a pt w anaphylaxis be held, due to rebound pattern of anaphylaxis?
10 hrs
The nurse at a health fair is evaluating a client's completed questionnaire about stress-related life events. The client scored 168 points on the Holmes and Rahe stress scale. Which statement by the nurse provides appropriate interpretation of the impact of stressors on the client's health?
"These life stressors place you at moderate risk for illness." -Clients who accumulate points totaling up to 150 are considered to have a low risk of developing illness in the near future. Those with points between 150 and 299 are considered to be in the moderate- to high-risk category. Clients with scores 300 and higher are at the greatest risk of stress-related illness.
s/s of acute otitis media?
(an infection of the middle ear) include a recent upper respiratory infection, inner ear pain, fever, and a red bulging tympanic membrane.
The nurse finds a visitor unconscious with spontaneous breathing sitting in a chair in the waiting room. What priority action(s) will the nurse implement?
Attempt to identify the visitor. Call a rapid response team.
A client's caretaker calls the home care nurse and states accidentally puncturing the central venous catheter after discontinuing the total parenteral nutrition. What instructions should the nurse provide to the caretaker?
CLAMP THE CATHETER to prevent air embolism, pt should be positioned on the left side with head lower than feet, not higher
After suctioning a pt, the nurse should expect to find...
CLEAR BREATH SOUNDS, this indicates that the secretions have been removed successfully
should pts taking furosemide take a potassium supplement?
Furosemide is a loop diuretic that is not potassium sparing; clients should take potassium supplements as prescribed and have their serum potassium levels checked at prescribed intervals.
What supplement is contraindicated to take with warfarin & why?
Ginseng is contraindicated with warfarin, which is commonly prescribed for the treatment of atrial fibrillation; an increased risk of hypercoagulation can occur. -CHECK THE PTS PTT & INR
The family of a client who dies lives an hour away from the facility. What should the nurse do to support the family at this time?
Keep the client in the bed until the family arrives.
when given to children with chickenpox, aspirin has been linked to what disorder?
Reye's syndrome (a disorder characterized by brain & liver toxicity)
When administering oral meds to an infant, what action does the nurse take to decrease risk of aspiration?
Use an oral syringe to place the med beside the tongue, & admin the med slowly -Using an oral syringe is the best way to prevent aspiration because it allows controlled administration of a small amount of medication.
A nurse is teaching a pt how to prevent vaginal infection. Which activity puts the pt at risk of altering the normal pH of her vagina?
douching (clean/wash), may disrupt normal flora of vagina & change pH
A pt reports pain level of 8/10. What is the nurse's best action?
further asses the pain, BEFORE admin meds
The client with a lumbar laminectomy asks to be turned onto the side. The nurse should:
get another nurse to help logroll the client into position.
What illness does a baby need prophylaxis with antibiotics to prevent eye infection if mom is infected?
gonorrhea
The nurse observes that a client with a history of panic attacks is hyperventilating. What action should the nurse take?
have the pt breathe into a paper bag
Which STI can lie dormant in the body & reoccur?
herpes
Risk factors for colon cancer? a. chronic constipation b. laxative use c. hx of inflammatory bowel disease
hx of inflammatory bowel disease!
If a manual end-of-shift count of controlled substances isn't correct, the nurse's best action is to
immediately report the discrepancy to the nurse-manager, nursing supervisor, and pharmacy.
A nurse is caring for a neonate with a suspected diaphragmatic hernia. The nurse should question an order for
mask ventilation. -The nurse should question an order for mask ventilation because this procedure may introduce air into the neonate's GI tract.
A child is receiving amoxicillin for otitis media. Which action should the nurse recommend the mother do when the child develops diarrhea?
offer yogurt sever times a day to restore normal gut flora
A 3-month-old infant just had a cleft lip and palate repair. To prevent trauma to the operative site, the nurse should:
place the infant's arms in soft elbow restraints.
what is hyphema?
the presence of blood within the aqueous fluid of the air
when is epidural anesthesia usually administered during labor?
when the cervix is dilated to 4-5 cm
Which instruction should the nurse provide about climbing stairs with crutches?
"Place the unaffected leg on the first step, followed by the crutches and the injured leg, which should move together."
What is stress incontinence?
a small loss of urine with activities that increase intra-abdominal pressure, such as running, laughing, sneezing, jumping, coughing, and bending.
The health care provider (HCP) plans to perform an amniotomy on a multiparous client admitted to the labor area at 41 weeks' gestation for labor induction. After the amniotomy, what should the nurse do first?
