nclex pn data collection
A client admitted to the hospital with a neurological problem indicates to the nurse that magnetic resonance imaging (MRI) may be done. Which finding noted in the client history indicates that the client may be ineligible for this diagnostic procedure?
Prosthetic valve replacement
Penicillin G procaine (Wycillin), 1 million units intramuscularly, has been prescribed for the child with a throat infection. The child's weight is 62 pounds. The safe pediatric dosage for a child that weighs greater than 60 pounds is 600,000 to 1,200,000 units daily. Which should the nurse determine about the medication dosage?
The dosage is within the safe range.
Which laboratory results indicate a therapeutic drug level? Refer to chart. Select all that apply.
1,3,5
The nurse notes that the health care provider has documented a diagnosis of presbycusis on the client's chart. The nurse understands that this condition is accurately described as which?
A sensorineural hearing loss that occurs with aging
The nurse is caring for a child receiving carbamazepine (Tegretol) who has a carbamazepine level drawn. Which result indicates a therapeutic level?
6 mcg/mL
The nurse is planning care for a hospitalized child with syndrome of inappropriate antidiuretic hormone (SIADH). The health care provider has prescribed that the 24-hour fluid maintenance for the child weighing 12 kg be at 3/4 of the maintenance. Using the formula shown (refer to figure), which volume of fluid should the nurse plan as the 24-hour maintenance for this child?
825 mL
Which client is at risk for developing thyrotoxicosis?
A client with Graves' disease who is having surgery
Which individual is least at risk for the development of Kaposi's sarcoma?
An individual working in an environment where exposure to asbestos exists
The nurse is caring for a child with a diagnosis of intussusception. Which manifestation should the nurse expect to note in this child?
Blood and mucus in the stools
The nurse observes that a client's nasogastric tube has suddenly stopped draining. The tube is connected to suction, the machine is on and functioning and all connections are snug. The tube is secured properly and does not appear to have been dislodged. After checking placement, the nurse gently flushes the tube with 30 mL of normal saline, but the tube still is not draining. The nurse analyzes this problem as which?
Channels of gastric secretions may be bypassing the holes in the tube; turning the client will promote stomach emptying.
A client with a fractured femur is placed in skeletal traction. The nurse should do which to monitor for nerve injury?
Check the neurovascular status of the affected extremity.
The nurse reads the chart of a client who has been diagnosed with stage 3 Lyme disease. Which sign/symptom supports this diagnosis?
Complaints of joint pain
The nurse is collecting data on a client diagnosed with Parkinson's disease. Which finding indicates a serious complication of this disorder?
Congested cough and coarse rhonchi heard during auscultation
The nurse is caring for a client with pheochromocytoma. Which data are indicative of a potential complication associated with this disorder?
Congestion heard on auscultation of the lungs
The nurse is collecting data on a newborn infant with a diagnosis of a hiatal hernia. Which finding should the nurse expect to note in the infant?
Coughing, wheezing, and short periods of apnea
The client who has a cold is seen in the emergency department with an inability to void. Because the client has a history of benign prostatic hyperplasia, the nurse determines that the client should be questioned about the use of which medication?
Decongestants
A complete blood cell count is performed on a client with systemic lupus erythematosus (SLE). The nurse should suspect that which finding will be reported from this blood test?
Decrease of all cell types
A nurse is monitoring a pregnant client for the warning signs/symptoms of gestational hypertension. Which are signs/symptoms of this complication of pregnancy? Select all that apply.
Edema Proteinuria Thrombocytopenia
Which are risk factors for systemic lupus erythematous (SLE)? Select all that apply.
Female gender African-American origin Being in the childbearing years
A client is admitted with a diagnosis of pneumonia and dehydration. The nurse monitors the client for which symptom that correlates with this client's fluid imbalance?
Flat neck veins
The nurse is admitting a child with a diagnosis of lactose intolerance. Which finding does the nurse expect to note?
Frothy stools
The nurse is assessing a client diagnosed with sinusitis. Which are signs and symptoms of sinusitis? Select all that apply.
Headache especially in the morning Elevated white blood cell (WBC) count Feeling of heaviness over affected area
A prenatal client diagnosed with anemia has come to the clinic. After reviewing the client's health record, the nurse notes that the laboratory values indicate low hemoglobin and hematocrit levels. Which problem does the data best support?
High risk for infection
Warfarin sodium (Coumadin) is prescribed for a client. The nurse expects that the health care provider will prescribe which laboratory test to monitor for a therapeutic effect of the medication?
