NCLEX PN Final for Knott

The intensive care nurse is caring for a client who has just been extubated. Which interventions are appropriate at this time? Select all that apply.

*Administer warm humidified oxygen via face mask *provide mouth care with oral sponges *start the client on the incentive spirometer

A nurse is reinforcing education to an adolescent client on skin cancer prevention with special focus on melanoma. Which statements should the nurse include? Select all that apply.

*Apply broad spectrum sunscreen before and during activities *reapply sunscreen after swimming *sunburns can occur even on overcast days

The nurse is reinforcing teaching on oral care and symptom management to a client with head and neck cancer who has developed mouth sores related to external radiation therapy. What should the nurse encourage the client to do? Select all that apply.

*Apply water soluble lubricating agent to moisturize mouth *Avoid hot liquids and food that is spicy or acidic *Brush teeth with soft bristle toothbrush *Cleanse mouth with normal saline after meals

The practical nurse is collaborating with the registered nurse to develop a plan of care for a 16-year-old client with bulimia nervosa. Which interventions would be included in the plan of care? Select all that apply.

*Assess for electrolyte imbalance *Be alert for hidden wrappers *Monitor client 60-90 after meals

Which actions would the nurse expect to be included in the care plan for a client hospitalized for bipolar disorder, acute manic episode? Select all that apply.

*Assign the client a private room *Choose clothing for client *Schedule client for physical activity for a staff member

A client with throat cancer receives radiation therapy to the head and neck. Which strategies are appropriate to increase oral intake? Select all that apply.

*Avoid irritants such as spicy or acidic foods *Encourage liquid nutritional supplements *Use artificial saliva to control dryness

The nurse is inspecting the legs of a client with a suspected lower-extremity deep venous thrombosis. Which of the following clinical manifestations should the nurse expect? Select all that apply.

*Calf pain *Dry, shiny, hairless skin *lower leg warmth and redness *Unilateral leg edema

The nurse cares for a client with a pulmonary embolism. Which of the following clinical manifestations would the nurse anticipate?

*Chest pain *dyspnea *hypoxemia *tachypnea

Several clients attend a health screening program at a local health fair. The nurse recognizes that which of the following clients are at risk for gastric cancer? Select all that apply.

*Client currently undergoing treatment for pernicious anemia *Client who frequently consumes pickled and smoked foods *Client who is obese with a BMI >30 *Client who was previously treated for Helicobacter pylori infection

The medical-surgical nurse cares for a group of clients. Which client situations would prompt the nurse to notify the health care provider during the middle of the night? Select all that apply.

*Client develops right upper sided and lower extremity drift *Client found lying unconscious on the floor *Client has order for heparin, surgery scheduled for am *client has serum sodium of 124

The practical nurse is assisting the registered nurse in conducting client intake histories at a family practice clinic. Which client findings or histories indicate a need for heightened concern that the client may have cancer? Select all that apply.

*Client reports nagging cough with hoarseness in the last three months *female client weighed 150lb and lost 15 lb in the last three months *Male client who reports orange peel skin on his breast

The nurse identifies which of the following clients as being at high risk for developing colorectal cancer? Select all that apply.

*Client who consumes a diet high in red meat and low in fiber *Client who is moribly obese *Client with a 15 yr history of ulcerative colitis *Client with a 40 history of smoking *Client with family history of colorectal cancer

The nurse is caring for a client with community-acquired pneumonia. When collecting client data, the nurse should anticipate which findings? Select all that apply.

*Crackles *Pleuritic chest pain *productive cough

Which findings support a diagnosis of post-traumatic stress disorder? Select all that apply.

*Difficulty concentrating *feeling detached from others *flashbacks of traumatic experience *persistent angry, fearful mood

The practical nurse is collaborating with the registered nurse to develop a care plan for a homeless client just brought into the emergency department with frostbite to the fingers and toes. The client is experiencing numbness, and assessment shows mottled skin. Which interventions should be included in the client's plan of care? Select all that apply.