Assess the fetal heart rate (FHR) for 1 full minute. -One of the complications of amniotomy is cord compression and/or prolapsed cord, and a FHR of 100 bpm or less should be promptly reported to the HCP.
A pt who is in rehabilitation following a stroke is experiencing total hemiplegia on the dominant right side. The nurse finds that the client needs assistance with eating to ensure optimum nutrition. Which action is most important for the nurse to take to facilitate rehabilitation with eating?
Assist the pt in learning to eat with the left hand
The nurse is providing discharge instructions for a client who had an inguinal herniorrhaphy. What information should the nurse give the client?
Avoid lifting items weighing >5 lb (2.3 kg).
For a primigravid client with the fetal presenting part at -1 station, what would be the nurse's priority immediately after a spontaneous rupture of the membranes?
Check the fetal heart rate for bradycardia
reflex incontinence?
an involuntary loss of urine at predictable intervals when a specific bladder volume is reached.
what is negligence, plus an example?
Negligence refers to careless acts on the part of an individual who is not exercising reasonable or prudent judgment. It also refers to the failure to do something that a reasonable person (another nurse) would do. -The nurse fails to routinely assess the pedal pulses on the affected leg, and missed the warning sign that the blood vessel was becoming occluded.
what is a dangerous SE of fluphenazine?
Neuroleptic malignant syndrome
what are examples of iron rich food?
eggs, fortified cereals, meats, and green vegetables
Which statements would indicate that the parents of a child being treated with antibiotics for an ear infection understand the reason for a follow-up visit after the child completes the course of therapy?
"We need to make sure that her ear infection has completely cleared."
What is protocol for caring for a pt addicted to oxycodone (r/t to chronic back pain) who almost overdosed?
"Your pain will be controlled by tapering doses of oxycodone and with other pain management strategies and medicines."
How often should a pt change the ostomy appliance?
every 3-7 days
How is Hepatitis A transmitted?
fecal-oral route
The night nurse has completed the change of shift report. As the day nurse makes rounds on a postpartum client receiving magnesium sulfate, it is noted the client developed significantly elevated blood pressure during the past shift. Further assessment reveals the magnesium sulfate rate is infusing well below the prescribed rate. In addition to adjusting the infusion rate and notifying the health care provider (HCP), what is the most important action by the nurse?
Complete an incident report. -Safety is the highest priority, and a nursing error has occurred. If the day nurse decides to tell the night nurse, the timing of the notification will be up to the nurse initiating the incident report.
s/s of hypoglycemia versus hyperglycemia
HYPO; nervousness, diaphoresis, weakness, light headedness, tachycardia, & changes in speech HYPER: the three poly's
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.
what is the difference in timeless of postpartum depression & postpartum blues?
PPD; usually appears at week 4 postpartum while PPB; is seen in the later part of the first week after birth & s/s usually disappear shortly after
A pt with COPD has an order for oxygen at 3L, should the nurse question this order? WHY?
People with COPD retain CO2, which is the normal trigger for respiratory rate. In clients with COPD and high levels of CO2, oxygen levels trigger breathing. Too much oxygen and the body slows breathing. Clients with COPD may quit breathing completely when given oxygen at very high levels (greater than 2 L).
How do you treat metastatic liver cancer?
Place emphasis on providing symptomatic and comfort measures, b/c there is no cure for this kind of cancer. Liver transplants are NOT recommended
A nurse gives a pt the wrong medication. After assessing the pt, the nurse completes an incident report. Which statement describes what will happen next?
The incident report will provide a basis for promoting quality care and risk management.
In which conditions might the nurse auscultate crackles?
acute respiratory distress syndrome, pneumonia, pulmonary edema
What length of time should gentamicin be administered over?
at LEAST 30 minutes
The nurse understands that a pt with severe dementia & motor apraxia may still be able to preform which action?
brush teeth when handed a tooth brush
The nurse is administering a subcutaneous injection (see accompanying figure). After releasing the skin, prior to injecting the medication, the needle pulls out of the skin. The nurse should:
discard the needle, attach a new needle to the syringe, and administer the medication.
The nurse should teach clients that the most common route of transmitting tubercle bacilli from person to person is through contaminated:
droplet nuclei.
