NCLEX Review 4

True or false: A parent should place a newborn with GERD on their side when they sleep

false, prone/side-lying positioning is not recommended as an intervention for reducing reflux in infants due to the risk of sudden infant death syndrome

True or false: A UAP can measure patients for compression stockings

false, the UAP may apply compression stockings or devices, but the RN or LPN should measure the patient to choose the appropriate size

The ED nurse cares for a patient whose college roommate reports recent changes in the patient's behavior. Which behaviors and clinical data meet the criteria for involuntary admission to the mental health unit? Select all that apply. A. Patient has been sleeping on the floor in the den rather than the bed B. Patient has refused food and water for 4 days and has poor skin tumor C. Patient repeatedly mumbles, "I must kill them before they get me" D. Marijuana was found in the patient's personal belongings E. The HCP makes a diagnosis of schizophrenia

B,C

When taking orthostatic vital signs, if any position change produces decreased systolic BP >20 mm Hg, decreased diastolic BP >10 mm Hg and or increased pulse >20/min from supine values what should the nurse do?

discontinue assessment, and place the patient in a recumbent position and notify the HCP

What is a syndrome many patient experience after a partial gastrectomy, which occurs when gastric contents empty too rapidly into the duodenum, causing a fluid shift into the small intestine?

dumping syndrome

The nurse observes a patient who is postoperative left total knee replacement use a cane. Which action by the patient indicates an understanding of the correct technique when walking down the stairs? A. Descends with the cane on the step first, followed by the left leg, and then the right leg B. Descends with the cane on the step first, followed by the right leg, and then the left leg C. Descends with the left leg on the step first, followed by the cane, and then the right leg D. Descends with the right leg on the step first, followed by the left leg, and then the cane

A

The nurse prepares to administer a cleansing enema to a patient with constipation. Which of the following interventions are appropriate? Select all that apply. A. Assist the patient into left lateral position with right knee flexed B. Encourage the patient to retain the enema after administration C. Insert tubing into the rectum with the tip directed towards the umbilicus D. Keep the enema solution refrigerated until ready to administer E. Stop administration briefly if the patient reports abdominal cramping

A, B, C, E

The nurse is assisting with the care of a newborn during circumcision. Which intervention is appropriate? A. Anticipate the use of clean technique during the circumcision. B. Apply a snug-fitting diaper following the procedure. C. Offer a bottle during the procedure. D. Wrap the newborn's upper body in a blanket for the circumcision.

D

True or false: Patients with placenta prevue should receive clearance for sexual activity if bleeding stops

false, patients with placenta prevue should be instructed to remain on pelvic rest, vaginal examinations, douching, and vaginal intercourse are contraindicated

True of false: A patient prescribed methadone for opioid use disorder can take an additional tablet of cravings are not managed with one tablet.

false, patients can easily overdose on methadone if they take additional tablets, the patient should notify the HCP if additional treatment is necessary

True or false: patients experiencing delirium tremens will experience lethargy.

false, patients experiencing alcohol withdrawal syndrome or delirium tremens will be agitated and have tremors and hyperreflexia

A nurse in the surgical admitting unit is preparing a patient for elective coronary artery bypass surgery. Which statement by the patient should the nurse report immediately to the HCP? A. "I haven't had anything to eat or drink since 8 PM yesterday." B. "I took my prasugrel this morning with just a tiny sip of water." C. "I'm really nervous about this surgery." D. "It always takes several attempts to start my IV."

B, prasugrel is an anti platelet medication and should be stopped at least 5-7 days prior to the surgery to reduce the chance of intraopertive and postoperative bleeding

Blood products should be administered within _ hours to reduce the risk of bacterial contamination.

4

What is a psychomotor disorder characterized by a complete absence of or excessive involuntary movements?

catatonia

The nurse is obtaining a patient's history during an initial prenatal visit. The patient's last menstrual period was from March 1 to March 5. Unprotected intercourse occurred on March 15. Slight vaginal spotting was noted on March 23. The patient's menstrual cycles are regular and 28 days long. Using the Nagele rule, what is the estimated date of birth? A. December 8 B. December 12 C. December 22 D. December 30

A

A nurse is inserting an indwelling (Foley) urinary catheter for a male patient. After inserting the catheter about 6 in, the nurse notes drops of urine in the tubing. What action should the nurse take next? A. Further insert the catheter 1-2 in B. Have the patient hold his breath C. Immediately inflate the 5 mL balloon D. Secure the tubing to the patient's leg

A

A nurse is teaching the parent of a 2-year-old how to instill ear drops into the child's ear. Which of the following is the correct instruction to the parent about moving the pinna of the ear before instilling drops? A. Down and to the back B. Down and to the front C. Up and to the back D. Up and to the front

A

A patient is able to partially bear weight and follow the nurse's instructions. Which would be the most appropriate method for the nurse to use to safety transfer this patient? A. 1-person stand and pivot with gait belt and walker B. 1-person standby assist with walker C. 2-person motorized stand-assist lift D. 2-person stand and pivot with gait belt and walker

A

A patient is undergoing chest tube placement into ED after being involved in a motor vehicle collision. The patient's spouse arrives and demands to be with the patient. Which action should the nurse take? A. Allow the spouse in the room, out the wat of care providers, and explain the events occurring with the patient. B. Assist the spouse in observing outside the room through a window and have a chaplain explain the care being provided. C. Explain the patient's condition but inform the spouse that entering the room is not allowed until the patient is stabilized. D. Inform the spouse that being in the room during procedures is unsafe for the patient, and escort the spouse to the waiting area.

