Nclex PN study

At a health fair, a woman, age 43, with a family history of osteoporosis asks the nurse how much calcium she should consume. The nurse tells her that the recommended daily calcium intake for premenopausal women is:

1,000 to 1,200 mg. Explanation: Most authorities recommend that premenopausal women consume 1,000 to 1,200 mg of calcium daily. Less than 1,000 mg may not provide adequate protection against osteoporosis; more than 1,200 mg isn't necessary and may be harmful.

A health care provider has ordered an IV of 5% dextrose in lactated Ringer's solution at 125 mL/hour. The IV tubing delivers 10 drops per mL. How many drops per minute should fall into the drip chamber?

20 to 21 Multiply the number of milliliters to be infused (125) by the drop factor (10); 125 x 10 = 1,250. Then divide the answer by the number of minutes to run the infusion (60). Use the following equation: 1,250 / 60 = 20.83 (or 20 to 21 gtt/minute).

After a 3-month trial of dietary therapy, a client with type 2 diabetes still has blood glucose levels above 180 mg/dl. The physician adds glyburide, 2.5 mg P.O. daily, to the treatment regimen. The nurse should instruct the client to take glyburide:

30 minutes before breakfast. Like other oral antidiabetic agents prescribed in a single daily dose, glyburide should be taken at breakfast or 30 minutes before breakfast. If the client takes glyburide later, such as in the mid-morning, after dinner, or at bedtime, the drug won't provide adequate coverage for all meals consumed during the day.

A client who has been treated for diverticulitis is being discharged on oral propantheline bromide. The nurse should instruct the client to take the drug at which times?

30 minutes before meals and at bedtime Explanation: Propantheline bromide is used to reduce secretions and spasms of the GI tract in clients with diverticulitis, a condition characterized by bowel inflammation and colonic irritability and spasticity.

A nurse is to administer 1,000 ml of normal saline over 6 hours to a client in labor. The drip factor of the IV administration set is 15 drops/ml. What is the rate of the infusion?

42 drops/minute; To determine the drip rate, set up the following equation: X drops/minute = 15 drops/1 ml × 1,000 ml/6 hours × 1 hour/60 minutes X = 15,000/360X = 41.6, or 42 drops/minute.

A client with pneumonia has just finished dinner. The nurse must calculate the client's fluid intake before taking the tray from the room. The client had 6 oz of soup, 4 oz of milk, and 8 oz of juice. How many milliliters of fluid should the nurse record on the client's intake record? Record your answer using a whole number.

540 mL Explanation: The nurse should know that 1 oz equals 30 mL. Therefore, 18 oz multiplied by 30 equals 540 mL.

The nurse, in collaboration with the health care practitioner, is performing vision evaluation on four clients. When reviewing the data collection, which client's criteria would suggest to the nurse that further visual evaluation is needed?

9-year-old with 20/20 vision in one eye and 20/40 vision in the other eye on two lines on the Snellen chart Explanation: The client with a difference of vision between the eyes of two or more lines on the Snellen chart requires further visual evaluation.

A client is evaluated for severe pain in the right upper abdominal quadrant, which is accompanied by nausea and vomiting. The physician diagnoses acute cholecystitis and cholelithiasis. For this client, which nursing diagnosis takes top priority?

Acute pain related to biliary spasms

An agitated client with left-sided heart failure reports increasing shortness of breath and coughs up pink-tinged, foamy sputum. The nurse should recognize these findings as signs and symptoms of which disorder?

Acute pulmonary edema Explanation: Heart failure causes decreased contractility and increased fluid volume and pressure. Fluid may be driven from the pulmonary capillary beds into the alveoli, causing pulmonary edema. The client may become short of breath and cough up pink-tinged, foamy sputum. In right-sided heart failure, hepatomegaly, jugular vein distention, and peripheral edema occur. A client with pneumonia would have a temperature spike and sputum that varies in color. Cardiogenic shock is characterized by hypotension and tachycardia.

A nurse is caring for a client diagnosed with bipolar disorder who is taking lithium carbonate. When reviewing information about this therapy, what instruction would be most important to reinforce with this client?

Be sure to drink at least 2 ½ quarts [2500 mL] a day." Explanation: Clients taking lithium for bipolar disorder need to maintain a high fluid intake, at least 2 ½ liters per day. Salt should not be limited because lowered sodium levels increase the risk for lithium toxicity. Exercising outdoors in warm weather is not safe; photosensitivity occurs with lithium use, and increased activity in warm weather could increase sodium loss, predisposing the client to a toxic reaction to lithium

False labor contractions

Braxton Hicks contractions begin in the abdomen and remain irregular

The nurse should include which in-home management instruction for a child who's receiving desmopressin acetate for symptomatic control of diabetes insipidus?

