NCLEX Personal Review

What are airborne precautions?

used for diseases or very small germs that are spread through the air from one person to another (examples: tuberculosis, measles, chickenpox).

What are contact precautions?

used for infections, diseases, or germs that are spread by touching the patient or items in the room (examples: MRSA, VRE, diarrheal illnesses, open wounds, RSV).

The nurse cares for the client admitted with a diagnosis of myocardial infarction (MI) 36 hours ago. An appropriate nursing diagnosis is "Risk for Decreased Cardiac Output" related to which item?

ventricular dysrhythmias

Normal BUN

10-20

Normal Hgb

12.5-17.5 male 12-16 female

Which of the following is a correct instruction by the nurse to the parent of a 4-year-old client regarding collecting a specimen to be tested for pinworms?

Collect the specimen early in the morning with a piece of scotch tape to the child's anus

Verapamil (Calan)

Antihypertensive, calcium channel blocker

Haldol

Antipsychotic, can treat tourette syndrome

The nurse obtains a history for the client with hyperthyroidism. Which assessment does the nurse report to the health care provider?

Anxiety with extreme nervousness

The nurse cares for a client who has just returned to his room after a scleral buckling procedure was completed to repair a detached retina. Which of the following is the MOST important nursing action?

Ask the client if he is nauseated- priority because vomiting can increase intraocular pressure

The nurse cares for a client just returning to the postsurgical unit following abdominal surgery for cancer of the colon. It is MOST appropriate for the nurse to take which of the following actions?

Ask the client to life his head off the pillow- assessing whether there is remaining neuromuscular block in effect

The nurse prepares the client for a paracentesis. It is most important for the nurse to take which action?

Ask the client to void before the procedure- prevents the bladder from getting punctured

The physician orders ranitidine hydrochloride (Zantac) 150 mg PO daily for the client. The nurse should advise the client the BEST time to take the medication is which of the following?

At hour of sleep- absorption not affected by taking with food

A client takes perphenazine (Trilafon) by mouth for 2 days and now displays the following: head turned to the side, neck arched at an angle, and stiffness and muscle spasms in neck. The nurse expects to give which of the following as a PRN medication?

Biperiden (Akineton) - antiparkinsonian agent used to counteract extrapyramidal effects

A patient is returned to the room after a subtotal thyroidectomy for treatment of hyperthyroidism. Which of the following, if found by the nurse at the patient's bedside, is essential?

Calcium gluconate for tetany, tracheostomy setup for airway, and suction equipment

The 10-year-old child weighing 50 lb (23.6 kg) returns from surgery for a skin graft to the left leg. The child has an IV of D5W infusing into the left arm. The health care provider's orders read: "D5W 2,000 mL/24 h." It is most important for the nurse to take which action?

Call the healthcare provider and confirm the order- excessive amount and does not have electrolytes in the fluid

Caution with mag sulfate in infants?

Can cause decreased BP

The nurse provides care for a client in cardiogenic shock after a myocardial infarction (MI). Which is the priority nursing diagnosis for the client?

Cardiac tissue death

The nurse cares for the client following a coronary artery bypass graft (CABG). Which symptom does the nurse expect to see if the client is in the early stages of circulatory overload?

Change in characteristics of respirations

At approximately 2000 hours the nurse begins to open the nurses' notes for the 0700 - 1900 shift. The last entry is noted for 0400 and there is no signature. Which response by the nurse is most appropriate?

Chart on the line below the area and leave a note that the other charting must be finished

The nurse observes the student nurse check the placement of a nasogastric (NG) tube prior to administering an intermittent feeding. Which student nurse actions are correct?

Check pH of contents aspirated, use large-barrel syringe to aspirate contents, flush with 30 mL of air before aspirating. Do NOT listen in upper abdomen for air bolus because that could be lungs or esophagus, and don't place end in cup of water to watch for bubbling

The home care nurse instructs a client recently diagnosed with tuberculosis. It is MOST important for the nurse to include which of the following as a part of the teaching plan?

Client should take medications for 6-9 months

talipes equinovarus

Clubfoot

What should the nurse do when she notes late decels?