*Elevate affected extremities after rewarming *Provide adequate analgesics *Provide continuous warm water soaks

The nurse is caring for a client with overflow urinary incontinence related to diabetic neuropathy. Which of the following interventions are appropriate? SATA

*Encourage client to bear down while attempting to void *Inspect perineal area for evidence of skin breakdown *Measure postvoid residual volumes as prescribed *Tell the client to wait 30 seconds after voiding and then attempt to void again

The nurse is participating in a staff presentation to review risk factors for skin cancer. Which of the following risk factors should the nurse include? Select all that apply.

*Family history of skin cancer *High number of moles *Immunosuppressant meds *Outdoor occupation

The nurse reinforces safety precautions of home oxygen use to a client with chronic obstructive pulmonary disease (COPD) being discharged with a nasal cannula and portable oxygen tank. Which client statement indicates the need for further teaching? Select all that apply.

*I can apply vasoline when my nostrils feel dry *I can cook on my gas stove *I can increase my oxygen from 2 to 6 liters when I feel short of breath

A client with a 20-year history of schizophrenia is hospitalized. The client appears visibly upset, approaches the nurse, and says in a shaky voice, "I can't find my headband. I can't find my headband. The oil is going to leak out of the crack in my head." What is the best response by the nurse?

Let's go back to your room and find your headband

The nurse provides teaching for a client newly prescribed disulfiram for alcohol abstinence. Which information is the priority for the nurse to include?

List of everyday items that contain alcohol

A client with schizophrenia says to the nurse, "The world turns as the world turns on a ball at the beach. But all the world's a stagecoach and I took the bus home." The nurse recognizes this statement as an example of which of the following?

Loose associations

The nurse is caring for a 10-year-old diagnosed with attention-deficit hyperactivity disorder (ADHD). In addition to the 3 core symptoms of ADHD (hyperactivity, impulsiveness, and inattention), which of the following would the nurse expect to find?

Low self esteem and impaired social skills

The nurse is caring for a hospitalized client diagnosed with thyrotoxicosis (thyroid storm). Which action is most appropriate to assign to unlicensed assistive personnel?

Lower the temperature in the client's room

The nurse is reinforcing home care education to a client newly diagnosed with von Willebrand disease. Which of the following client statements demonstrate correct understanding of the education? Select all that apply.

*I can use a humidifier to prevent nosebleeds *I need to avoid contact sports such as soccer and hockey *I should use a soft bristle toothbrush and electric razor *I will call my doctor if I soak a menstrual pad in an hour

The nurse is reinforcing information for a client with chronic obstructive pulmonary disease. Which statements by the client indicate an understanding of the pursed-lip breathing technique? Select all that apply.

*I exhale 4 seconds thru pursed lips *I inhale 2 seconds thru nose, keeping mouth closed

The nurse is assisting with data collection from clients in a gastroenterology clinic. Which of the following client statements include risk factors for gastric cancer? Select all that apply.

*I frequently eat salt cured meat *I was told I have not cleared the Helicobacter pylori infection *My health care provider prescribed vitamin B12 for pernicious anemia *My health provider told me to lose 30 lbs

A client with chronic kidney disease has a subcutaneous arteriovenous fistula (AVF) placed in the nondominant left wrist for hemodialysis. Which of the following statements indicate the client understands how to care for the fistula properly? Select all that apply.

*I will squeeze a small ball with my left hand several times a day *I will touch the site and feel for a vibration several times a day *I will try not to sleep on my left arm

The nurse is reinforcing general skin care guidelines to a client receiving teletherapy (external beam radiation therapy). Which statements does the client make that indicate proper understanding of the information? Select all that apply.

*I will use extra measures to prevent sun, skin exposure *I will wash the treatment site with lukewarm water and mild soap *I will wear, soft loose fitting clothes

A nurse is assisting with preventive health screenings at a community health event. Which of the following client statements should the nurse recognize as a warning sign of cancer? Select all that apply.

