NCLEX Questions
A client is diagnosed with Haemophilus influenzae pneumonia. In addition to standard precautions, which other precautions should be instituted immediately by the nurse? 1. Droplet precautions 2. Contact precautions 3. Airborne precautions 4. Neutropenic precautions
*1. Droplet precautions 2. Contact precautions 3. Airborne precautions 4. Neutropenic precautions Rationale: Droplet precautions are instituted when the disease is transmitted via large particle droplets, such as in the case of H. influenzae pneumonia. Contact precautions are initiated when the organism can be transmitted by direct client contact or by contact with items in the client's environment. Airborne precautions are instituted when the organism is transmitted by airborne droplet nuclei, such as in the case of tuberculosis. Neutropenic precautions are initiated when the client is at risk of contracting a life-threatening infection.
The 16-year-old client presents to the dermatology clinic with a diagnosis of acne vulgaris. The client says to the nurse, "I don't know what else to do! I wash my face twice a day. I wear noncomedogenic makeup. I shower after I work out. I guess I'm just going to have acne on my face forever." Which responses by the nurse would be most appropriate? Select all that apply. 1. "You need to try witch hazel." 2. "I understand. When I was your age, I had acne problems, too." 3. "You feel like there's nothing else you can do to cure your acne." 4. "Your acne really isn't that bad! Our last client's acne was much worse." 5. "You seem frustrated by your acne. Please tell me what it is about your acne that is frustrating."
1. "You need to try witch hazel." 2. "I understand. When I was your age, I had acne problems, too." * 3. "You feel like there's nothing else you can do to cure your acne." 4. "Your acne really isn't that bad! Our last client's acne was much worse." * 5. "You seem frustrated by your acne. Please tell me what it is about your acne that is frustrating." Rationale: Acne vulgaris is a condition of the skin caused by inflamed sebaceous glands and hair follicles; it causes papules on the face, neck, shoulders, chest, and back. Acne can be especially distressing for those who suffer from it because it is worsened during puberty. It is vital that the nurse use therapeutic techniques when talking to the teenager suffering from acne to cultivate and maintain a therapeutic relationship. The nurse should respond with, "You feel like there is nothing else you can do to cure your acne," because this is the therapeutic communication technique of restating. It allows the client to clarify her point. Additionally, the nurse should say, "You seem frustrated by your acne. Please tell me what it is about your acne that is frustrating." This statement is therapeutic because it explores the teenager's feelings and allows the client to open up more to the nurse. Telling the client she needs to try witch hazel is telling the client what to do and is not therapeutic. It is belittling to the client's feelings to tell her that her acne really isn't that bad. Self-disclosure can be a therapeutic technique when used very carefully, but telling the teenager that the nurse understands and that when the nurse was her age, she had acne problems, also is likely to alienate the client.
A client in labor states to the nurse, "I think my water just broke." On examination of the client, the nurse sees that the umbilical cord is protruding from the vagina. Which should the nurse do immediately? 1. Gently push the cord into the vagina and place the client on her side. 2. Transport the client to the delivery room and call the health care provider. 3. Summon for help from other staff members and place the client supine and flat. 4. Place a gloved hand into the vagina and hold the presenting part off of the umbilical cord.
1. Gently push the cord into the vagina and place the client on her side. 2. Transport the client to the delivery room and call the health care provider. 3. Summon for help from other staff members and place the client supine and flat. *4. Place a gloved hand into the vagina and hold the presenting part off of the umbilical cord. Rationale: When cord prolapse occurs, prompt actions are taken to relieve cord compression and increase fetal oxygenation. The mother should be positioned with the hips higher than the head to shift the fetal presenting part toward the diaphragm. The nurse should also place a gloved hand into the vagina and hold the presenting part off of the umbilical cord. The nurse should summon for help, and other staff members should contact the health care provider and notify the delivery room. If the cord is protruding from the vagina, no attempt should be made to replace it because to do so could traumatize it and further reduce blood flow. Oxygen at 8 to 10 L/min by face mask is also administered to the mother to increase fetal oxygenation.
A female client has a prescription for a clean-catch urine culture. After providing a sterile specimen cup to the client, the nurse should give which instruction so that the specimen is collected properly? 1. Void into the container, saving the full amount of urine. 2. Cleanse the labia using cleansing towels, position the container, and begin to void. 3. Cleanse the labia using cleansing towels, begin to void into toilet, and then collect the specimen. 4. Wipe the labia front to back with toilet paper and void into the sterile specimen container.