Discontinue oxytocin, turn client to left side (aids in placenta blood flow), apply oxygen at 8 L/min, increase primary IV infusion rate (increasing IV fluids will increase volume for oxygen transfer to fetus)

The 5-year-old child is scheduled for a lumbar puncture (LP). Which nursing action best prepares the child for the procedure?

Do a mock run through of the procedure- the patient can feel some of the interventions beforehand

The client has an infected abdominal incision. The home care nurse instructs the partner of the client how to change the moist-to-dry abdominal dressing. What is correct and incorrect?

Do not wet it before removing- want to remove necrotic tissue with the dressing. The purpose of the moist to dry is to debride the wound and cover with moist 4x4. You may irrigate with a bulb syringe and may use Montgomery straps to secure

The teenager comes to the clinic reporting fatigue, a sore throat, and flu-like symptoms for the previous 2 weeks. Physical exam reveals enlarged lymph nodes and temperature of 100.3° F (37.9° C). Which statement by the nurse is best?

Don't share utensils or drinks with anyone- suspected mono

The nurse prepares to suction the client with a new tracheostomy. Which nursing action indicates a break in proper technique?

Don't suction mouth before throat- breaks sterile field. Use suction 90-120 mmHg, use intermittent suction on way out, hyper oxygenates before insertion

When assisting with a bone marrow aspiration, the nurse should take which of the following actions?

Drop sterile supplies onto a sterile tray

Lidocaine

Drug of choice for frequent PVCs

Ketoconazole (Nizoral)

Drug of choice for treatment of candidiasis

The nurse cares for the 2-month-old infant diagnosed with reflux. Which nursing action is most appropriate?

Elevate HOB 30 degrees

The client reports pain after an appendectomy. After administering an analgesic, the nurse takes which action?

Elevated HOB 30-45 degrees- decreases pressure on suture line

The client returns to the room following a myelogram. The nursing care plan should include which interventions?

Encourage fluids- helps flush the dye from the system, Lie flat for several hours- helps prevent headache, and monitor neurological and vital signs to catch abnormalities early

The multidisciplinary team decides to implement behavior modification with a client. Which of the following nursing actions is of primary importance during this time?

Ensure everyone on the team understands and complies with treatment plan

An abdominal wound irrigation with a normal saline solution is ordered for the client. To perform this procedure, the nurse takes which action?

Establishes a sterile field including the equipment

How often do you change IV tubing?

Every 48-72 hours

What are standard precautions?

Expected in all situations, hand hygiene, PPE as needed, coughing hygiene, safe injections

cranial nerve VII

Facial- motor activity to the face

The client tested positive for the tuberculosis antibody and was placed on isoniazid 4 weeks ago. The nurse is most concerned if which observation is made?

Fatigue and dark urine- indicates initial hepatic dysfunction

The client had an aortic aneurysm resection 2 days ago. A complete blood count reveals a very low red blood cell count. The nursing assessment is most likely to reveal which information?

Fatigue and exertion dyspnea, pallor and dizziness, malaise and tachycardia

In planning anticipatory guidance for parents of a beginning school-aged child, it is MOST important for the nurse to include which of the following?

Give responsibilities around the house

bromocriptine

Given to Parkinson's patients, diabetics, and can interfere with menstrual problems/lactating. Give with food to decrease GI upset

The client had abdominal surgery 4 days ago. The client has been coughing and says it "feels like something gave." The nurse observes the edges of the incision have separated and a small loop of the bowel protrudes through the incision. In which position does the nurse place the client?

HOB elevated 15 degrees

A patient is admitted to the surgical unit with a diagnosis with rule out (R/O) intestinal obstruction. The nurse prepares to insert a Salem sump NG tube as ordered. It is BEST for the nurse to place the patient in which of the following positions?

HOB elevated 60-90 degrees- facilitates swallowing

The nurse cares for the client in the ICU. Hemodynamic monitoring is accomplished by way of a Swan-Ganz catheter. The nurse is aware this type of monitoring will provide which information?