*Last month when I was doing my breast exam, I noticed a marble size bump *My mole is itchy, and the edges have become uneven with a bluish blackish color

An elderly client with emphysema comes for a routine follow-up visit. The nurse assisting with the initial assessment knows that which manifestations are most characteristic of emphysema? Select all that apply.

*barrel chest *decreased activity tolerance *diminished breath sounds

The nurse is caring for a child newly diagnosed with cystic fibrosis. What interventions does the nurse expect to be included in the client's multidisciplinary plan of care? Select all that apply.

*chest physoitherapy *genetic counseling *spiritual support

The nurse is reviewing the records of an adolescent client. Which findings suggest that the client may need referral for depression screening? Select all that apply.

*client has had school disciplinary issues and absenteeism due to outbursts *Client has lost 8 lbs over the last 3 weeks w/o trying *Client is often found sleeping during class *Client quit sports, despite receiving atheletic awards

The nurse reinforces discharge instructions to a client who was hospitalized for deep venous thrombosis that has now resolved. Which instructions should the nurse include to prevent reoccurrence? Select all that apply.

*drink plenty of fluids and limit caffeine and alcohol *Elevate legs on footstool when sitting and dorsiflex feet often *Resume the walking and swimming asap

Which teaching instructions should the nurse reinforce to a client with advanced chronic obstructive pulmonary disease? Select all that apply.

*obtain a pneumococcal vaccine *report increased spetum

A nurse in the pulmonology clinic is reinforcing teaching for a college athlete who was recently diagnosed with moderate persistent asthma. Which common asthma trigger should this client avoid?

Aspirin and NSAIDS

The nurse caring for multiple clients on a medical-surgical unit should delegate which action to the nursing assistant?

Assist client, post hip fracture to the bathroom

The nurse is preparing to administer morning medications to a client with type 2 diabetes mellitus and end-stage renal disease who is scheduled for dialysis today. Which medication should the nurse hold for clarification prior to administration?

Atenolol

The nurse is caring for a client recently diagnosed with an active deep vein thrombosis (DVT). Which action by the client would require an immediate intervention by the nurse?

B-type natriuretic peptide (BNP)

While completing hourly rounds, the nurse finds a client lying on the floor in a gown that is soiled with stool. Which documentation entry by the nurse is inappropriate to include in the client's medical record?

Client repeatedly refused to use call light, despite teaching

The nurse assists with a community skin cancer screening program. Which finding would be most concerning?

Client with a flat, 1cm lesion on the neck that is black and brown

The nurse is reinforcing teaching on nutritional therapy for a client with chronic kidney disease. Which statement indicates that further teaching is needed?

I can use salt substitute because I am required to both sodium and potassium in my diet

he nurse is conducting a seminar for parents of adolescents about health issues common to this age group. Which parent's statement indicates that the adolescent may have bulimia nervosa?

I found several empty boxes in my child's waste basket

The nurse reinforces teaching about strategies to prevent community-acquired pneumonia. Which statement made by the client indicates the need for further instruction?

I got the one time pneumonia shot, so I don't need it again

The nurse is caring for a client receiving treatment for benign prostatic hyperplasia. Which client statement requires further investigation?

I have a burning sensation when I urinate

The nurse is caring for a client with schizophrenia who has been experiencing visual hallucinations. The client says in a trembling voice, "There's a bad man standing over there in the corner of my room." What is the best response by the nurse?

I know your frightened but I do not see a man in your room

The nurse reinforces teaching about the use of the peak flow meter to evaluate airflow to a client newly diagnosed with asthma. Which statement by the client indicates an understanding of the correct technique?

I will exhale quickly and forcibly through the mouthpiece

The nurse is reinforcing discharge teaching for a client who had aortic valve replacement with a mechanical heart valve. Which statement by the client indicates that teaching has been effective?

