NCLEX-PN Assesment test 23

The nurse is assigned to care for a client who is agitated. On entering the room, the client screams, "Why don't you just leave me alone?" The nurse should make which therapeutic response to the client?

"I can see that you are upset. I'll be back in a few minutes to see how you are doing."

The nurse has given the client with hepatitis instructions about postdischarge management during convalescence. The nurse determines that the client needs further teaching if the client makes which statement?

"I should resume a full activity level within 1 week."

Several children have contracted measles (rubeola) in a local school, and the nurse provides information to the mothers of the children about this communicable disease. Which statement by a mother indicates a need for further teaching?

"The infectious period ranges from 10 days before symptoms start to 15 days after the rash appears."

The nurse informs a client with an eating disorder about group meetings with Overeaters Anonymous. Which statement by the client indicates the need for further teaching about this self-help group?

"The leader of this self-help group is the nurse or psychiatrist."

A 2-year-old child is a suspected victim of child abuse. The nurse is interviewing the child's parent. Which statement made by the parent indicates a characteristic associated with child abuse?

"When I tell my child to do something once, I don't expect to have to repeat it."

A client is going to be transfused with a unit of packed red blood cells (PRBCs). The nurse understands that it is necessary to remain with the client for what time period after the transfusion is started?

15 minutes

The nurse is caring for a client who sustained burns on the entire right leg and anterior thorax. Using the rule of nines, the extent of the burn injury would be which percentage?

36%

A client who has been prescribed indomethacin (Indocin) for gout is asked to provide a stool sample for guaiac testing. The nurse explains that the purpose of the test is to make which determination?

A client who has been prescribed indomethacin (Indocin) for gout is asked to provide a stool sample for guaiac testing. The nurse explains that the purpose of the test is to make which determination?

The nurse is assisting in preparing to care for a child with a brain tumor who will be returning from the recovery room following debulking of the tumor. Which item should the nurse place at the bedside in preparation for the child's return from surgery?

A cooling blanket

The nurse is collecting data from the client about the presence of presumptive, probable, and positive signs of pregnancy. Which are the positive signs of pregnancy? Select all that apply.

Ballottement Fetal movements felt by examiner

Which finding would indicate that a child had a tonic-clonic seizure during the night?

Blood on the pillow

Vasopressin (Pitressin) is prescribed for the client with diabetes insipidus. During data collection, the nurse is particularly cautious in checking the client for which preexisting condition?

Coronary artery disease

The nurse is caring for a client who has been prescribed citalopram (Celexa) and checks the client for which signs/symptoms of serotonin syndrome? Select all that apply.

Abdominal pain 5. Increased blood pressure Diarrhea

A client who sustained a severe burn injury is brought to the emergency department. The nurse prepares to implement which immediate action?

Administer 100% humidified oxygen.

The nurse prepares to administer digoxin (Lanoxin) to a 3-year-old with a diagnosis of heart failure and notes that the apical heart rate is 120 beats per minute. Which nursing action is appropriate?

Administer the digoxin.

The nurse is providing information to unlicensed assistive personnel (UAP) regarding caring for the older adult. The nurse tells the UAPs that which situation portrays ageism?

Advising older adults to forgo aggressive treatment

The nurse is caring for a Hispanic client who reports that she is a practicing Roman Catholic. Which actions by the nurse demonstrate spiritual and cultural sensitivity? Select all that apply.

Allow client to observe communion daily if requested. 4. Facilitate anointing of the client by a priest if requested.

Which individual is least likely at risk for the development of Kaposi's sarcoma?

An individual working in an environment in which exposure to asbestos is possible

The clinic nurse is assisting to perform a focused data collection process on a client who is complaining of symptoms of a cold, a cough, and lung congestion. Which should the nurse include for this type of data collection? Select all that apply.

Auscultating lung sounds 2. Obtaining the client's temperatureObtaining information about the client's respirations

A 15-year-old child is scheduled to receive a series of the hepatitis B vaccine. The child arrives at the clinic for the first dose. The nurse collects data on the child before administering the vaccine and asks the child about a history of an allergy to which product?