A

A patient with schizophrenia says to the nurse, "I was walking down the street and really enjoyed the weather, but carrots are probably my favorite vegetable. Did the ocean always look blue?" The nurse recognizes this statement as an example of which of the following? A. Associative looseness B. Concrete thinking C. Tangentiality D. Word salad

A

A school nurse observes a 3-year-old begin to choke and turn blue while eating lunch. What should be the nurse's initial action? A. Abdominal thrusts B. Back blows and chest thrusts C. Blind sweep of the child's mouth D. Call 911 for an ambulance

A

The RN is working with a UAP. Which task can the RN safely delegate to the UAP? A. Assisting a 2-day postoperative hip athroplasty patient with morning care B. Collecting a urine specimen for culture and sensitivity from a patient with a Foley catheter C. Initial change of colostomy bag for a patient who is 1-day postoperative colostomy D. Refilling the empty enteral feeding container with tube feeding

A

The charge nurse in an ICU is rounding and reviewing hemodynamic data for patients in the unit. Which patient requires immediate intervention? A. Patient who is septic due to pneumonia with central venous pressure of 6 mm Hg B. Patient who recently underwent a coronary artery bypass graft with cardiac output of 5 L/min C. Patient with a gastrointestinal bleed and mean arterial pressure of 58 mm Hg D. Patient with

A

The nurse is caring for a patient newly prescribed crutches. Which finding indicates the need for further teaching? A. The axillary pads are torn and show signs of wear B. The patient has a 30-degree band at the elbow when walking C. The crutches and injured foot are moved simultaneously in a 3-point gait D. There is a 3 finger-width space noted between the axilla and axillary pad

A

The nurse is caring for a patient who has been hospitaliized for major depressive disorder. When the nurse reminds the patient that breakfast will be served in the dining room in 20 minutes, the patient says, "I'm not hungry and I don't feel like doing anything." What is the best response by the nurse? A. "I will help you get ready, then we can walk to the dining room together." B. "I will have breakfast brought to your room. I know you don't have much energy right now." C. "It is okay. You can join us when you are ready. Take your time." D. "You will feel better when you get up and get dressed. You need to eat something."

A

The school nurse is speaking with the parent of a 4th grade student about a bed bug that was found on the child's sweater. The parent confirms that their home is infested but that the issue is being resolved. What is the best action by the nurse? A. Instruct the parent to launder the child's clothing and store it in tightly sealed plastic bags B. Instruct the teacher of the child's classroom to use a insecticide spray C. Send letters home to all of the children's parents informing them about the finding D. Send the child home and prohibit school attendance until the infestations has been resolved

A

When developing the teaching plan for a primiparous patient who is bottle feeding her term neonate for the first feeding, which of the following instructions should the nurse include? A Keep the nipple of the bottle full of formula while feeding B. All term babies have well-developed sucking skills C. Burp the baby after 6 oz. of formula have been taken D. Propping of the bottle may make it easier to feed the baby

A

What is the cure for preeclampsia-eclampsia?

delivery

Patient with AB blood can receive blood from who?

A, B, AB, or O

The nurse working in an intensive care unit receives a prescriptions from the primary health care provider to discontinue a triple-lumen subclavian central venous catheter. Which interventions will help prevent air embolism on removal? Select all that apply. A. Applying an air-occlusive dressing B. Instructing the patient to bear down C. Instructing the patient to lie in a supine position D. Pulling the line harder if there is resistance E. Pulling the line out when the patient is inhaling

A, B, C

A nurse is planning a teaching session for a patient who has type 2 diabetes mellitus. Which of the following topics should the nurse incorporate in the teaching plan? (Select all that apply). A. Weight management B. Lipid profile monitoring C. Blood pressure assessments D. Decreasing physical activity E. Food preferences

A, B, C, E

A home health nurse is supervising a home health aide who is changing the dressing for a patient with a chronic heel wound. Which actions by the aide indicate adherence to appropriate infection control procedures? Select all that apply. A. Open a sterile container of 4x4's using the outermost corner to pee back the cover B. Pull glove off over the soiled dressing to encase it before disposal C. Save unused sterile 4x4's by taping original package shut for the next dressing change D. Wash hands prior to putting on gloves and after removing them E. Wrap soiled dressing in paper towels before disposing of it in the trash can

A, B, D

The nurse is preparing to administer an intermittent enteral feeding to a patient who has a NG tube. The patient has a gastric residual volume of 75 mL. Which of the following actions should the nurse take? Select all that apply. A. Administer the scheduled feeding as prescribed. B, Check the pH of the residual and hold the feeding for a pH of 6. C. Discard the aspirated residual in a biohazard container. D. Flush the NG tube before and after administering the feeding. E. Place the patient in the semi-fowler position during the feeding