I will shave with an electric razor from now on

An elderly client is admitted with an acute exacerbation of chronic obstructive pulmonary disease. Pulse oximetry is 84% on room air. The client is restless, has expiratory wheezing and a productive cough, and is using the accessory muscles to breathe. Which prescription should the nurse question?

IV morphine 2mg now and may repeat every 2 hours

A client's arterial blood gases (ABGs) are shown in the exhibit. The nurse would expect which finding to demonstrate that the client is compensating for the ABGs?

Increase in respiratory rate

The nurse is reinforcing teaching to a support group for partners of military veterans suffering from posttraumatic stress disorder (PTSD). A participant asks the nurse how to identify the typical symptoms of PTSD. The nurse responds that most individuals with PTSD report which symptoms?

Increased anxiety, reliving the event, isolation of others

A client is receiving nasogastric tube feedings as nutritional rehabilitation for anorexia nervosa. After a weigh-in, the client learns of gaining 2 lb (0.9 kg) and says to the nurse, "See what your force feeding has done to me? I'm fatter and uglier than ever." What is the best action by the nurse?

Initiate one on one supervision during client feedings

The nurse is caring for a client who was raped 2 months ago and has rape trauma syndrome. The client says, "There is something that I need to share, but I am afraid. I need to know that you will not tell anyone else if I share it with you." Which response by the nurse is appropriate?

It depends on what you tell me. Some things may need to be shared with your therapist

A client with chronic kidney disease has blood laboratory results as shown in the exhibit. What is the best afternoon snack to provide to this client?

Apple slices and caramel dip

A client has just returned from the cardiac catheterization laboratory for a permanent pacemaker placement. How should the nurse document the rhythm on the client's cardiac monitor?

Artiroventricular paced rhythm

The nurse reviews the admission history of a 70-year-old client diagnosed with chronic obstructive pulmonary disease (COPD). Which of the following statements by the client does the nurse recognize as contributing to the development of COPD? Select all that apply.

* I have smokes a pack of cigarettes for since I was 16. stopped smoking a year ago *I was a car mechanic for 40 yrs

The nurse is caring for a client with an exacerbation of asthma following a viral respiratory illness. When collecting data, the nurse expects to find which clinical characteristics of a severe asthma exacerbation? Select all that apply.

*Accessory muscle use *chest tightness *high pitched expiratory phase *tachypnea

The nurse is reinforcing discharge teaching for a client who had aortic valve replacement with a mechanical heart valve. Which statement by the client indicates that teaching has been effective?

80 year old who just had surgery four hours ago for a fractured hip

Which client is at greatest risk for pulmonary embolism?

A client 6 hours post c-section

A client comes to the community mental health clinic seeking treatment for severe anxiety associated with a recent job promotion that requires a 30-minute commute via train. The nurse recognizes that this client most likely suffers from which psychological disorder?

Agoraphobia

Which clinical manifestations would the nurse identify with severe anorexia nervosa? Select all that apply.

Amenorrhea, electrolyte imbalace, prescence of lanugo, weight loss of more than 25% below normal weight

The nurse is caring for a client with an exacerbation of chronic obstructive pulmonary disease and pneumonia. The nurse notes that the client has become disoriented and restless and becomes concerned that the client may have impaired oxygenation due to poor secretion clearance. Which is the nurse's priority action?

Administer oxygen via venturi mask

A client underwent a transurethral resection of the prostate (TURP) today and has a 3-way Foley urinary catheter with continuous bladder irrigation (CBI). The client reports lower abdominal pain rated as an 8 on a scale of 0-10. What action should the nurse carry out first?

Check the amount and charcteristics of urine output

The nurse is caring for a client with advanced chronic obstructive pulmonary disease. Which clinical finding will require further investigation by the nurse?

Bilateral 3+ pitting edema in the client's ankles

Which task would the practical nurse on a surgical unit assign to experienced unlicensed assistive personnel?