Baker's yeast

A pregnant client tests positive for the hepatitis B virus (HBV), and the client asks the nurse whether she will be able to breast-feed the baby as planned after delivery. The nurse makes which response to the client?

Breast-feeding is allowed once the baby has been vaccinated."

The nurse is caring for a 3-hour-old infant and notes that the infant has not eaten since birth, is jittery, and has a weak cry. The mother states that she can't get the baby to eat. Which action should the nurse take first?

Check the blood glucose level.

Milieu therapy is prescribed for a client. The nurse understands that this type of therapy can best be described as which?

Client involvement in goal setting

The nurse is preparing to administer medications to an assigned client and notes that the prescription for furosemide (Lasix) is higher than the recommended dosage. The nurse calls the health care provider to clarify the prescription and asks the health care provider to prescribe a dosage within the recommended range. The health care provider refuses to change the prescription and instructs the nurse to administer the dose as prescribed. Which action should the nurse take?

Contact the nursing supervisor.

The nurse understands that which is a correct guideline for adult cardiopulmonary resuscitation (CPR) for a health care provider?

Each rescue breath should be given over 1 second and should produce a visible chest rise.

A pregnant client tells the nurse that she felt wetness on her peri-pad and that she found some clear fluid. The nurse immediately inspects the perineum and notes the presence of both a clear liquid and a portion of the umbilical cord. Which initial action should the nurse take?

Gently hold the presenting part upward.

A child with a right-to-left cardiac shunt is receiving propranolol (Inderal-LA). The health care provider visits the child and writes prescriptions in the child's record. The licensed practical nurse (LPN) reviews the prescriptions and notes that the child is placed on a nothing-by-mouth (NPO) status. The LPN consults with the registered nurse and prepares to monitor which parameter closely?

Glucose level

The nurse performs an admission assessment on a client who visits a health care clinic for the first time. The client tells the nurse that propylthiouracil (PTU) is taken daily. The nurse continues to collect data from the client, suspecting that the client has a history of which disorder?

Graves' disease

A client newly diagnosed with diabetes mellitus takes NPH insulin every day at 7:00 am. The nurse has taught the client how to recognize the signs of hypoglycemia. The nurse determines that the client understands the information presented if the client watches for which signs and symptoms in the late afternoon?

Hunger; shakiness; and cool, clammy skin

The nurse is assisting in the care of a group of clients on the nursing unit. The nurse determines that a client with which diagnosis is the one who has the least likely risk for developing third-spacing of body fluid?

Ischemic stroke

The nurse is assigned to a client who is psychotic. The client is pacing, agitated, and using aggressive gestures and rapid speech. The nurse determines which action is the immediate priority of care?

Provide safety for both the client and other clients on the unit.

The nurse is preparing a client for a magnetic resonance imaging (MRI) examination. Which action by the nurse is important?

Remove metallic objects from the client.

The nurse enters the room to find that the client's trash can is in flames. The nurse should take which action first?

Remove the client from the room.

A child with rubeola (measles) is being admitted to the hospital. When preparing for the admission of the child, which precautions should be implemented?

Respiratory

A client scheduled for a skin biopsy asks the nurse how painful the procedure is. The nurse should make which response to the client?

The local anesthetic may cause a burning or stinging sensation."

The nurse is providing information to the family of a child about a synthetic cast that has been applied to the child for the treatment of a clubfoot. Which information should the nurse provide to the mother?

The synthetic cast allows for greater mobility than a plaster cast.

The nurse is reviewing the preoperative prescriptions of a client with a colon tumor who is scheduled for abdominal perineal resection. The nurse notes that the health care provider has prescribed neomycin sulfate (Mycifradin) for the client. Which is the rationale for prescribing this medication?

To decrease the bacteria in the bowel

Lamivudine (Epivir) is prescribed for a client with human immunodeficiency virus (HIV) who is presently taking zidovudine (Retrovir). Which should the nurse reinforce in the medication instructions to the client?