Call the health care provider for an alternate route of desmopressin acetate when the child has an upper respiratory infection (URI) or allergic rhinitis. Explanation: Excessive nasal mucus associated with URI or allergic rhinitis may interfere with desmopressin acetate absorption because it's given intranasally.

During labor, a client's cervix fails to dilate progressively, despite her uncomfortable uterine contractions. To augment labor, the physician orders oxytocin. When preparing the client for oxytocin administration, the nurse describes the contractions the client is likely to feel when she starts to receive the drug. Which description is accurate?

Contractions will be stronger and more uncomfortable and will peak more abruptly; Oxytocin administration causes stronger, more uncomfortable contractions, which peak more abruptly than spontaneous contractions. Oxytocin doesn't affect the duration of contractions.

A client must take streptomycin for tuberculosis. Before therapy begins, the nurse should instruct the client to notify the physician if which health concern occurs?

Decreased hearing acuity: Decreased hearing acuity indicates ototoxicity, a serious adverse effect of streptomycin therapy.

A client is admitted to the hospital disoriented and weak, has an irregular pulse, and takes hydrochlorothiazide. Which imbalance should the nurse suspect as the underlying cause for the client's symptoms?

Hypokalemia Explanation: The symptoms of hypokalemia include gastrointestinal, cardiac, renal, respiratory, and neurologic disturbances. The use of potassium-wasting diuretics, such as hydrochlorothiazide, without potassium replacement therapy is a primary cause of hypokalemia.

A client who was trapped inside a car for hours after a head-on collision is rushed to the emergency department with multiple injuries. During the neurologic examination, the client responds to painful stimuli with decerebrate posturing. This finding indicates damage to which part of the brain?

Midbrain Explanation: Decerebrate posturing, characterized by abnormal extension in response to painful stimuli, indicates damage to the midbrain. With damage to the diencephalon or cortex, abnormal flexion (decorticate posturing) occurs when a painful stimulus is applied. Damage to the medulla results in flaccidity.

A client in labor is receiving oxytocin. Which priority action should the nurse take?

Report hourly output of 15 ml per hour to the health care provider. Oxytocin has an antidiuretic effect; prolonged IV infusion may lead to severe water intoxication, resulting in seizures, coma, and even death.

The nurse is developing a teaching plan for a client receiving clozapine. The nurse should stress the importance of which aspect of follow-up care?

Routine complete blood count (CBC) with differential Explanation: The client requires routine CBCs with differentials because clozapine can cause potentially fatal blood dyscrasia characterized by severe neutropenia. Although this adverse effect is rare, it's potentially fatal if not detected early

A client with persistent, severe schizophrenia has been treated with phenothiazines for the past 17 years. Now the client's speech is garbled as a result of drug-induced rhythmic tongue protrusion. What is another name for this extrapyramidal symptom?

Tardive dyskinesia

A client with left-sided heart failure reports of increasing shortness of breath and is agitated and coughing up pink-tinged, foamy sputum. The nurse should recognize these as signs and symptoms of:

acute pulmonary edema. Explanation: Because of decreased contractility and increased fluid volume and pressure in clients with heart failure, fluid may be driven from the pulmonary capillary beds into the alveoli, causing pulmonary edema.

A client has a phenytoin level of 32 mg/dl. Which symptoms should the nurse monitor based on the result?

ataxia and confusion Explanation: A therapeutic phenytoin level is 10 to 20 mg/dl. A level of 32 mg/dl indicates phenytoin toxicity. Symptoms of toxicity include confusion and ataxia.

frank breech presentation

buttocks present, fetal hips are flexed and knees are extended

the nurse is initiating an intravenous (IV) access for a client who needs an infusion of normal saline solution. Which nursing action should the nurse perform before the venipuncture?

check for latex allergy before applying the tourniquet. Explanation: Priming the IV tubing is done after the access has been secured. Verifying that the client does not have latex allergy ensures the safety of the client

A nurse is preparing to administer a medication to a client. Which method is best for verifying the client's identity?

check the patients identification bracelet

A nurse is caring for several clients on a medical floor. Which client does the nurse identify to have the greatest chance of developing cardiogenic shock?

client with acute myocardial infarction (MI) Explanation: Of all clients with an acute MI, 15% suffer cardiogenic shock secondary to the myocardial damage and decreased function.

