NCLEX Prep Exam 1
The nurse has given a client with schizophrenia discharge instructions. Which statement by the client would indicate understanding of the teaching? Select all that apply. 1X - "If I am having trouble sleeping or eating, I will call the mental health center." 2X - "I can't drink even one or two beers." 3X - "Anxiety makes it more likely I will hear voices." 4X - "I can skip a pill when I am feeling too tired from them." 5X - "Possible bad effects from the pills only last a few days."
1X, 2X, 3X Expl. - In schizophrenia, the client and the family need to receive teaching in order to manage the illness and to prevent a relapse. In the initial phase of the illness, teaching will need to be continued at the health care provider's office or the local mental health center. The client needs to understand that difficulty with eating or sleeping or increased anxiety can increase symptoms. Alcohol even in small amounts depresses the CNS and can interfere with pharmacological actions of medications. Reactions to the client's medications like tardive dyskinesia, dystonia, or the other extra-pyramidal side effects may take longer periods of time. The client needs to report any unusual symptoms.
A client is typed and cross-matched for three units of packed cells. What are important precautions for the nurse to take before initiating the transfusion? Select all that apply. 1X - Initiate an IV with dextrose 2X - Have two nurses check the blood type and identity 3X - Warm the blood to room temperature 4X - Initiate an IV with normal saline 5X - Take baseline vital signs
2X, 4X, 5X Expl. - Prior to administering blood, the unit must be checked by two registered nurses. Baseline vital signs are obtained before the transfusion is started so any changes would be identified. Blood is always transfused with normal saline as other IV fluids are incompatible with blood. Warming to room temperature is not necessary.
A client with chronic obstructive pulmonary disease presents with respiratory acidosis and hypoxemia. The client tells the nurse that they don't want to be placed on a ventilator. What action should the nurse take? A. Notify the physician immediately to have the physician determine client competency B. Have the client sign a do-not-resuscitate (DNR) form C. Determine whether the client's family was consulted about this decision D. Consult the palliative care group to direct care for the client
A. Notify the physician immediately to have the physician determine client competency Expl. - Three requirements are necessary for informed decision-making: the decision must be given voluntarily; the client making the decision must have the capacity and competence to understand; and the client must be given adequate information to make the decision. In light of the client's respiratory acidosis and hypoxemia, the client might not be competent to make this decision. The physician should be notified immediately so the physician can determine client competency. The physician, not the nurse, is responsible for discussing the implications of a DNR order with the client. The Patient's Bill of Rights entitles the client to make decisions about the care plan, including the right to refuse recommended treatment. The client's family may oppose the client's decision. Consulting the palliative care group isn't appropriate at this time and must be initiated by a physician order.
What measure should the nurse take that will be most helpful in preventing wound infection when changing a client's dressing after coronary artery bypass surgery? A. Wash hands before changing the dressing. B. Clean the incisional area with an antiseptic. C. Use prepackaged sterile dressings to cover the incision. D. Place soiled dressings a hazardous waste container.
A. Wash hands before changing the dressing Expl. - Many factors help prevent wound infections, including washing hands carefully, using sterile prepackaged supplies and equipment, cleaning the incisional area well, and disposing of soiled dressings properly. However, most authorities say that the single most effective measure in preventing wound infections is to wash the hands carefully before and after changing dressings. Careful hand washing is also important in reducing other infections often acquired in hospitals, such as urinary tract and respiratory tract infections.
A nurse is caring for 4 clients on the cardiac unit. Which client has the greatest risk for contracting infective endocarditis? A. a client 4 days postoperative after mitral valve replacement B. a client with hypertrophic cardiomyopathy C. a client with a history of repaired ventricular septal defect D. a client 1 day post coronary stent placement
A. a client 4 days postoperative after mitral valve replacement Expl. - Having prosthetic cardiac valves places the client at high risk for infective endocarditis. Hypertrophic cardiomyopathy and repaired ventricular septal defects are moderate risks for infective endocarditis. Coronary stent placement isn't a risk factor for infective endocarditis.