International Normalized Ratio (INR)
The nurse is caring for a client with kidney failure. The laboratory results reveal a magnesium level of 3.6 mg/dL. Which sign does the nurse expect to note in the client, based on this magnesium level?
Loss of deep tendon reflexes
The nurse is assisting in caring for a client who is receiving an intravenous infusion of 1000 mL of normal saline with 40 mEq of potassium chloride. The nurse is monitoring the client for signs of hyperkalemia. Which sign/symptom should be noted in the client if hyperkalemia is present?
Muscle weakness
The nurse is checking the insertion site of a peripheral intravenous (IV) catheter. The nurse notes the site to be reddened, warm, painful, and slightly edematous in the area of the vein proximal to the IV catheter. The nurse interprets that this is likely the result of which?
Phlebitis of the vein
A client is at risk for developing hypocalcemia. The nurse determines that the client is experiencing this electrolyte disturbance if which sign is noted?
Positive Trousseau's sign
A client with acquired immunodeficiency syndrome (AIDS) is diagnosed with cutaneous Kaposi's sarcoma. Based on this diagnosis, the nurse understands that this has been determined by which?
Punch biopsy of the cutaneous lesions
An adult client had a cerebrospinal fluid (CSF) analysis after lumbar puncture. The nurse interprets that a negative value of which is consistent with normal findings?
Red blood cells
The nurse is caring for a client with a diagnosis of chronic obstructive pulmonary disease (COPD). The nurse should monitor the client for which acid-base imbalance?
Respiratory acidosis
Oxybutynin chloride (Ditropan XL) is prescribed for a client with neurogenic bladder. Which sign would indicate a possible toxic effect related to this medication?
Restlessness
The nurse is assisting in performing a prenatal examination on a client in the third trimester of pregnancy. The health care provider performs Leopold's maneuvers on the client. Which maneuver indicates the position of the fetus?
Second
The nurse is collecting data from a client who is suspected of having mittelschmerz. Which should the nurse expect to note?
Sharp pain located on the right side of the pelvis
The nurse is caring for a client who has been prescribed gabapentin (Neurontin) and is monitoring for adverse effects of the medication. Which finding indicates a potential adverse effect?
Slurred speech
The nurse is caring for a 2-year-old child diagnosed with croup. The nurse collects data on the child, knowing that which is characteristic of this illness? Select all that apply.
The cough is harsh and metallic. Inspiratory stridor may be present. Symptoms usually worsen at night and are better during the day It is usually preceded by several days of upper respiratory infection symptoms.
A health care provider has prescribed phenobarbital sodium (Luminal Sodium), 25 mg orally twice daily for a child with febrile seizures. The child's weight is 7.2 kg. The safe pediatric dosage is 1 to 6 mg/kg/day. What should the nurse determine about the medication dosage?
The dosage is too high.
The client has been on treatment for rheumatoid arthritis for 3 weeks. Which is most important for the nurse to check during the administration of etanercept (Enbrel)?
The white blood cell counts and platelet counts
The client with acute myelocytic leukemia is being treated with busulfan (Myleran). Which laboratory value should the nurse specifically monitor during treatment with this medication?
Uric acid level
An emergency department nurse is caring for a client who sustained a burn injury to the anterior arms and anterior chest area. The client sustained the burn from a home fire that occurred in the basement. Which data would indicate that the client sustained a respiratory injury as a result of the burn?
Use of accessory muscles for breathing
Which arterial blood gas (ABG) result should the nurse anticipate in the client with profuse vomiting for 2 days?
pH 7.49; Pco2 45; HCO3- 30
An adult client is admitted to the emergency department following a burn injury. The burn initially affected the client's upper half of the anterior torso, and there were circumferential burns to the lower half of both of the arms. The client's clothes caught on fire, and the client ran, causing subsequent burn injuries to the entire face (anterior half of the head) and the upper half of the posterior torso. Using the rule of nines, which percentage would characterize the burn injury? Refer to the figure. Fill in the blank.
31.5
The nurse is reviewing the client's health record and notes that the client elicited a positive Romberg sign. The nurse understands that this indicates which finding?
A significant sway when the client stands erect with feet together, arms at the side, and the eyes closed
The nurse is monitoring the daily weight of an infant with heart failure (HF). Which finding alerts the nurse to suspect fluid accumulation and thus the need to notify the registered nurse?
A weight gain of 1 lb in 1 day
A client with a nasal tumor is being admitted to the hospital. The nurse collects data about which primary symptom that the client is expected to exhibit?
Nasal obstruction