A, B, D, E

Which of the following actions would the nurse include in planning care for a patient hospitalized for bipolar disorder, acute manic episode? Select all that apply. A. Assign the patient to a private room B. Choose clothing for the patient C. Have the patient be in charge of planning an outling for the unit D. Have the patient join other patient in the dining room for meals E. Have the patient participate in physical exercise with a staff member F. Include the patient in group therapy sessions

A, B, E

A nurse is caring for a 3-month-old patient with a new tracheostomy. Which findings would indicate a need for suctioning? Select all that apply. A. Audible gurgling B. HR 105/min C. Increased irritability D. Oxygen saturation 88% E. Respiratory rate 30/min

A, C, D

The student nurse verbalizes the procedure for obtaining a wound culture to the nurse preceptor. Which of the following statements indicate a correct understanding? Select all that apply. A. "I will apply the prescribed bacitracin ointment after collecting the wound culture." B. "I will cleanse the wound by gently flushing it with normal saline." C. "I will obtain a sample of the drainage accumulated since the last dressing change." D. "I will perform hang hygiene and apply new gloves before obtaining the wound culture." E. "I will swab the wound from the outermost margin toward the center."

A, C, D

The charge nurse is observing the nurse perform wound irrigation on an infected ulcer. Which of the following actions by the nurse are appropriate? Select all that apply. A. Administers prescribed analgesic 30 minutes prior to irrigation. B. Holds the syringe tip 1/2 inch above the wound while irrigating. C. Instills the irrigation solution using low continuous pressure. D. Prepares a sterile syringe with a large bore angiocatheter. E. Tilts the patient on the side and irrigates downward from top of the wound.

A, C, D, E

The nurse prepares to draw up regular and NPH insulins into one syringe. Place in order the steps the nurse should take when mixing the insulins. A. Clean the vial tops with alcohol swabs. B. Inject air into the regular insulin vial. C. Draw up the regular insulin solution D. Inject air into the NPH insulin vial. E. Draw up the NPH insulin solution.

A, D, B, C, E

The nurse in a long-term facility is caring for a patient with major depressive disorder who is reporting difficulty sleeping. The patient gets up during the night, paces the hallway, wrings the hands, and appears teary. Which of the following actions should the nurse take? Select all that apply. A. Arrange for the patient to receive at least 20 minutes of natural sunlight each day B. Encourage the patient to take naps during the day to make up for diminished sleep C. Instruct the patient to engage in physical exercise just before bedtime D. Spend time with the patient in a quiet environment just before bedtime E. Suggest that the patient listen to soft music before going to be

A, D, E

The oncoming nurse is receiving report on 4 patients. Which should be the priority assessment? A. Patient who had a carotid endarterectomy that day with a blood pressure of 160/88 mm Hg B. Patient who is 1 day post bowel resection with absent bowel sounds C. Patient with a pulse of 109/min who has a history of Afib D. Patient with pancreatitis whose total parenteral nutrition is almost finished.

A, HTN may strain the surgical site and trigger hematoma formation. which can cause hemorrhage or airway obstruction

A patient at 20 weeks gestation states that she started consuming an increased amount of cornstarch about 3 weeks ago. Based on this assessment, the nurse should anticipate that the HCP will order which laboratory test(s)? A. Hemoglobin and hematocrit levels B. Human chorionic gonadotropin level C. Serum folate level D. WBC count

A, pica if often accompanied by iron deficiency anemia

The urgent care nurse is caring for a patient at 37 weeks gestation diagnosed with influenza. The patient is stable and is being discharged home with a prescription for oseltamivir. Which assessment finding requires further action by the nurse? A. Fetal heart rate baseline of 170/min B. Five fetal movements in the past hour C. Maternal hemoglobin of 11 g/dL D. Two irregular, painless contractions in the past hour

A, the nurse can expect an elevated fetal HR in the presence of maternal fever and infection, although continuous fetal monitoring is indicated to assess for signs of fetal hypoxemia

The nurse is planning care for a patient with schizophrenia. The patient is observed sitting in the day room watching television but does not participate in social interaction with others. What is the most appropriate activity for thr patient? A. A board game with a staff member B. A card game with peers C. A scavenger hunt around the unit D. A unit group trivia session

A, the nurse should develop a therapeutic relationship to promote trust by providing one-on-one interaction

The nurse assess a patient at term gestation and the patient states, "I'm not sure, but I think my water broke." The nurse performs a nitrazine pH test, which turns blue. When documenting the results of the test, which patient statement is most important for the nurse to consider? A. "I had vaginal intercourse with my male partner 1 hour before coming in today." B. "I have noticed constant wetness in my underwear since I thought my water broke." C. "It is difficult for me to tell if my water broke or if I just peed on myself a little bit." D. "With my last three pregnancies, my water never broke on its own."

A, the presence of blood or semen may result in a false positive, as both are alkaline

The nurse observes a patient who is postoperative left total knee replacement use a cane. Which action by the patient indicates an understanding of the correct technique when walking down the stairs? A. Descends with the cane on the step first, followed by the left leg, and then the right leg. B. Descends with the cane on the step first, followed by the right leg, and then the left leg. C. Descends with the left leg on the step first, followed by the cane, and then the right leg. D. Descends with the right leg on the step first, followed by the left leg, and then the cane.