Feeding a client with dementia with a blood sugar <70

The nurse is reinforcing information to a client in preparation for discharge from the hospital when the client breaks down crying, saying "the health care provider thinks I am crazy because I was diagnosed with a functional disorder." Which statement would be the best reply to this client?

Functional disorder is a diagnosis for a genuine medical issue that the medical science does not fully understand

The nurse is caring for a client recently diagnosed with an active deep vein thrombosis (DVT). Which action by the client would require an immediate intervention by the nurse?

The client is massaging the leg at site of inflammation

A client recently admitted to an inpatient unit for treatment of alcoholism says to the nurse, "I only came here to get away from my nagging spouse. Sometimes I think my spouse is the one who should be here. I can stop drinking any time I want." The nurse recognizes that the client is exhibiting which of the following defense mechanisms?

Denial and projection

The nurse on the mental health unit recognizes the use of which defense mechanism when a client leaves a stressful family meeting and immediately begins to verbally abuse a roommate?

Displacement

The nurse at a mental health clinic is performing a suicide risk screening on four clients experiencing depression. Which client does the nurse recognize as being most at risk for suicide?

Divorced man, with parkinson, newly laid off

The nurse is reinforcing information to a client in preparation for discharge from the hospital when the client breaks down crying, saying "the health care provider thinks I am crazy because I was diagnosed with a functional disorder." Which statement would be the best reply to this client?

Encourage the client to talk about the trauma

The nurse is reinforcing teaching to the parent of a child recently diagnosed with attention-deficit hyperactivity disorder, combined type. Which statement by the parent requires intervention?

My child will outgrow this disorder by 20 yrs of age

A client undergoes transurethral resection of the prostate for benign prostatic hyperplasia. The client has a 28 Fr, 30-mL balloon, 3-way Foley catheter with continuous bladder irrigation. Which finding by the nurse best indicates that the bladder irrigation is running at an adequate rate?

Output urine is pink in color

A female client with liver cirrhosis and chronic anemia is hospitalized for a deep venous thrombosis. The client is receiving a heparin infusion and suddenly develops epistaxis. Which laboratory value would indicate that the heparin infusion needs to be turned off?

PPT of 110 seconds

A nurse is caring for an elderly client who had a colectomy for removal of cancer 2 days ago. The client is becoming increasingly restless and has been given IV morphine every 2 hours for severe pain. Respirations are 28/min and shallow. Which arterial blood gas results best indicate that the client is in acute respiratory failure and needs immediate intervention?

PaO2 49mm (6.5) PaCO2 60 mm

A nurse is caring for a client 2 days after surgical creation of an arteriovenous fistula in the forearm. Which finding should the nurse report immediately to the health care provider?

Pale skin of the hand of the arm with the arteriovenous fistula

The nurse is caring for a postoperative client with a Hemovac drain. Which task request is inappropriate for the nurse to make to the experienced unlicensed assistive personnel?

Please change sterile dressing on Hemovac after bathing

The nurse is assigning client care tasks to unlicensed assistive personnel. Which statement by the nurse is appropriate?

Please take Mr. Wu's vital signs in 10 mins and let me know if systolic is less than 100

A client on a medical unit recently received a diagnosis of end-stage renal disease and was told of the need to go on dialysis. This morning the client was found in the bathroom trying to commit suicide by hanging using hospital gown ties. The client was stabilized and transferred to the psychiatric unit. Which of the following is the highest priority nursing action for this client?

Provide continuous one on one supervision

A client with schizophrenia has been hospitalized for a week and placed on an antipsychotic medication. The client tells the nurse of hearing multiple voices all day long arguing about whether the client is a good or bad person. The client says, "Everyone tells me that the voices are not real, but they are driving me crazy." What is the best action by the nurse?

Provide earphones and have client sing along to music

The nurse is caring for a client with a chest tube that was placed 2 hours ago for a pneumothorax. Where would the nurse expect gentle, continuous bubbling?