A nurse collecting data on a post-craniotomy client finds the urinary catheter bag with 1,500 mL the first hour and the same amount for the second hour. Which complication should the nurse suspect as a cause of this amount of output?

diabetes insipidus Explanation: Diabetes insipidus triggers an abrupt onset of extreme polyuria that commonly occurs in clients after brain surgery. Cushing's syndrome is excessive glucocorticoid secretion resulting in sodium and water retention. A hyperglycemic state is marked by polyuria, polydipsia, and polyphagia. Adrenal crisis is under secretion of glucocorticoids resulting in profound hypoglycemia, hypovolemia, and hypotension.

A 6-year-old child with a history of varicella and aspirin intake is brought to the emergency department. The nurse suspects Reye's syndrome. Which data collection findings are consistent with this syndrome?

fever, decreased level of consciousness (LOC), and impaired liver function Explanation: Reye's syndrome occurs in children with a history of a viral infection, varicella, or influenza. It's often associated with the administration of aspirin. The child presents with fever and decreased LOC, which can lead to coma and death. As the disease progresses, the child also develops impaired liver function.

A client begins clozapine therapy after several other antipsychotic agents fail to relieve her psychotic symptoms. The nurse instructs her to return for weekly white blood cell (WBC) counts to monitor for which adverse reaction?

granulocytopenia Explanation: Clozapine can cause life-threatening neutropenia or granulocytopenia. To detect this adverse reaction, a WBC count should be performed weekly.

The nurse is caring for a neonate whose mother is infected with hepatitis B. The nurse would inform the mother that her child will receive which treatment?

hepatitis B immune globulin within 12 hours of birth, and hepatitis B vaccine at birth, age 1 month, and age 6 months

After checking the client's chart for possible contraindications, the nurse is administering meperidine, 50 mg I.M., to a client with pain after an appendectomy. The nurse would question which medication if noted on the physician's orders for this client?

monoamine oxidase (MAO) inhibitor Explanation: MAO inhibitors increase the effects of meperidine and can cause rigidity, hypotension, and excitation. The client shouldn't receive meperidine within 14 days after administration of an MAO inhibitor.

The nurse is working as part of multidisciplinary team in developing the plan of care for a premature neonate. Breast milk is being encouraged as part of the plan. The nurse understands that the use of breast milk for this neonate would help prevent which condition?

necrotizing enterocolitis Explanation: Components specific to breast milk have been shown to lower the incidence of necrotizing enterocolitis in premature neonates.

The nurse, who is providing care for four clients, receives a report on the clients. Which report is an outcome indicator?

pain level 3/10 one hour after administration of pain medication Explanation: An outcome indicator describes client status at a defined time following care interventions.

A child is brought to the school nurse with the index finger of the left hand partially amputated and hanging by a shred of skin. What is the appropriate action by the nurse?

securely wrap the hand and finger and place them in a cold water-filled baggie. Explanation: Leave the skin intact, wrap the entire hand and finger with a towel, and place it in a cool solution to preserve cell life and increase the chance of successful reattachment. The finger should not be detached, warm water should not be used and the circulation to the finger should not be decreased by tightly squeezing about the cut.

Order the phases of a uterine contraction from the beginning of contraction to its conclusion

strong Braxton Hicks contractions acme decrement relaxation

The nurse is caring for a client with a long leg cast. Which nursing intervention can best prevent foot drop?

support the foot with 90 degrees of flexion. Explanation: To prevent foot drop in a casted leg, the foot should be supported with 90 degrees of flexion. Bed rest can cause foot drop.

A child returns to the unit after a cardiac catheterization. The nurse should reinforce education for the child and parents on which point regarding mobility?

the child will be maintained on bed rest with the affected extremity immobilized. Explanation: Following cardiac catheterization, the child should be maintained on bed rest with the affected extremity immobilized to prevent hemorrhage.

The newly hired graduate nurse asks the nurse preceptor what is the only advantage of using a floor stock system. Which rationale does the preceptor give the graduate nurse?

the nurse can implement medication orders quickly. Explanation: A floor stock system enables the nurse to implement medication orders quickly. However, this method is considered unsafe because it doesn't allow for pharmacist input, nor does it minimize transcription errors or reinforce accurate calculations.

A client has a serum calcium level of 7.2 mg/dl. During the physical examination, the nurse expects to assess:

trousseau's sign. Explanation: This client's serum calcium level indicates hypocalcemia, an electrolyte imbalance that causes Trousseau's sign (carpopedal spasm induced by inflating the blood pressure cuff above systolic pressure).