1. Void into the container, saving the full amount of urine. 2. Cleanse the labia using cleansing towels, position the container, and begin to void. *3. Cleanse the labia using cleansing towels, begin to void into toilet, and then collect the specimen. 4. Wipe the labia front to back with toilet paper and void into the sterile specimen container. Rationale: The client should cleanse the labia, begin to void, and then "catch" the sample midstream. Proper cleansing and voiding techniques are necessary so that the specimen does not become contaminated from external sources. The use of toilet paper (option 4) contaminates the specimen because of improper cleansing. The method described in option 2 is not midstream.
Which clients are at risk for developing skin breakdown? Select all that apply. 1. A client who is underweight 2. A client diagnosed with sinusitis 3. A client diagnosed with heart failure 4. A client diagnosed with spinal cord injury 5. A client diagnosed with benign prostatic hypertrophy
*1. A client who is underweight 2. A client diagnosed with sinusitis *3. A client diagnosed with heart failure *4. A client diagnosed with spinal cord injury 5. A client diagnosed with benign prostatic hypertrophy Rationale: The client who is underweight does not have any cushioning to protect bony prominences. A client with a spinal cord injury has decreased mobility, which can cause skin breakdown to develop. Many clients with heart failure have edema, which can also lead to the development of skin breakdown. Sinusitis and benign prostatic hypertrophy do put the client at risk for skin breakdown.
A client has arrived back to the nursing unit from special procedures with an epidural catheter in place for pain control. The nurse is revising the plan of care to reflect the epidural catheter and the interventions needed to prevent infection at the site. Which interventions should the nurse include in the plan of care? Select all that apply. 1. Monitor vital signs. 2. Change dressing as needed. 3. Change infusion tubing every 24 hours. 4. Use strict aseptic technique when caring for the catheter. 5. Contact the health care provider for a prescription for antibiotics.
1. Monitor vital signs. * 2. Change dressing as needed. * 3. Change infusion tubing every 24 hours. * 4. Use strict aseptic technique when caring for the catheter. 5. Contact the health care provider for a prescription for antibiotics. Rationale: To prevent an infection, the dressing is changes only as needed, the infusion tubing is changed every 24 hours (or per agency protocol), and strict aseptic technique is used when caring for the catheter. The other options do not prevent infection. Monitoring the client's vital signs helps determine if an infection has occurred but does not prevent infection. An antibiotic is not indicated and is administered if a bacterial infection is present.
Methenamine is prescribed for a client with a gram-positive urinary tract infection. The nurse questions the prescription if which preexisting disorder is noted in the client's record? 1. Cirrhosis 2. Hypothyroidism 3. Diabetes mellitus 4. Peripheral vascular disease
*1. Cirrhosis 2. Hypothyroidism 3. Diabetes mellitus 4. Peripheral vascular disease Rationale: Methenamine is contraindicated in clients with renal or hepatic disease or those with severe dehydration. The nurse would question the health care provider's prescription for this medication in the client with cirrhosis.
The nurse is reviewing the treatment plan with the parents of a newborn infant with hypospadias. Which statement by the parents indicates their understanding of the plan? 1. "Caution should be used when straddling my infant on a hip." 2. "Catheterization will be necessary if my infant does not void." 3. "Vital signs should be taken daily to check for bladder infection." 4. "Circumcision has been delayed to save tissue for surgical repair."
1. "Caution should be used when straddling my infant on a hip." 2. "Catheterization will be necessary if my infant does not void." 3. "Vital signs should be taken daily to check for bladder infection." *4. "Circumcision has been delayed to save tissue for surgical repair." Rationale: Hypospadias is a congenital defect involving abnormal placement of the urethral orifice of the penis. In hypospadias, the urethral orifice is located below the glans penis along the ventral surface. The infant should not be circumcised because the dorsal foreskin tissue will be used for surgical repair of the hypospadias. The incorrect option is unrelated to this disorder.
The nurse is caring for a client who is scheduled for surgery. The client is concerned about the surgical procedure. Which action should alleviate the client's fears and misconceptions about surgery? 1. Tell the client that preoperative fear is normal. 2. Explain all nursing care and possible discomfort that may result. 3. Ask the client to discuss information known about the planned surgery. 4. Provide explanations about the procedures involved in the planned surgery.
1. Tell the client that preoperative fear is normal. 2. Explain all nursing care and possible discomfort that may result. *3. Ask the client to discuss information known about the planned surgery. 4. Provide explanations about the procedures involved in the planned surgery. Rationale: Explanations should begin with the information that the client knows. Option 1 is a block to communication, and options 2 and 4 may produce additional anxiety in the client.