Suction control chamber

The nurse on the mental health unit receives report about a client diagnosed with schizophrenia who is experiencing a delusion of reference. Which client statement supports this symptom?

That song is a message sent to me in secret code

The nurse is working with a client admitted with delirium and reduced level of consciousness due to pneumonia and respiratory failure. The nurse anticipates that the client may need to be intubated soon. The client is not able to make decisions. Who will make decisions for the client?

The healthcare proxy

What information would be most important for the nurse to obtain from a client with suspected bladder cancer who reports blood in the urine but no associated pain?

Tobacco Use

The nurse prepares to instill dialysate for a client receiving peritoneal dialysis. Which nursing action is the priority?

Using a sterile technique when spiking and attaching the bag of dialysate

A client recently diagnosed with schizophrenia is hospitalized. The client appears distraught and says to the nurse, "The voices are bad today...they are so angry with me." Which of the following is the best response by the nurse?

What are the voices saying to you?

A client with type 2 diabetes, coronary artery disease, and peripheral arterial disease developed hospital-acquired pneumonia (HAP) and has been receiving intravenous (IV) antibiotics for 4 days. Which parameter monitored by the nurse best indicates the effectiveness of treatment?

White blood count

A client recently diagnosed with schizophrenia is brought to the mental health clinic by the identical twin sibling for the first follow-up visit after hospitalization. The client's sibling says to the nurse, "I read that schizophrenia runs in families. I guess I'm doomed." Which is the best response by the nurse?

You are at risk. However, there are other factors for developing schizophrenia

A female client who was the victim of acquaintance rape 2 months ago is receiving therapy for posttraumatic stress disorder (PTSD). She says to the nurse, "It's all my fault. I should have known not to accept a drink from someone I just met in a bar." What is the best response by the nurse?

You could not have anticipated the rape. You did not deserve nor ask for it

A client with a history of major depressive disorder with psychotic features was rescued before jumping off a dam. The client is pacing, picking at the arms, and repeatedly mumbling, "I have to die. You cannot stop me." When the health care provider recommends electroconvulsive therapy (ECT) as the initial treatment, the client's spouse says to the nurse, "I can't allow such a cruel treatment. Why can't they just give my spouse medication?" Which is the best response by the nurse?

Your spouse is very ill at this time and ECT, might be the best treatment

The nurse practicing on a long-term care unit cares for a client with type 1 diabetes mellitus. Which action should the nurse assign to experienced unlicensed assistive personnel?

check blood glucose before meals

The nurse is caring for a client newly admitted with an acute manic episode of bipolar disorder. The nurse identifies which dinner selection as the most appropriate to promote client nutrition?

cheeseburger, apple and vanilla milkshake

The nurse responds to the call light of a client with chronic obstructive pulmonary disease (COPD) who says, "I can't breathe." The client seems to be having difficulty breathing and is nervous and tremulous. Vital signs are stable, oxygen saturation is 92% on 2 L, and there are clear breath sounds bilaterally. Which intervention would be most appropriate at this time?

coach the client through controlled breathing exercises

When unlicensed assistive personnel (UAP) assist a client with a chest tube back to bed from the bedside commode, the plastic chest drainage unit accidentally falls over and cracks. The UAP immediately report this incident to the nurse. What is the nurse's immediate action?

place distal end of the tube in bottle of sterile saline

The nurse is caring for a client involved in a motor vehicle collision who had a chest tube inserted to evacuate a pneumothorax caused by fractured ribs. Where would the nurse observe an air leak?

section C

An elderly client with a history of stable chronic obstructive pulmonary disease, alcohol abuse, and cirrhosis has a serum theophylline level of 25.8 mcg/mL (143 µmol/L). Which clinical manifestation associated with theophylline toxicity should worry the nurse most?

seizure activity

Arterial Steal Syndrome

too much blood is diverted to the vein, and arterial perfusion to the hand is compromised. Heart failure can occur from high blood flow. Teaching - do not use arm with graft for blood pressure, placing IV's or administering injections