It indirectly measures the pressure of the left ventricle

Drug of choice for treatment of candidiasis

Ketoconazole (Nizoral)

The nurse cares for the client diagnosed with schizophrenia. Which statement is most descriptive of the affect of this client?

Laughs while talking about being raped

What is biofeedback? What is it used for?

Learning to control the autonomic nervous system, used to control stress in physiological disorders

The nurse monitors a client's EKG strip and notes coupled premature ventricular contractions greater than 10 per minute. The nurse should expect to administer which of the following?

Lidocaine hydrochloride (Xylocaine) IV- drug of choice for frequent PVCs

The nurse cares for the client recently diagnosed with AIDS. The nurse identifies the nursing diagnosis: Risk for Infection. Which intervention by the nurse is best?

Limit the number of healthcare providers involved in the patient's care- decreases microorganism exposure

Gemfibrozil (Lopid)

Lipid-lowering, can cause abdominal pain or cholelithiasis, take 30 minutes before breakfast and supper

The nurse makes rounds on the postpartum unit. The nurse notes that a client's uterus is relaxed. The nurse should take which actions?

Massage the funds, put the baby to breast, assess the bladder for fullness

The client is scheduled to have a parathyroidectomy. The nurse is most concerned if the client is observed eating quantities of food from which food group?

Milk products- low calcium diet before procedures

The nurse knows which of the following observations is indicative of chronic cocaine use?

Nasal septum disruption

The child comes to the school nurse with a honey-colored crusted lesion below the right nostril. Which action does the nurse take first ?

Notifies the child's parents- impetigo is highly infectious

cranial nerve III

Oculomotor- extra ocular movement

Prior to a caesarean delivery, the client is treated for abruptio placenta. The nurse cares for the client during the postpartum period. Which symptom is suggestive of disseminated intravascular coagulation (DIC)?

Oozing blood at venipuncture site- over clotting of blood

glipizide

Oral hypoglycemic agent for type 2 diabetics with minimal insulin secretion

What does a Swan-Ganz catheter measure?

PAWP (pulmonary artery wedge pressure) which is an indirect measurement of left ventricle

The client develops right-sided heart failure. The nurse expects to observe which symptoms?

Peripheral edema and anorexia, polycythemia, distended neck veins

What might a patient experience if they have a detached retina?

Photophobia, loss of a portion of the visual field

During a first aid class, the nurse instructs clients on the emergency care of partial thickness burns. The nurse identifies which of the following interventions for partial thickness burns of the chest and arms BEST prevents infection?

Remove clothing, wrap victim in clean sheet

The client diagnosed with Addison's disease is admitted with pneumonia. The nurse suggests salted broth for lunch. The appropriateness of this decision is based on which statement about Addison's disease?

Sodium should be increased during periods of stress- decrease in aldosterone leads to excess sodium excretion

The client is transferred to the neurology unit after developing right-sided paralysis and aphasia. The nurse includes which intervention in the client's plan of care?

Speak using short phrases and sentences

cranial nerve XI

Spinal accessory, innervation to trapezius/sternocleidomastoid

The young adult has a sprained right ankle. The nurse in the outpatient clinic teaches the client to walk with a cane. Where is the nurse positioned?

Stand on the left side of the client and slightly behind

The newborn infant of an HIV-positive mother is admitted to the nursery. The nurse should include which of the following in the plan of care?

Standard precautions

The visiting nurse instructs a client how to use esophageal speech following a total laryngectomy. Which of the following actions, if performed by the client, indicates teaching is effective?

The client swallows air and then eructates it while forming words with his mouth.

When caring for a client with a nursing diagnosis of rape trauma syndrome, acute phase, the nurse should consider which of the following the MOST important initial goal for the client?

The client will begin to express her reactions and feelings about the rape by the time she leaves the ER

The nurse cares for a young adult admitted to the hospital with a severe head injury. The nurse should position the patient in which of the following positions?

With the client's neck in midline position and HOB 30 degrees- decreases ICP

The nurse administers terbutaline (Brethine) to a client in labor. Prior to administration of the medication, the nurse assesses the client's pulse to be 144. Which of the following actions should the nurse take FIRST?