A, when descending stairs the patient should lead with the cane, bring the weaker leg down next, then step down with the stronger leg

What is an assessment tool used to describe how well a newborn is transitioning to extrauterine life and is done at 1 and 5 minutes of life?

Apgar score

A patient with schizophrenia has been hospitalized for a week and placed on an antipsychotic medication. The patient tells the nurse of hearing multiple voices all day long arguing about whether the patient is a good or bad person. The patient says, "Everyone tells me that the voices are not real, but they are driving me crazy." What is the best action by the nurse? A. Give the patient a book to read B. Provide earphones and a DVD plalyer and have the patient sing along with the music C. Tell the patient that the voiuces will go away when the medication starts to work D. Tell the patient to ignore the voices

B

An elderly patient is brought to the ED with lethargy, chills, and sharp chest pain with deep breathing. Pulse oximeter shows 93% on room air and respirations are 24/min. What is the nurse's initial action? A. Administer IV morphine B. Auscultate the patient's lung sounds C. Initiate an IV infusion of normal saline D. Initiate nasal oxygen at 3 L/min

B

The charge nurse is notified that a patient is being admitted with a diagnosis of active shingles with a disseminated rash. Which room assignment is most appropriate for this patient? A. A private room with contact and droplet precautions B. A private room with negative airflow and contact and airborne precautions C. A private room with positive airflow and airborne precautions D. A semi-private 2-bed room with standard precautions

B

The home health nurse is visiting a patient who underwent a left total knee replacement seven days ago. The patient is using a cane to go up and down the stairs. Which patient action indicates an understanding of the correct technique when using a cane? A. Holds the cane with the left hand B. Leads with the right leg when going up stairs C. Moves the left leg down first when descending stairs D. Uses a side-facing technique to go up stairs

B

The home health nurse is visiting a patient who underwent a left total knee replacement seven days ago. The patient is using a cane to go up and down the stairs. Which patient action indicates an understanding of the correct technique when using a cane? A. Holds the cane with the left hand. B. Leads with the right leg when going up stairs. C. Moves the left leg down first when descending stairs. D. Uses a side-facing technique to go up stairs.

B

The nurse explains to Kim she can have sexual intercoure but condoms should always be worn between HSV outbreaks, and should be avoided when lesions are present and during the prodromal phase. Which symptoms are indicative of the prodromal phase? A. Crusting of the lesions B. Tingling, burning, or itching at the site lesions will eventually appear C. Shallow moist ulcerations around the genitals D. Vesicular lesions on the genitals

B

The nurse is assigned to care for a hospitalized confused patient with an indwelling urinary catheter. On entering the patient's room. the nurse notes the patient pulling at the catheter and grimacing in pain. Blood is trickling from the patient's meatus and the urine in the drainage bag is pink. Which action should the nurse take first? A. Collect a urine specimen and send to the lab. B. Deflate the balloon on the urinary catheter. C. Remove the catheter by gently pulling from the urethra. D. Use a sterile 4x4 pad to absorb the blood around the meatus.

B

The nurse is evaluating a return demonstration by the patient of a dry dressing change. Which action by the patient would cause the nurse to intervene? A. Patient applies sterile adhesive dressing over gauze without touching the wound bed B. Patient applies sterile gauze moistened with sterile saline to wound surface C. Patient cleanses site with a sterile swab in a spiral pattern from the center out D. Patient removes old dressing with clean gloves and checks site for signs of infection

B

The nurse is performing an assessment on a one-week-old infant born at term with no complications. The infant is feeding well and gaining weight, but the mother expresses concern about an area of bluish discoloration to a bruise, just above the buttocks. Which of the following is the best response by the nurse? A. "Has the infant suffered an injury of any sort since coming home from the hospital?" B. "Let's take a look. This type of spot is common in babies of Asian descent and will likely disappear eventually." C. Why didn't anyone notice this until just now?" D. "I will notify the HCP right away." E. "I hope it's nothing serious.."

B

The nurse is providing teaching for parents of a child diagnosed with fifth disease. Which statement by a parent indicates a need for further teaching? A. "Our child should be feeling much better in 7-10 days." B. "Our child's condition in communicable until the rash disappears." C. "We will ensure out child covers the mouth and nose when coughing or sneezing." D. "We will give our child ibuprofen to treat the joint pain."

B

The nursing team consists of a RN, LPN, and 2 UAP. The nurse considers the assignment appropriate if the LPN is assigned to care for which pediatric patient? A. A 1-day-old with tracheoesophageal fistula scheduled for surgical repair today B. A 6-month-old who had diaphragmatic hernia repair 5 days ago C. A 12-year-old newly admitted with productive cough and white blood cell count of 15,000/mm3 D. A 16-year-old admitted for uncontrolled diabetes experiencing Kussmaul breathing

B

A patient with a 20-year history of schizophrenia is hospitalized. The patient 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? A. "How long has the oil been leaking from your head?" B. "Let's go back to your room and lock for your headband together." C. "There is no oil coming out of your head." D. "You are going to miss breakfast if you do not go into the dining room."