To report vomiting or abdominal pain to the health care provider

Isotretinoin (Amnesteem, Clavaris) is prescribed for a client with severe acne. Before the administration of this medication, the nurse anticipates that which laboratory test will be prescribed?

Triglyceride level

In providing initial care to the newborn following delivery, what is the nurse's priority action?

Turn the infant's head to the side.

The nurse is collecting data on a client with rheumatoid arthritis. The nurse looks at the client's hands and notes these characteristic deformities. The nurse identifies this deformity as which? Refer to figure.

Ulnar drift

The nurse is performing an environmental assessment in the home of an older client. Which requires immediate attention?

Unsecured scatter rugs

Meperidine hydrochloride (Demerol) is prescribed for the client with pain. Which should the nurse monitor as a side effect of this medication?

Urinary retention

The nurse is caring for a client with glaucoma who is receiving acetazolamide (Diamox Sequels) daily. Which sign/symptom indicates to the nurse that the client is experiencing an adverse effect related to the medication?

Low back pain and dysuria

A client underwent creation of an ileostomy 2 days ago. The nurse checks the client for signs of which acid-base disorder that can occur in a client with an ileostomy?

Metabolic acidosis

The nurse is reinforcing instructions to a mother who is bottle-feeding a baby and who is complaining of breast engorgement. Which statement by the client indicates a need for further teaching?

I should avoid wearing a bra at this time."

The nurse has reinforced instructions about measuring blood glucose levels to a client newly diagnosed with diabetes mellitus. The nurse determines that the client understands the procedure when making which most accurate statement?

I should check my blood glucose level before eating each meal, regardless of how much I eat."

The nurse reinforces instructions to the mother of a child who has been hospitalized with croup. Which statement made by the mother would indicate the need for further teaching?

I will give my child cough syrup if a cough develops."

A client is scheduled for insertion of a peripherally inserted central catheter (PICC), and the nurse explains the advantages of this catheter. Which statement by the client indicates a lack of understanding about this type of catheter?

It is specifically designed for short-term use.

The nurse is reinforcing teaching to a pregnant woman about the physiological effects and hormone changes that occur during pregnancy. The woman asks the nurse about the purpose of estrogen. The nurse bases the response on which purpose of estrogen?

It stimulates uterine development to provide an environment for the fetus and stimulates the breasts to prepare for lactation.

A client has just undergone a gastroscopy. Which action should be taken by the nurse as the essential postprocedure nursing intervention?

Monitoring for the gag reflex

Which statement should the nurse include when providing safety instructions to the parents of an infant with a diagnosis of hydrocephalus?

When picking up your infant, support the infant's neck and head with the open palm of your hand."

The nurse is reinforcing instructions to a client regarding the use of ice packs to treat an eye injury. The nurse instructs the client to do which action?

Wrap a plastic bag filled with ice with a pillowcase and place it on the eye.

The nurse is caring for a client who has a history of opioid abuse and is monitoring the client for signs of withdrawal. Which manifestations are specifically associated with withdrawal from opioids?

Yawning, irritability, diaphoresis, cramps, and diarrhea

A client with a herniated intervertebral lumbar disk complains of a knifelike, stabbing pain in the lower back, as well as pain radiating into the right buttock. The nurse interprets that the sharp, stabbing pain is probably a result of which?

Muscle spasm in the area of the herniated disk

The nurse is assessing a client who takes antipsychotic medication for which signs/symptoms that might indicate the development of neuroleptic malignant syndrome? Select all that apply.

Temperature of 104.8° F 5. Blood pressure of 210/130mm Hg Diaphoretic

The nurse is caring for a client with severe cardiac disease. While the nurse is caring for the client, the client states, "If anything should happen to me, please make sure that the doctors do not try to push on my chest and revive me." Which is the appropriate nursing action?

Tell the client that it is necessary to notify the health care provider of the client's request.