Which documentation tool will the nurse use to record the client's vital signs every 4 hours? A. a graphic sheet B. acuity charting forms C. medication record D. 24-hour fluid balance record
A. a graphic sheet Expl. - A graphic sheet is a form used to record specific client variables such as pulse, respiratory rate, blood pressure readings, body temperature, weight, fluid intake and output, bowel movements, and other client characteristics. Acuity charting forms allow nurses to rank clients as high to low acuity in relation to their conditions and need for nursing assistance or intervention. Medication records include documentation of all medications administered to the client. The 24-hour fluid balance record form is used to document the intake and output of fluids for a client with special needs.
The client with acute renal failure asks the nurse for a snack. Because the client's potassium level is elevated, which snack is most appropriate? A. gelatin dessert B. yogurt C. an orange D. peanuts
A. gelatin dessert Expl. - Gelatin desserts contain little or no potassium and can be served to a client on a potassium-restricted diet. Foods high in potassium include bran and whole grains; most dried, raw, and frozen fruits and vegetables; most milk and milk products; chocolate, nuts, raisins, coconut, and strong brewed coffee.
A client comes to the emergency department after being attacked and sexually assaulted. What is the most accurate nursing diagnosis for this client? A. rape-trauma syndrome B. fear C. anxiety D. hopelessness
A. rape-trauma syndrome Expl. - The nursing diagnosis rape-trauma syndrome refers to the acute and long-term phases experienced by the victim of sexual assault. Specific nursing interventions can be planned on the basis of this diagnosis. A rape victim may also experience fear, anxiety, and hopelessness; however, these aren't the most accurate nursing diagnoses for this client.
The nurse is assessing a client who has been experiencing black stools for the past month. The client suddenly reports chest and stomach pain. What is the most important action by the nurse? A. Administer oxygen via nasal cannula B. Assess the client's vital signs C. Initiate cardiac monitoring D. Draw blood for laboratory analysis
B. Assess the client's vital signs Expl. - Assessing vital signs would determine this client's hemodynamic stability. Monitoring the heart rhythm may be indicated based on assessment findings. Administering oxygen and drawing blood require a health care provider's order, and would not be part of a screening evaluation.
Which nursing intervention would be most effective in helping a 2-year-old child stay quiet after a bronchoscopy? A. Allow the child to go to the playroom B. Have the parents stay at the bedside C. Have the child play with another child in the room D. Turn on the television so the child can watch cartoons
B. Have the parents stay at the bedside Expl. - A toddler has a short attention span and is energetic. Thus, keeping a 2-year-old child quiet is a challenge. Because the parents know their child well, the parents have a better chance of helping the child stay quiet. Therefore, they should be encouraged to stay with the child at the bedside
The nurse is discharging a baby with clubfoot who has had a cast applied. The nurse should provide additional teaching to the parents if they make which statement? A. I should call if I see changes in the color of the toes under the cast B. I should use a pillow to elevate my child's foot as he sleeps C. My baby will need a series of casts to fix her foot D. Having a cast should not prevent me from holding my baby
B. I should use a pillow to elevate my child's foot as he sleeps Expl. - Elevating the extremity at different points during the day is helpful to prevent edema, but pillows should not be used in the crib because they increase the risk of sudden infant death syndrome (SIDS). A change in the color of the toes is a sign of impaired circulation and requires medical evaluation. Children typically need a series of 5 to 10 casts to correct the deformity. Infants with club feet still need frequent holding like any other newborn.
A client diagnosed with seminomatous testicular cancer expresses fear and questions the nurse about his prognosis. Which information should the nurse give the client about the prognosis for testicular cancer? A. Testicular cancer can be cured B. Testicular cancer has a cure rate of 90% when diagnosed early C. Surgery is the treatment of choice for testicular cancer D. Testicular cancer has a 50% cure rate when diagnosed early
B. Testicular cancer has a cure rate of 90% when diagnosed early Expl. - When diagnosed early and treated aggressively, testicular cancer has a cure rate of about 90%. Treatment of testicular cancer is based on tumor type, and seminoma cancer has the best prognosis. Modes of treatment include combinations of orchiectomy, radiation therapy, and chemotherapy. The chemotherapeutic regimen used currently is responsible for the successful treatment of testicular cancer. The nurse should not indicate to the client that the cancer will be cured, even though cure rates are high.