B, priority nursing action for a patient exhibiting anxiety is to intervene in a manner that helps make the patient feel more at ease

The nurse is caring for a patient with newly prescribed hearing aids. Which of the following actions by the patient indicate proper use and care of hearing aids? Select all that apply. A. Keeps hearing aids clean by rinsing them with water. B. Lowers television volume when talking with nurse. C. Places hearing aids on food tray when not in use D. Turns volume completely down prior to insertion of aid into the ear. E. Verifies that battery compartment is closed before insertion.

B, D, E

A patient started a 24-hour urine collection test at 6 AM. The UAP reports discarding a urine specimen of 250 mL at 10 AM by mistake but adding all specimens to the collection container before and after that time. What action should the nurse take? A. Add 250 mL to the total output after the 24-hour urine collection is complete tomorrow morning. B. Discard urine and container and restart the 24-hour urine collection tomorrow morning. C. Discard urine and container, have patient void, add urine to new container, and then restart test. D. Relabel the same collection container, and change the start time from 6 AM to 10 AM

B, if any urine is discarded by accident during the test period, the procedure must be restarted

A nurse is assessing an 8-year-old child who weighs 82 lbs and is in the 97th percentile of weight for age. The child has a BMI of 26. Which of the following is the priority assessment before beginning a weight loss plan/ A. Family dietary habits and preferences B. Family readiness for change C. Family financial resources for purchase of healthy food items D. Child's normal routine of physical activity

B, implementation of a treatment plan for weight loss is unlikely to succeed if the family and the child are not ready to change

The caregiver of a toddler calls the clinic because the child has accidentally ingested one capsule of amitriptyline found in the medicine cabinet. The caregiver states that the child appears to be acting normally. Which response by the nurse is appropriate? A. "Give syrup of ipecac immediately and proceed to the hospital." B. "Please go directly to the nearest emergency department for evaluation." C. "Stay home and monitor the child closely for any symptoms." D. "You should come immediately to the clinic with the pill bottle."

B, ingestion of even a small amount may be life-threatening for a toddler bc it can produce cardiac toxicity and neurological disturbances

A patient at 39 weeks gestation with preeclampsia has a blood pressure of 170/100 mm Hg, 2+ proteinuria, and moderate peripheral edema. Immediately after hospital admission, she develops seizures and uterine contractions. Magnesium sulfate is prescribed. Which finding indicates that the drug has achieved the desired therapeutic effect? A. Blood pressure <130/80 mm Hg B. Seizure activity stops C. Urine has 1+ protein D. Uterine contractions stop

B, is a CNS depressant used to prevent/control seizure activity

The nurse assessing a patient notices pearly white plaque-like lesions on the mouth mucosa. The nurse understands that which patient is at highest risk for oral candidiasis ? A. A patient with asthma who uses an albuterol nebulizer once a day B. A septic patient receiving intravenous broad-spectrum antibiotics daily C. A teenage patient with braces who drinks several sugary drinks daily D. An elderly patient with poor oral hygiene and inadequate nutrition

B, patients receiving prolonged or high-dose antibiotic treatment are at increased risk as the normal microbial flora of the mouth is reduced

Within thirty seconds after birth, an unresponsive and limp newborn is placed on the warmer in the "sniffing" position. The nurse clears the airway, dries, and stimulates the newborn. At 1 minute of life, the newborn has shallow, gasping respirations with a heart rate of 62/min. What action should the nurse take? A. Administer epinephrine B. Begin positive pressure ventilation C. Continue stimulating the newborn D. Start chest compressions

B, positive pressure ventilation should be started when a newborns heart rate is <100

The RN prepares to give out patient care assignments. Which patient is appropriate for the RN to assign to the LPN? A. Patient admitted 3 hours ago with suspected acute pancreatitis B. Patient who had a total right hip replacement 2 days ago C. Patient who had a total thyroidectomy 2 hours ago D. Patient with alcohol withdrawal syndrome

B, the LPN should be assigned to patients who are medically able and have expected outcomes

A nurse is caring for a 2-year-old child diagnosed with nephrotic syndrome who is in diapers and has red, edematous genitals. Which collection technique is appropriate for the nurse to obtain daily urine specimens for proteinuria testing with a urine dipstick. A. Apply adhesive urine collection bag around the genital area and wait for the child to void. B. Intermittently catheterize the child every morning to avoid contaminating the specimen. C. Place cotton balls in a dry diaper; when wet, squeeze urine onto dipstick. D. Place urine dipstick in the child's diaper overnight and check result in the morning

C

A patient who gave birth vaginally with epidural anesthesia still has limited movement and strength of the right leg, and reports no urge to urinate at 2 hours postpartum. The nurse palpates the patient's funds 2 cm above the umbilicus and to the right. What should the nurse do next? A. Assist the patient to the bathroom in a wheelchair B. Encourage the patient to drink plenty of fluids C. Perform in-and-out catheterization D. Reassess for bladder distension hourly

C

An elderly patient at the end of life is visited by family members. One begins to cry and asks the nurse, "Will you please stay for a few minutes?" The nurse has other patients to care for as well. Which statement by the nurse is the most helpful? A. "I am busy right now but stay for a few minutes." B. "I can call the clergy to come sit with you." C. "I can stay and sit with you if you would like." D. "I don't think I should interrupt your family time."