A client who had a lung resection for cancer has been told that bone metastasis has occurred. The client is considering megavitamin and diet therapy because the original surgery did not provide a cure. The client asks the nurse for an opinion of these therapies. In formulating a response, the nurse incorporates which concepts?

The client's right to autonomy and the nurse's obligation to behave ethically

A client has a new prescription to take guaifenesin every 4 hours as needed. Which medication instructions should the nurse reinforce?

Take the tablet with a full glass of water.

Two weeks following delivery, a client experiences subinvolution of the uterus. Which findings indicate subinvolution? Select all that apply.

Persistent pelvic heaviness 5. Foul-smelling vaginal discharge Constant fever of 101° F

One unit of packed red blood cells has been prescribed for a client postoperatively because the client's hemoglobin level is low. The health care provider prescribes diphenhydramine (Benadryl) to be administered before the administration of the transfusion. Why is this medication being given?

Prevent a rash and pruritus.

The nurse is preparing to reinforce instructions to a client regarding how to safely use crutches. Before initiating the teaching, the nurse collects data on the client. Which priority data would be included?

The client's vital signs, muscle strength, and previous activity level

The nurse reviews a client's electrolyte results and notes that the potassium level is 5.4 mEq/L. Which should the nurse observe for on the cardiac monitor as a result of this laboratory value?

Narrow, peaked T waves

The nurse is reading the results of a tuberculin skin test for a client who has no documented health problems. The site has no induration and a 1-mm area of ecchymosis. The nurse interprets the data as which result?

Negative

The nurse is monitoring a client in active labor and notes that the client is having contractions every 3 minutes that last 45 seconds. The nurse notes that the fetal heart rate between contractions is 100 beats per minute. Which nursing action is appropriate?

Notify the registered nurse (RN).

A postgastrectomy client who is being discharged from the hospital tells the nurse, "I hope my stomach problems are over. I need to get back to work right away. I've missed a lot of work, and I'm really behind. If I don't get my act together, I may lose my job." Based on the client's statement, the nurse determines that at this time, it is appropriate to discuss which topic?

Reducing stressors in life

The nurse is planning care for a child with hemolytic-uremic syndrome (HUS). The child has been anuric and will be receiving peritoneal dialysis treatment. The nurse should plan to include which intervention in the care of the child?

Restriction of fluids, as prescribed

A licensed practical nurse (LPN) is told that baclofen (Lioresal) is prescribed for an assigned client. The LPN questions the registered nurse about the health care provider's prescription if which condition is noted on the client problem list?

Seizure disorder

A health care provider tells the nurse that a potassium-retaining diuretic is being prescribed for the client with heart failure. The nurse reviews the health care provider's prescriptions, expecting that which medication will be prescribed?

Spironolactone (Aldactone)

The nurse is assisting in conducting a group therapy session, and a client with a manic disorder is monopolizing the group. The appropriate nursing action is which?

Suggest that the client stop talking and try listening to others.

A mother arrives at the clinic with her child. The mother tells the nurse that the child has had a fever and a cough for the past 2 days, and this morning the child began to wheeze. Viral pneumonia is diagnosed. Which component of the treatment plan should the nurse anticipate?

Supportive treatment

A 6-year-old child has just been diagnosed with localized Hodgkin's disease, and chemotherapy is planned to begin immediately. The mother of the child asks the nurse about radiation therapy because it was not prescribed as a part of treatment. Which is the most appropriate response to the mother?

The child is too young to have radiation therapy."

A client is being prepared for electroconvulsive therapy (ECT). The nurse's plan of care for the night before ECT treatment should include which intervention?

The client shampoos and dries the hair, freeing it of all hair spray and creams.

The client with chronic kidney disease who is scheduled for hemodialysis this morning is due to receive a daily dose of enalapril (Vasotec). When should the nurse plan to administer this medication?

On return from dialysis

A client with a seizure disorder is being admitted to the hospital. Which should the nurse plan to implement for this client? Select all that apply.

Pad the bed's side rails. 2. Place an airway at the bedside. 3. Place oxygen equipment at the bedside. 4. Place suction equipment at the bedside.