NCLEX questions

low-density lipoprotein (LDL)

should be less than 100 mg/dL (2.6 mmol/L) or 70 mg/dL (1.8 mmol/L) for very high risk clients.

The nurse discusses symptoms of the onset of labor with a primipara client. Which client statement indicates to the nurse the need for further teaching?

"I will note an increase in fetal movement." movement decreases at the onset of labor

The nurse teaches a class to pregnant clients. The nurse discusses fetal movements and positions during labor that facilitate the birth of the fetus. Which information does the nurse include? (Select all that apply.) 1.The sutures and fontanelles of the fetal head allow it to mold as it passes through the pelvis. 2.The most common orientation is the transverse lie. 3.The fetal attitude is normally one of flexion. 4.The fetal head is fully flexed in the brow presentation. 5.The fetal occiput is in the left front quadrant of the mother 's pelvis.

1) CORRECT - The sutures and fontanelles of the fetal head allow it to mold as it passes through the pelvis. 2) INCORRECT - The orientation for more than 99% of births is the longitudinal lie, in which the fetus is parallel to the mother 's spine. 3) CORRECT - Fetal attitude is normally one of flexion with the head flexed forward and the arms and legs flexed. 4) INCORRECT - In a brow presentation, the fetal head is partly extended. The longest diameter of the fetal head is presenting, which is unstable and tends to convert to either a vertex or a face presentation. 5) CORRECT - The fetal occiput is in the left front quadrant of the mother 's pelvis, in the left occiput anterior (LOA) position. This position facilitates delivery.

The home care nurse visits an older adult client with a recent history of a cerebrovascular accident (CVA) resulting in a neurogenic bladder. The client is incontinent and has developed repeated urinary tract infections (UTI). Which action by the nurse is most appropriate? 1.Teach the client exercises to strengthen the pelvic floor. 2.Perform an intermittent catheterization for residual urine. 3.Assess the client's fluid intake over the last 48 hours. 4.Teach the client about high fiber dietary intake.

2) CORRECT - Even though a client with a neurogenic bladder is incontinent, the bladder may not be empty completely. Residual urine can cause a UTI

The nurse obtains a history from a client who is prescribed rosuvastatin. Which client report is most important for the nurse to report to the health care provider? 1.Rash. 2.Headache. 3.Abdominal pain. 4.Muscle tenderness.

4) CORRECT - Even though it is rare, one of the greatest risks to a client who is taking rosuvastatin (Crestor) is myositis, or muscle inflammation, that can progress to rhabdomyolysis. Therefore, a client report of muscle tenderness is the priority for the nurse to report to the health care provider.

normal cholesterol level

<200 mg/dL

A female client with hypothyroidism (myxedema) is receiving levothyroxine (Synthroid), 25 mcg P.O. daily. Which finding should nurse Hans recognize as an adverse drug A Dysuria B Leg cramps C Tachycardia D Blurred vision

Tachycardia Explanation: Levothyroxine, a synthetic thyroid hormone, is given to a client with hypothyroidism to simulate the effects of thyroxine. Adverse effects of this agent include tachycardia. The other options aren't associated with levothyroxine.

Early this morning, a female client had a subtotal thyroidectomy. During evening rounds, nurse Tina assesses the client, who now has nausea, a temperature of 105° F (40.5° C), tachycardia, and extreme restlessness. What is the most likely cause of these signs? A Diabetic ketoacidosis B Thyroid crisis C Hypoglycemia D Tetany

Thyroid Crisis Thyroid crisis usually occurs in the first 12 hours after thyroidectomy and causes exaggerated signs of hyperthyroidism, such as high fever, tachycardia, and extreme restlessness. Diabetic ketoacidosis is more likely to produce polyuria, polydipsia, and polyphagia; hypoglycemia, to produce weakness, tremors, profuse perspiration, and hunger. Tetany typically causes uncontrollable muscle spasms, stridor, cyanosis, and possibly asphyxia.

Atorvastatin (Lipitor)

used to treat high cholesterol

Symtoms of of Addisons disease?

fatigue, weakness, dehydration, decreased blood pressure, "eternal tan, " decreased resistance to physical stress, and alopecia.

High density lipoprotein (HDL) levels should be

more than 40 mg/dL (1 mmol/L) for males 50 mg/dL (1.3 mmol/L) for females.

The nurse provides care for a client who experienced a spinal cord injury at the level of T-2. The nurse enters the room and notes that the client's face is flushed, is sweating profusely, and the blood pressure is 260/160 mm Hg. Which medication does the nurse prepare to administer? 1.Docusate sodium 100 mg PO. 2.Prochlorperazine 10 mg IM. 3.Hydralazine hydrochloride 10 mg IV. 4.Diazepam 20 mg IV.

1) INCORRECT — A stool softener should be a part of the client's regime to help prevent fecal impaction, which can cause autonomic dysreflexia. 2) INCORRECT — An antiemetic is used to control nausea, vomiting, and anxiety. Nausea is a symptom of autonomic dysreflexia. The elevated blood pressure is the first priority. 3) CORRECT— Symptoms indicate autonomic dysreflexia with the elevated blood pressure as the most critical symptom. Hydralazine hydrochloride is a fast acting antihypertensive and relaxes smooth muscle. Side effects can include headache, angina, tachycardia, palpitations, sodium retention, anorexia, or a lupus erythematosus-like syndrome of sore throat, fever, muscle-joint aches, rash. 4) INCORRECT — Diazepam is for the treatment for seizures. Untreated autonomic dysreflexia can cause seizures, a stroke, or MI.

Nurse Ruth is assessing a client after a thyroidectomy. The assessment reveals muscle twitching and tingling, along with numbness in the fingers, toes, and mouth area. The nurse should suspect which complication? A Tetany B Hemorrhage C Thyroid storm D Laryngeal nerve damage

Tetany Tetany may result if the parathyroid glands are excised or damaged during thyroid surgery. Hemorrhage is a potential complication after thyroid surgery but is characterized by tachycardia, hypotension, frequent swallowing, feelings of fullness at the incision site, choking, and bleeding. Thyroid storm is another term for severe hyperthyroidism — not a complication of thyroidectomy. Laryngeal nerve damage may occur postoperatively, but its signs include a hoarse voice and, possibly, acute airway obstruction.