Withhold the med- can cause maternal tachycardia

The client has surgery for cancer of the colon, and a colostomy is established. Before discharge, the client tells the nurse that swimming will no longer be allowed. Which response by the nurse is correct?

You may resume all previous activities

What precautions for TB?

airborne

Metronidazole (Flagyl)

anti-infective, used for treatment of intestinal amebiasis, trichomoniasis, and IBS

Which eye condition is loss of acuity?

cataracts

Pertussis has what precautions?

droplet

What precautions for rubella?

droplet

Which eye condition is loss of peripheral vision?

glaucoma

Atropine

symptomatic bradycardia

What are droplet precautions?

used for diseases or germs that are spread in tiny droplets caused by coughing and sneezing (examples: pneumonia, influenza, whooping cough, bacterial meningitis).

The newborn is diagnosed with cystic fibrosis (CF). Which parental statement to the nurse indicates understanding of the cause of CF?

"Both of us carry a recessive trait for CF"

A woman has been recently diagnosed with systemic lupus (SLE) and shares with the nurse, "I am thinking about getting pregnant, but I don't know how I will be able to tolerate a pregnancy because I have lupus." Which of the following responses by the nurse is BEST?

"How long have you been in remission?" - recommended remission for 5 months prior to getting pregnant

A client is transferred to a psychiatric crisis unit with a diagnosis of a dissociative disorder. The nurse identifies which of the following comments by the client is MOST indicative of this disorder?

"I don't know who I am, and I don't know where I live"

The nurse changes the dressing on the client who had a mastectomy 2 days ago. After the nurse removes the old dressing, the client turns the head away. Which is the best response by the nurse?

"I noticed you looked away from your incision site"

The nurse cares for the client diagnosed with vasoocclusive crisis. The nurse instructs the client how to use patient-controlled analgesia (PCA). The nurse determines teaching is effective if the client makes which statement?

"I should call you if I start itching"

The nurse cares for the client who delivered an 8 lb, 4 oz newborn. The newborn is diagnosed with talipes equinovarus. The client confides to the nurse, "I feel so bad that my baby is abnormal." Which response by the nurse is best?

"It's understandable that you feel this way but there are ways to correct this problem"

A client diagnosed with bipolar disorder receives haloperidol (Haldol) 2 mg PO tid. The client tells the nurse, "Milk is coming out of my breasts." Which of the following responses by the nurse is BEST?

"You are experiencing a side effect of Haldol"

Normal stomach pH when aspirating contents

0-4

A school-aged child injured his right knee yesterday during a soccer game. He is brought to the outpatient clinic by his mother. The child's right knee is painful, swollen, and bruised. During the interview, the nurse learns that the boy is diagnosed with hemophilia A. The nurse identifies which of the following medications is BEST for this patient?

Codeine phosphate (Paveral) - analgesic for moderate to severe pain Not oxycodone, ibuprofen, or aspirin as these increase bleeding time

What is normal specific gravity of urine?

1.01-1.03

Normal WBC

5,000-10,000

The nurse in the well-baby clinic observes a group of children. The nurse notes that one child is able to sit unsupported, play "peek-a-boo" with the nurse and is starting to say "mama" and "dada". The nurse determines the infant's behaviors are consistent with which of the following ages?

9 months

Series of events leading up to surgery:

> 1hr before surgery: administer enema, perform preoperative shave and scrub, and evaluate for food and medication allergies. 1 hour before confirm consent has been signed

What can a three month old infant play with while in traction?

A rattle

A client takes gemfibrozil. It is most important for the nurse to monitor which laboratory value?

AST- indicates liver function, normal 8-20,

What is important during tube feeding?

Administer at room temp

The client with chronic pain due to cancer receives morphine 10 mg PO q4h PRN for pain without much relief. Which change in narcotic pain management is the most valid suggestion for the nurse to make to the health care provider?

Administer medication q4 hr around the clock

An adult client has regular insulin ordered before breakfast. The nurse notes that the client's blood glucose level is 68 mg/dL and the client is nauseated. Which action should the nurse take?