C

Following the precipitous birth of a term newborn, what is the best action by the nurse while awaiting expulsion of the placenta and arrival of the HCP? A. Clean the perineal area B. Gently pull on the cord C. Keep the infant warm D. Massage the fungus

C

The nurse has been assigned to the staging area of a disaster response to an act of terrorism that developed a caustic chemical agent. A patient comes to the triage area with burns to the skin, severe pain, and visible chemical residue. What is the nurse's priority action? A. Assess skin to determine severity of burns and wounds B. Assign patient to a cot with other similarly triaged patients C. Assist the patient to the designated showering area D. Prepare supplies to establish IV access

C

The nurse is inserting an indwelling urinary catheter into a female patient who has urinary retention. The patient has not voided in 6 hours, and bladder scan reveals 400 mL of urine. During the first attempt of placing the urinary, catheter, no urine is returned. What action should the nurse take? A. Leave the catheter in place and recheck for urine output in 30 minutes B. Notify the prescribing HCP that there is an obstruction C. Obtain a new kit and insert the catheter higher up in the perineal area D. Remove the catheter and reinsert it at a position higher than the initial insertion

C

The nurse is managing the care of a patient diagnosed with generalized anxiety disorder. What behavior demonstrates that the patient is building resiliency and an improvement in anxiety symptoms? A. Actively avoids producing situations B. Identifies triggers that induce anxiety C. Practices stress reduction techniques daily D. Relies on medication to manage symptoms

C

The nurse is performing an Apgar assessment on a newborn patient at 1 minute of life. The newborn is completely blue, has a HR of 110/min, and is emitting a weak cry. Active movement and flexion of extremities are noted and the newborn grimaces when nares are suctioned. Which Apgar score should the nurse assign this newborn? A. Apgar score of 4 B. Apgar score of 5 C. Apgar score of 6 D. Apgar score of 8

C

The nurse is preparing to flush a patient's central venous catheter. Which size syringe is best for the nurse to choose? A. 1 mL B. 3 mL C. 10 mL D. 30 mL

C

The nurse plans to start an IV line on a female patient hospitalized with pneumonia. The nurse reviews the EMR for relevant information and learns that the patient is right-handed and has a history of a left-sided mastectomy with lymph node removal. Which site is best for the nurse to select for the patient's IV line? A. Basilic vein of the left forearm B. Cephalic vein in the right antecubital space C. Median vein of the right forearm D. Radial vein of the left wrist

C

The nurse prepares to administer the prescribed 8 AM medications to 4 patients. The nurse should administer medication to which patient first? A. Patient 2 days postoperative abdominal surgery who is to receive enoxaparin for venous thromboembolism prophylaxis. B. Patient with HTN who has a BP of 196/98 mm Hg and is to receive IV hydralazine. C. Patient with suspected sepsis who has a temperature of 102.3 F and is to receive an initial dose of IV ceftazidime. D. Patient with DMT2 and blood sugar of 500 mg/dL who is to receive subcutaneous regular insulin and insulin glargine.

C

The nurse prepares equipment for insertion of a large-bore nasogastric (NG) tube for a hospitalized patient. Which actions should the nurse take to measure and mark the tube? Select all that apply. A. Fold tube in half and mark at the halfway point B. Extend tape measure from naris to stomach. C. Measure from tip of nose to earlobe to xiphoid process D. Place a small piece of tape at the point of measurement E. Use rubber clamp after measuring the mark the point of measurement.

C, D

A patient with a diagnosis of schizophrenia with catatonia has recently been admitted to the behavioral health unit. What is the best nursing diagnosis for this patient? A. Impaired skin integrity B. Impaired verbal communication C. Self-care deficit D. Social isolation

C, catatonia can result in a self-care deficit because patients are unable to meet their own needs, placing them at risk for dehydration and malnutrition

The nurse assistant reports vital signs on 4 patients. Which patient should be a priority for the nurse to assess? A. 28-year-old with infective endocarditis and heart rate of 105/min B. 45-year-old with acute pancreatitis and sinus tachycardia of 120/min C. 65-year-old with tachycardia of 110/min after liver biopsy D. 74-year-old on diltiazem drip with atrial fibrillation and heart rate of 115/min

C, the liver is a highly vascular organ and bleeding is a major complication

The nurse is assessing a patient with pericardial effusion and notes muffled heart tones. Which of the following actions should the nurse take to assess for pulsus paradoxus? A. Check for variation in the amplitude of QRS complexes on the ECG strip. B. Compare the apical and radial pulses for any deficit. C. Measure the difference between Korotkoff sounds auscultated during expiration and throughout the respiratory cycle. D. Multiply the diastolic blood pressure (DBP) by 2, add the systolic blood pressure (SBP), and divide the result by 3: ((DBP x 2) + (SBP))/3

C. pulsus paradoxus is defined as an exaggerated fall in systolic blood pressure during inspiration and is measured by option C

A newly admitted patient with schizophrenia who is accompanied by the mental health technician is sitting in the group room. The nurse enters the room and sits next to the patient to prepare for a group session. Without responding, the patient stands and starts to leave. What action by the nurse is appropriate? A. Gently grasp the patient's arm and redirect the patient back to the seat B. In a loud, firm voice, direct the patient to come back to the room C. Reinforce the unit rules and importance of attending group sessions D. Remain silent and allow the patient to leave the room