A student nurse witnesses a registered nurse performing a procedure on a client without obtaining informed consent for the procedure. The student nurse recognizes that the registered nurse is guilty of committing: A. breach of confidentiality B. assault and battery C. harassment D. neglect of duty
B. assault and battery Expl. - Performing a procedure on a client without informed consent can be grounds for charges of assault and battery. Harassment means to annoy or disturb someone, and breach of confidentiality refers to conveying information about the client. Neglect of duty is failure to perform care that a prudent nurse would provide under similar circumstances.
In discussing home care with a client after transurethral resection of the prostate (TURP), what should the nurse tell the male client about dribbling of urine after this surgery? Dribbling of urine: A. can be a chronic problem B. can persist for several months C. is an abnormal sign that requires intervention D. is a sign of healing within the prostate
B. can persist for several months Expl. - Dribbling of urine can occur for several months after TURP. The client should be informed that this is expected and is not an abnormal sign. The nurse should teach the client perineal exercises to strengthen sphincter tone. The client may need to use pads for temporary incontinence. The client should be reassured that continence will return in a few months and will not be a chronic problem. Dribbling is not a sign of healing, but is related to the trauma of surgery.
The nurse is assessing an older adult's skin. The assessment will involve inspecting the skin for color, pigmentation, and vascularity. What should the nurse assess? A. similarities from one side to the other B. changes from the normal expected findings C. appearance of age-related wrinkles D. skin turgor
B. changes from the normal expected findings Expl. - Noting changes from the normal expected findings is the most important component when assessing an older client's integumentary system. Comparing one extremity with the contralateral extremity (i.e., comparing one side with the other) is an important assessment step; however, the most important component is noting changes from an expected normal baseline. Noting wrinkles related to age is not of much consequence unless the client is admitted for cosmetic surgery to reduce the appearance of age-related wrinkling. Noting skin turgor is an assessment of fluid status, not an assessment of the integumentary system.
Before advising a 24-year-old client desiring oral contraceptives for family planning, the nurse would assess the client for which signs and symptoms? A. anemia B. hypertension C. dysmenorrhea D. acne vulgaris
B. hypertension Expl. - Before advising a client about oral contraceptives, the nurse needs to assess the client for signs and symptoms of hypertension. Clients who have hypertension, thrombophlebitis, obesity, or a family history of cerebral or cardiovascular accident are poor candidates for oral contraceptives. In addition, women who smoke, are older than 40 years of age, or have a history of pulmonary disease should be advised to use a different method. Iron-deficiency anemia, dysmenorrhea, and acne are not contraindications for the use of oral contraceptives. Iron-deficiency anemia is a common disorder in young women. Oral contraceptives decrease the amount of menstrual flow and thus decrease the amount of iron lost through menses, thereby providing a beneficial effect when used by clients with anemia. Low-dose oral contraceptives to prevent ovulation may be effective in decreasing the severity of dysmenorrhea (painful menstruation). Dysmenorrhea is thought to be caused by the release of prostaglandins in response to tissue destruction during the ischemic phase of the menstrual cycle. Use of oral contraceptives commonly improves facial acne.
A client with manic episodes is taking lithium. Which electrolyte level should the nurse check before administering this medication? A. calcium B. sodium C. chloride D. potassium
B. sodium Expl. - Lithium is chemically similar to sodium. If sodium levels are reduced, such as from sweating or diuresis, lithium will be reabsorbed by the kidneys, increasing the risk of toxicity. Clients taking lithium should not restrict their intake of sodium and should drink adequate amounts of fluid each day. Calcium, chloride, and potassium are important for normal body functions but sodium is most important to the absorption of lithium.
For a client in the oliguric phase of acute renal failure (ARF), which nursing intervention is the most important? A. Encouraging coughing and deep breathing B. Promoting carbohydrate intake C. Limiting fluid intake D. Providing pain relief measures
C. Limiting fluid intake Expl. - During the oliguric phase of ARF, urine output decreases markedly, possibly leading to fluid overload. Limiting oral and I.V. fluid intake can prevent fluid overload and its complications, such as heart failure and pulmonary edema. Encouraging coughing and deep breathing is important for clients with various respiratory disorders. Promoting carbohydrate intake may be helpful in ARF but doesn't take precedence over fluid limitation. Controlling pain isn't important because ARF rarely causes pain.