Administer on time

Best overall indicators of long-term nutritional status

Albumin level

procalnamide HCl (Pronestyl)

Antiarrhythmic Give slowly by IV push, can cause hypotension or bradycardia

The nurse cares for the client with a three-chamber water-seal drainage system. The nurse notices the fluid in the water-seal chamber does not fluctuate. Which action by the nurse is best?

Anticipate chest x-ray. No fluctuation indicates chest expansion, X-ray will confirm

Isoproterenol (Isuprel)

Antidysrhythmic used for heart block, ventricular dysrhythmias

The nurse prepares a patient for a cesarean section. The patient says that she had major surgery several years ago and asks if she will receive a similar "shot" before surgery. The nurse's response should be based on an understanding that the preoperative medication given before a cesarean section

Contain lower amounts of NARCOTICS than general surgery- these are not safe for baby because of respiratory depression

The nurse prepares a 5-year-old child for surgery. The nurse notes that the child's parents are divorced and have joint legal custody. The informed consent for surgery has been signed by the mother. Which of the following actions by the nurse is BEST?

Continue with the preoperative prep- when joint custody can have one

The nurse monitors the client in active labor. The client is receiving oxytocin 1 mU/min IV. The nurse stops the infusion if which observation is made?

Contractions 2 minutes apart and last 90 seconds or more

The nurse is the first on the scene of a motor vehicle accident. The victim has sucking sounds with respirations at a chest wound site and tracheal deviation toward the uninjured side. Which action does the nurse take first?

Covers the wound with loose dressing- allows air to escape but not enter the wound

The nurse cares for the client diagnosed with venous thromboembolism (VTE) of the left leg. Which nursing goal is appropriate for the client?

Decrease inflammatory response in the affected extremity and prevent embolus formation

The client exhibits symptoms of myxedema. The nursing assessment should reveal which of the following?

Decreased temperature- slowing of all systems

The client is admitted with a diagnosis of subdural hematoma and cerebral edema after a motorcycle accident. Which symptoms should the nurse expect to see initially?

Decreasing LOC, ipsilateral pupil dilation (dilated on side of hematoma), headache is first symptom

The client has been on bedrest for 48 hours in an unsuccessful attempt to arrest premature labor at 33 weeks gestation. The lab reports a lecithin/sphingomyelin (L/S) ratio of 3:1. Based on this result, the nurse anticipates which occurrence?

Deliver the baby via cesarean section

The elderly client has a depressed affect. Which nursing action is most appropriate to help the client complete activities of daily living?

Develop a written schedule for the day, allowing for extra time

The health care provider prescribes cimetidine 300 mg PO qid for the client. The nurse instructs the client about the medication. What should you know?

Diarrhea for awhile, call doc if acne-like rash, take at meals

The nurse prepares the client for an 0800 outpatient electroconvulsive (ECT) treatment. Which question is most important for the nurse to ask?

Did you have anything to eat or drink before you came in today? NPO after midnight, general anesthesia

The client takes chlorpromazine. The client is instructed to notify the nurse immediately if which sign or symptom is experienced?

Difficulty urinating, problem with anticholinergics

The nurse learns a client has a history of heart failure (HF), is on a low sodium diet, and is taking chlorothiazide 500 mg. Diagnostic tests indicate sodium 127 mEq/L (127 mmol/L), potassium 3.8 mEq/L (3.8 mmol/L), glucose 110 mg/dL (6.1 mmol/L), and normal chest x-ray. It is most important for the nurse to assess for which signs?

Headache, apprehension, lethargy- symptoms of hyponatremia. Also includes muscle twitching, convulsions, diarrhea, and fingerprinting of skin

The nurse performs discharge teaching for the client after abdominal surgery. The nurse determines that teaching is effective if the client chooses which foods for lunch?

High protein, high calories, and high vitamin C

The 3-month-old infant is experiencing increased intracranial pressure (ICP). Which assessment finding does the nurse report to the health care provider?