D

A nurse is caring for a patient in the ED who is in active labor with rupture of membranes. On assessment, the nurse notes the patient has extrusion of the umbilical cord at the vaginal introitus. Which of the following is the priority nursing intervention after calling for assistance? A. Administer oxygen by face mask at 8 L/min B. Obtain IV access C. Prepare the patient for an emergency C-section D. Use a sterile gloves hand and apply finger pressure to elevate the presenting part of the fetus

D

A nurse is counseling a 45-year-old pregnant woman regarding the risks associated with amniocentesis. Which of the following is NOT a risk associated with this procedure? A. Infection B. Miscarriage C. Leakage of amniotic fluid D. Seizure E. Vaginal bleeding

D

A nurse is preparing to give a newborn an injection of vitamin K in the nursery. The infant's father is watching and asks, "What is that for?" Which response from the nurse is most accurate? A. "Your baby is more susceptible to infection right now. This will help protect him." B. "This shot helps your baby to excrete more bilirubin, which will reduce the risk of jaundice." C. We have to ensure that is blood glucose levels are stable before we can send him to your room." D. "This injection prevents bleeding as newborns have a higher risk."

D

A nurse receives the following change-of-shift morning report for the assigned patients. Which patient should the nurse assess first? A. Patient 1 day postoperative with fine inspiratory crackles in the lung bases on auscultation who is to ambulate for the first time this morning. B. Patient 1 day postoperative with serosanguineous drainage on the abdominal surgical dressing and temperature of 100.4 F C. Patient 2 days postoperative receiving intermittent epidural bolus analgesia who now reports incisional pain as a 4 on a 0-10 scale. D. Patient 2 days postoperative receiving fluids infusing at 125 mL/hr, with a Foley catheter and urine output of 100 mL during the last 8 hours.

D

The charge nurse is preparing for the admission of an elderly patient with delirium and agitation associated with urinary tract infection. To promote patient safety, which intervention is most important for the charge nurse to implement? A. A bed near the nursing station B. Four-point leather restraints C. Minimizing environmental stimuli D. One-on-one supervision from a sitter

D

The charge nurse must assign room to 4 patients who are scheduled for admission. Which patient has the highest priority for a private room assignment? A. Patient who is a known IV drug abuser who has osteomyelitis of the arm and chronic hepatitis C B. Patient with chronic obstructive pulmonary disease who has a latent tuberculosis infection C. Patient with diabetes mellitus and HIV infection who is in diabetic keto acidosis D. Patient with pneumonia who has a positive methicillin-resistant Staphylococcus aureus nose culture

D

The nurse is inserting an indwelling urinary catheter. The patient reports sharp pain while the nurse is instilling sterile water into the catheter balloon. Which action should the nurse take? A. Leave the balloon partially inflated without instilling additional sterile water. B. Remove the catheter and restart the procedure with a new, smaller urinary catheter. C. Rotate the catheter 180 degrees before instilling additional sterile water into the balloon. D. Withdraw the sterile water and advance the catheter further before attempting reinflation.

D

The nurse is preparing educational materials about histoplasmosis for a group of nursing students. Which teaching point is appropriate for the nurse to include? A. Histoplasmosis infection causes pink or purple spots to develop all over the patient's skin B. Histoplasmosis infection usually causes serious illness and often requires hospitalization C. Histoplasmosis is a bacterial infection that is spread through the air from an infected person D. Histoplasmosis is an opportunistic infection that occurs in patients who are immunocompromised

D

The nurse performing an initial newborn assessment observes a bluish discoloration of the hands and feet. The trunk is ink. Which action by the nurse is appropriate ? A. Apply blow-by oxygen and count respirations B. Auscultate heart sounds for a murmur C. Observe the newborn for expiratory grunting D. Place the newborn skin-to-skin with the parent

D

The nurse performs NG tube insertion using a large-bore NG tube on a hospitalized patient with a gastrointestinal bleed. During insertion, after the tube passes the nasopharynx, the patient begins to cough and gag. Which action should the nurse take first? A. Ask the patient to take several small sips of water B. Continue to slowly advance the tube until placement is reached. C. Gently remove the tube and reinsert the other naris if possible. D. Pull back on tube slightly and then pause to give the patient time to breathe.

D

The nurse received report on 4 patients. Which patient should the nurse assess first? A. Patient 1-day postoperative receiving patient-controlled analgesia with morphine who reports itching and nausea. B. Patient receiving maintenance IV normal saline solution with labeled tubing indicating that tubing was changed 48 hours ago. C. Patient with a pulmonary embolus receiving continuous IV heparin infusion and warfarin who has an International Normalized Ratio of 1.9 D. Patient with a resistant bacterial infection receiving IV vancomycin who reports discomfort at the peripheral IV site.

D

The parent of a 15-months-old calls the nurse and says that the child developed a rash and mild fever after receiving a routine MMRV vaccine in the pediatric clinic 5 days ago. What is the best response by the nurse? A. "Apply over-the-counter hydrocortisone cream to the rash." B. "Bring your child to the clinic this afternoon." C. "This is a common reaction to the MMRV vaccine." D."What is your child's temperature right now?"