A 40-year-old primigravid client with AB-positive blood visits the outpatient clinic for an amniocentesis at 16 weeks' gestation. The nurse determines that the most likely reason for the client's amniocentesis is to determine if the fetus has which problem? A. cri-du-chat syndrome B. ABO incompatibility C. erythroblastosis fetalis D. Down syndrome
D. Down syndrome Expl. - Because of the client's age, the amniocentesis is most likely being done to evaluate for Down syndrome (trisomy 21). Women older than 35 years are at higher risk for having a child with Down syndrome. Cri-du-chat syndrome is a genetic disorder involving a short arm on chromosome 5. This disorder is not associated with mothers who are older than 35 years. The client is AB-positive, so the amniocentesis is not being done for ABO incompatibility, in which the mother is type O and the fetus is type A, B, or AB. The amniocentesis is not being done to detect erythroblastosis fetalis because the mother is Rh-positive.
The registered nurse (RN) is referred to a client's home when spouses have been confirmed to have scabies. The family asks, "How will we get rid of this?" When instructing on the proper procedure to wash contaminated clothing and sheets, which nursing instruction is a priority? A. Use commercial grade laundry detergent B. Pretreat clothing where scabies contact existed C. Wash clothes through two laundry cycles D. Use hot water throughout wash cycle
D. Use hot water throughout wash cycle Expl. - The nurse instructs to use hot water throughout the wash cycle. Using hot water kills scabies and infectious agents on the laundry. If using the correct wash settings, the client does not need to use commercial grade laundry detergent and the clothing does not need pretreated or washed through two cycles. The family would also be instructed to dry the articles in a dryer. The family would clean all belongings thoroughly due to the ease of transmission.
The nurse assists the client to the operating room table and supervises the operating room technician preparing the sterile field. Which action, completed by the surgical technician, indicates to the nurse that a sterile field has been contaminated? A. Sterile objects are held above the waist of the technician B. Sterile packages are opened with the first edge away from the technician. C. The outer inch of the sterile towel hangs over the side of the table. D. Wetness in the sterile cloth on top of the nonsterile table has been noted.
D. Wetness in the sterile cloth on top of the nonsterile table has been noted. Expl. - Moisture outside the sterile package contaminates the sterile field because fluid can be wicked into the sterile field. Bacteria tend to settle, so there is less contamination above waist level and away from the technician. The outer inch of the drape is considered contaminated but does not indicate that the sterile field itself has been contaminated.
The nurse is administering medications to a client who has a gastrostomy tube (G-tube). The nurse reads the order for aspirin PO and crushes the aspirin and administers through the G-tube. What medication error did the nurse commit? A. Wrong client B. Wrong Time C. Wrong Dosage D. Wrong Route E. Wrong Drug
D. Wrong Route Expl. - Crushing enteric-coated tablets and caplets via a G-tube would be considered a medication error because the nurse did not administer the medication using the right route. The client could suffer erosion of the esophagus or stomach resulting in a bleeding ulcer, and the medication was enteric coated to move beyond the stomach before dissolving and prevent erosion of the gastrointestinal tissue.
Which position would be best for a client's right arm when she returns to her room after a right modified radical mastectomy with multiple lymph node excisions? A. across her chest wall B. at her side at the same level as her body C. in the position that affords her the greatest comfort without placing pressure on the incision D. on pillows, with her hand higher than her elbow and her elbow higher than her shoulder
D. on pillows, with her hand higher than her elbow and her elbow higher than her shoulder Expl. - Lymph nodes can be removed from the axillary area when a modified radical mastectomy is done and each of the nodes is biopsied. To facilitate drainage from the arm on the affected side, the client's arm should be elevated on pillows with her hand higher than her elbow and her elbow higher than her shoulder. A sentinel node biopsy procedure is associated with a decreased risk of lymphedema because fewer nodes are excised.