High-pitched cry

A 4-month-old infant is admitted to the pediatric intensive care unit with a temperature of 105°F (40.5°C). The infant is irritable, and the nurse observes nuchal rigidity. Which assessment finding indicates an increase in intracranial pressure?

High-pitched cry- one of the first indicators of increased ICP in infants

The nurse assesses the pregnant client with a diagnosis of mitral stenosis and heart failure (HF). The nurse identifies which finding in the client's history has a direct correlation with the current problem?

History of rheumatic fever 4 years ago

The nurse cares for the client receiving atorvastatin. It is most important for the nurse to report which client statement to the health care provider?

I take colchicine- concurrent use of atorvastatin and colchicine increases risk of rhabdomyolosis

The nurse recognizes which of the following as a positive response to fluoxetine HCl (Prozac)?

Increased energy levels and participation in activities

The nurse cares for the client who experienced a thermal injury 2 weeks ago. The nurse is most concerned if which vital sign is observed?

Increased respiratory rate and decreased blood pressure- could indicate burn wound sepsis complication

A nonstress test is scheduled for a client at 34 weeks' gestation who developed hypertension, periorbital edema, and proteinuria. Which of the following nursing actions should be included in the care plan in order to BEST prepare the client for the diagnostic test?

Instruct client to press button when she feels the fetus moving

The nurse cares for the client completing the first stage of labor. The client's partner is at the bedside and has been coaching according to exercises they learned in childbirth classes. Suddenly the client begins to shake and screams,"I can't stand this anymore!" The nurse encourages the partner to take which action?

Instruct the client to take shallow breaths during the contractions

The client comes to the clinic reporting severe facial pain. To collect subjective data from the client, it is most important for the nurse to take which action?

Interview the client

What is used during intravenous pyelogram (IVP) and how do you prep for an IVP?

Iodine- allergy can cause anaphylaxis. Administer cathartic enema and NPO midnight before

The nurse cares for the client recovering from abdominal surgery. During ambulation, the client reports a dull ache in the left leg. Which action does the nurse take first?

Place the client on bedrest and elevate the extremity. Need to start anticoagulant therapy before telling the patient to continue exercising because it could dislodge and cause a PE

The 2-year-old child is hospitalized. The nurse assesses the child and asks the parent about the activities the child does at home. Which activity would the nurse anticipate this child to perform?

Plays beside other children but not with them, able to build 6-7 block tower, can retrieve objects when asked to do so

What do CVP catheters measure?

Pressure in the right ventricle

The nurse plans care for the client immediately after a cesarean birth. Which nursing goal is most important?

Prevent fluid and electrolyte imbalances

The nurse cares for the client diagnosed with Cushing's syndrome. Which nursing action is the priority?

Prevent fluid overload- common in Cushing's syndrome. Also HF due to sodium/water retention. This is number one because it is a respiratory threat. Hyperglycemia is another issue, also skin breakdown and infections are least concerning

This med is always contraindicated in the same syringe with other meds

Prochlorperazine maleate (Compazine)

A woman is admitted to the labor and delivery unit in a sickle cell crisis. Which of the following nursing actions is the HIGHEST priority?

Provide adequate hydration

The nurse assists the parent to provide appropriate foods for the 3-year-old. Which action has the highest priority?

Provide finger foods

An older client has an order for digoxin 0.25 mg PO daily. Which information would cause the nurse to withhold the medication and contact the health care provider?

Pulse below 60, digoxin level outside 0.8-2, dysrhythmias

The nurse cares for the postoperative client. Four hours after surgery, the client voids 200 mL of urine with a specific gravity of 1.019. The nurse takes which action?

Records amount and time of urine. Normal specific gravity 1.01-1.03

The nurse cares for a client receiving IV antibiotics for 4 days. Which of the following should cause the nurse to be concerned about postinfusion phlebitis?

Reddened area or red streaks at the site

A client diagnosed with multiple sclerosis (MS) is at 39 weeks' gestation. The client is admitted to the labor and delivery unit in active labor. The client's vital signs are BP 127/72; pulse 72 bpm; cervix is 4 cm dilated; FHT 124 bpm; moderate contractions are 4 minutes apart. The nurse should anticipate the need for which of the following?