How should a pt with an ostomy clean the area surrounding his or her ostomy?
using a facecloth & mild soap
When is thrombolytic therapy contraindicated?
if the pt has had a major surgery within the previous 3 weeks
What does the nurse determine is the family's risk of having another child with sickle cell anemia?
one chance in four for each pregnancy -recessive gene
When implementing the planned care of a client with pneumonia, a nurse achieves proper placement of a tympanic thermometer probe in an adult's ear canal by which method?
pulling the ear pinna back, up, and out
what are expected findings associated with pancreatitis?
recent weight loss and temperature elevation, fatty diarrhea and hypotension are usually present, tachycardia -Inflammation of the pancreas causes a response that elevates temperature and leads to abdominal pain that typically occurs with eating. Nausea and vomiting may occur as a result of pancreatic tissue damage that's caused by the activation of pancreatic enzymes. The client may experience weight loss because of the lost desire to eat.
During a well-baby visit, a parent asks the nurse when the infant should start receiving solid foods. The nurse should instruct the parent to introduce which solid food first?
rice cereal -. Next, the infant can receive pureed fruits, such as bananas, applesauce, and pears, followed by pureed vegetables, egg yolks, cheese, yogurt and, finally, meat. Egg whites shouldn't be given until age 9 months because they may trigger a food allergy.
When is use of jet hydrotherapy tub for pain relief r/t active labor contraindicated?
rupture of membranes!! Increases risk of infection
A nurse is performing an admission assessment on a client entering a long-term care facility. She notices a broken area of skin that extends into the dermis on the client's coccyx. How should the nurse document this wound?
stage II pressure ulcer
What med would the nurse anticipate to see order for PE?
streptokinase; breaks down RBC in PE
A client is admitted for an overdose of amphetamines. When assessing this client, the nurse should expect to see:
tension and irritability -Amphetamines are a nervous system stimulant that are subject to abuse because of their ability to produce wakefulness and euphoria. An overdose increases tension and irritability. Amphetamines stimulate norepinephrine, which increases the heart rate and blood flow.
A client is scheduled for a treadmill stress test. Prior to the stress test, the nurse reviews the results of the laboratory reports. The nurse should report which elevated laboratory value to the health care provider (HCP) prior to the stress test?
troponin -elevated troponin indicates myocardial damage
How does Hep B spread?
unprotected sex
When changing a sterile surgical dressing, a nurse first must
wash her hands
What is the most effective way to decrease the spread of influenza?
washing the hands frequently, "the hands spread disease-causing organism"
An infant's skin is inelastic and the upper abdomen is distended. To palpate the olive-like mass most easily, the nurse should palpate the epigastrium just to the right of the umbilicus at which time?
when the infant is eating -The pyloric, olive-like mass is most easily palpated when the abdominal muscles are relaxed, the stomach is empty, and the infant is quiet. During eating, the stomach is still empty and the infant is relaxed and comfortable.
The nurse instructs parents about the physical signs to look for in their child suspected of using cocaine. What finding should the nurse tell the parents is consistent with cocaine use?
"His pupils would be large." -Amphetamines, including cocaine, cause pupils to dilate -marijuana causes eyes to be red & bloodshot -opioids, including heroin, cause pupils to be pinpoints
How should a pt self administer an enema?
"I will administer the enema while lying on my left side with my right knee flexed."
A client with suspected severe acute respiratory syndrome (SARS) comes to the emergency department. Which physician order should the nurse implement first?
Institute isolation precautions. -SARS, a highly contagious viral respiratory illness, is spread by close person-to-person contact. Contained in airborne respiratory droplets, the virus is easily transmitted by touching surfaces and objects contaminated with infectious droplets. The nurse should give top priority to instituting infection-control measures to prevent the spread of infection to emergency department staff and clients. After isolation measures are carried out, the nurse can begin an I.V. infusion of dextrose 5% in half-normal saline and obtain nasopharyngeal and sputum specimens.
what instruction should a nurse give regarding crutches use?
Maintain two to three finger widths between the axillary fold and underarm piece grip.
The nurse administers a tap water enema to a client. While the solution is being infused, the client has abdominal cramping. What should the nurse do first?
Temporarily stop the infusion, and have the client take deep breaths.
A client who had an open appendectomy for a perforated appendix has an incision secured with adhesive strips. What instruction should the nurse give the client about caring for the incision?
The adhesive strips should stay in place until they fall off. The client should not remove them to cleanse the area. It is not necessary to place an additional dressing over the adhesive strips. The client should not take a tub bath until the incision has healed.
Which finding will the nurse assess in a client diagnosed with peritonitis?
abdominal wall rigidity
What kind of precautions should be used for tuberculosis?
airborne