Reduce the amount of pain medication- need less because of MS

The college student has a positive Mantoux test. The health center clinic nurse takes which action?

Refers the student to appropriate center for testing- X-ray will be performed. TB suspected but not confirmed

The nurse cares for a postcholecystectomy client who had the T-tube removed this morning. Two hours after removal of the T-tube, the nurse notes that the 4 × 4 dressing covering the stab site is saturated with dark, greenish-yellow drainage. It is MOST appropriate for the nurse to take which of the following actions?

Remove the dressing and replace it with a more absorbent dressing

Which technique is correct for the nurse to use when changing a large abdominal dressing on an incision with a Penrose drain?

Remove the dressing layers at a time- avoids dislodging the drain

The client comes to the clinic for the hepatitis B vaccine. The client asks if more than one injection is necessary. Which response by the nurse is best ?

Repeated at 1 and 6 months

The nurse cares for clients in the pediatric clinic. The mother of a child calls the nurse to say that after administering Dimetane-DC cough syrup to her child, her child becomes very excitable and restless. Which of the following actions by the nurse is MOST appropriate?

Report the child's behavior to the physician for potential change in med

The nurse notices the elderly client has a dry, parched mouth and tongue. The nurse takes which action?

Rinses the mouth with room temperature tap water before and after meals

Which of the following symptoms are MOST likely to be observed by the nurse when a client is withdrawing from heroin?

Runny nose, yawning, fever, muscle and joint pain, diarrhea (narcotic withdrawal similar to flu)

Mantoux test

Screening for TB

The client has a subclavian triple lumen catheter used for administration of parenteral nutrition (PN). The health care provider orders all lumens be flushed with a diluted heparin solution BID. When the nurse attempts to flush the distal lumen, resistance is met. The nurse takes which action?

Secure with a leur lock cap and notifies the healthcare provider

A child returns to the recovery room after a bronchoscopy. The nurse should position the client in which of the following positions?

Semi-Fowler's position- check vitals every 15 minutes until stable

The client is diagnosed with a flaccid bladder following a spinal cord injury. The nurse teaches the client about dietary changes. Which beverages selected by the client indicate the teaching is effective?

Should give cranberry juice, prune juice, tomato juice. Not lemonade, excessive milk, orange juice, or overly acidic juices. Need to be somewhat acid drinks to prevent UTI and calculi formation

The client diagnosed with schizophrenia has become increasingly withdrawn to the point of mutism. It is most important for the nurse to take which action?

Sit with the patient for periods of time- still spend time with the patient and don't force communication

3 things about 3 month old

Sits up with head erect Turns head to locate sound Smiles spontaneously at mother

The nurse provides care for a client with left-sided hemiparesis from a stroke. The nurse notes a decrease in muscle tone on the client's left side. The nurse determines which nursing diagnosis is the priority?

Skin integrity

The nurse cares for the child diagnosed with a fractured right femur. The child is in balanced suspension traction with a Thomas splint and Pearson attachment. The nurse finds the weights on the floor and the child's feet touching the foot of the bed. Which nursing action is most appropriate?

Steady the traction and ask the child to bend the left leg and push up in bed.

The nurse performs discharge teaching for a client diagnosed with Addison's disease. It is MOST important for the nurse to instruct the client about which of the following?

Steroid replacement

The nurse instructs a client diagnosed with multiple sclerosis to perform intermittent self-catheterization at home. The nurse should include which of the following instructions?

Store catheter in plastic food-storage bag

The nurse prepares the client for a liver biopsy. How does the nurse position the client?

Supine with arms raised above the head

The client begins outpatient therapy sessions for management of a phobic disorder. The nurse identifies which intervention is most effective to reduce the client's symptoms?

Systematic desensitization- phobias are learned behaviors

The physician orders sucralfate (Carafate) 1 g PO bid for a client taking digoxin (Lanoxin) 0.25 mg daily. The client asks the nurse if both pills can be taken together at breakfast so that the client doesn't forget to take them. The nurse should advise the client to take which of the following actions?

Take sucralfate 1 hour before breakfast (works best on empty stomach) and digoxin 1 for after breakfast

The nurse cares for a patient following an appendectomy. The patient takes a deep breath, coughs, and then winces in pain. Which of the following statements, if made by the nurse to the patient, is BEST?

Take three deep breaths, hold your incision, and then cough- helps to breathe first to dilate airway and expand lungs

The nurse cares for clients in the hospital. Which nursing activities best promote nighttime rest for elderly hospitalized clients?

Tell the client how to call for help, postpone explanation of procedures etc., identify normal bedtime routine

The client begins doxepin hydrochloride 75 mg PO tid. The nurse recommends a change in the client's therapy if which occurs?

The client becomes excitable and has tremors. This med is an antidepressant and these symptoms may be overdose

A client at the health clinic asks the nurse if a "flu shot" should be obtained. Which health history factors are reasons for the client to receive the influenza vaccine?

The client is 69 years old The client plays poker with a group weekly The client volunteers at a preschool The client had bronchitis twice last year

The nurse cares for the client in the third trimester of pregnancy. The client has proteinuria, blood pressure of 154/92, and +3 pitting edema of the fingers. The nurse is most concerned by which additional assessment finding?

The client reports epigastric pain- usually indicative of impending convulsion

Which of the following assessments does the nurse expect to make regarding the developmental stage of a 40-year-old male?

The client starts measuring life accomplishments against goals

The nurse observes an LPN/LVN perform a wet-to-dry dressing change on a 2-inch abdominal incision. Which of the following behaviors, if performed by the LPN/LVN, indicates an understanding of proper technique?

The nurse packs wet gauze into the incision without overlapping the skin- if the wet gauze touches the skin it could cause breakdown. Need to take off old dressing without wetting it first to deride it. Clean from the inside of wound out.

The nursing team consists of an RN, two LPN/LVNs, and a nursing assistive personnel. The RN cares for which client?

The teenager with a head injury and GCS of 5 requiring personal care

Bactrim

Treatment for PCP- symptoms of dyspnea, tachypnea, persistent dry cough, fever, fatigue

Rifampin (Rifadin)

Treatment of TB- symptoms of fever, chills, night sweats, weight loss, anorexia

cranial nerve V

Trigeminal- sensation to facial muscles

The client is admitted with a diagnosis of a fractured right hip. The health care provider writes an order for Buck's traction. Which nursing action is most important?

Turn the client onto the affected side every 2 hours

The parents of a 1-month-old boy bring their son to the clinic for evaluation of a possible developmental dysplasia of the right hip. The nurse should observe for which of the following?

Uneven gluteal fold and thigh creases

The nurse cares for clients in the pediatric clinic. A mother reports that her infant's smile is "crooked". The nurse should assess which of the following cranial nerves?

VII- facial

A nurse recognizes that an initial positive outcome of treatment for a victim of sexual abuse by one parent would be that the client

Verbalizes that he/she is not responsible for the abuse

The client receives thrombolytic therapy. The health care provider orders morphine IM for pain. Before administering the injection, the nurse takes which action?

Verify order with physician- can have bleeding problems from thrombolytic therapy

The client returns to the room following an appendectomy. There is a large amount of serosanguineous drainage on the dressing. It is most important for the nurse to obtain an answer to which question?

Was there a tissue drain placed during surgery?

The primipara attends a class for women who plan to breast feed. To prepare for breast feeding, the nurse encourages the women to perform which implementation?

Wash breasts with warm water only

The elderly adult is admitted to a medical unit with shortness of breath. The client is diagnosed with an upper respiratory infection (URI). The client is placed on droplet precautions. The nurse administers oral medications to the client. As the nurse leaves the room, the nurse takes which action?

Wash hands then remove mask and throw away inside the room

The nurse provides care for a client who has a positive cytomegalovirus (CMV) titer. Which is the most appropriate action for the nurse to take while caring for the client?

Wear eyesore when emptying urinary drainage bag