D

The student nurse is preparing to perform a heel stick on a neonate to collect blood for diagnostic testing. Which statement by the student nurse indicates a need for further education? A. "I can perform the stick on either the medial or lateral side of the outer aspect of the heel." B. "Sucrose and a pacifier can help alleviate the infant's pain and stress during the puncture." C. "The heel area should be warmed for 3-5 minutes prior to puncture." D. "Venipuncture should be reserved only for failed heel sticks because it is more painful."

D

Which patient is most at risk for MRSA infection? A. 15-year-old student athlete in the ED with a closed femur fracture B. 46-year-old patient on the medical-surgical unit after a laparoscopic appendectomy C. 72-year-old patient who received a permanent pacemaker 24 hours ago D. 80-year-old patient with a hemodialysis catheter who lives in a log-term care facility

D

A laboring patient reports feeling the need to have a bowel movement and begin vomiting. The nurse notes that the patient's legs are trembling. What cervical examination finding would the nurse most expect this patient to have? A. 2 cm dilated, 50% effaced, -2 station B. 6 cm dilated, 70% effaced, -1 station C. 7 cm dilated, 80% effaced, 0 station D. 8 cm dilated, 100% effaced, +1 station

D, descent of fetal station below the maternal ischial spine (1+ or greater) often results in N/V and trembling or shivering

The nurse performs tracheostomy care for a patient with a disposable inner cannula and tracheostomy dressing. Place the steps in the correct order. A. Don mask, goggles, and clean gloves. B. Remove soiled dressing. C. Clean around stoma with sterile water or saline; dry and replace sterile gauze pad D. Gather supplies and position patient E. Don sterile gloves, remove old disposable cannula and replace with a new one

D, A, B, E, C

A pregnant patient in the first trimester tells the clinic nurse she will be traveling to an area with a known Zika virus outbreak and expresses concern regarding disease transmission. Which statement by the nurse is most appropriate? A. "If you experience Zika symptoms, notify your HCP." B. "Take precautions against mosquito bites throughout the trip." C. "You are not far enough for the Zika virus to affect your baby." D. "You should consider postponing your trip until after you have the baby."

D, Zika infection in a pregnant women can cause birth defects and developmental dysfunction, current guidelines recommend that pregnant women avoid travel to Zika-affected areas

The GN is inserting an oropharyngeal airway into a patient emerging from general anesthesia. Which action by the GN causes the nurse preceptor to intervene? A. Measures the oropharyngeal airway against the cheek and jaw angle before insertion. B. Rotates the device top downward once it reaches the soft palate. C. Suctions secretions from the mouth and pharynx prior to device insertion D. Tapes the external portion of the inserted oropharngeal airway to the patient's cheek

D, an OPA should never be taped in place because of the risk of choking and aspiration when the patient awakens

A patient in labor has reached 8 cm dilation, feels as urge to push, and reports a pain level of 7 on a scale of 0-10. The nurse observes thick, blood-tinged mucus during the vaginal examination. What is the nurse's best action? A. Administer prescribed IV meperidine for pain relief B. Encourage patient to bear down with spontaneous urges to push C. Place patient in the lithotomy position in preparation for birth D. Provide encouragement and coaching in breathing techniques

D, signs of near-complete dilation include bloody show and the urge to push, however patients should avoid pushing until fully dilated to prevent cervical trauma

The nurse is caring for a patient who reports severe abdominal pain and vaginal spotting. The patient has a positive urine pregnancy test at home, and her last menstrual period was 8 weeks ago. Which patient report to the nurse is most concerning? A. Abdominal pain rated as 8 out of 10 B. History of pelvic inflammatory disease C. Intermittent nausea and vomiting for the past 7 days D. Right shoulder pain and dizziness

D, symptoms of a ruptured ectopic pregnancy include hypotension, tachycardia, dizziness, and referred shoulder pain

The nurse in the pediatric clinic is triaging telephone messages. The nurse should call the parent of which child first? A. 2-year-old with bilateral tympanostomy tubes who has a small piece of plastic in the right outer ear. B. 4-year-ols post adenotonsillectomy who is now reporting ear pain. C. 6-year-old with strep throat who needs a note to return to school 24 hours after starting abx D. 7-year-old 5 days post tonsillectomy who wants to return to soccer practice today.

D, the nurse should this parent that the child should not resume strenuous activity or contact sports for at least 7-14 days post-surgery.

A patient is in restraints after punching another patient on the mental health unit. The patient states, "I'm Houdini. I can get out of anything. There could be trouble now." What is the nest response by the nurse? A. "Can you explain to me who Houdini is?" B. "Can you tell me how you are feeling?" C. Say nothing; signal to staff that help is needed D. "What kind of trouble are you thinking about?"

D, the priority nursing action is to explore potentially threatening statements and maintain an environment of safety

Which patient assignment is most appropriate for the nurse on an orthopedic unit to assign to a float nurse from a general medical unit? A. Patient 1-day postoperative with external fixators to stabilize a complex fracture of the wrist B. Patient 3-days post knee replacement surgery awaiting discharge C. Patient who is scheduled for an above-the-knee amputation today D. Patient with a long leg cast applied yesterday morning to treat a fractured ankle

D, this patient is stable and is the most appropriate assignment for the float nurse

True or false: The nurse should apply calamine lotion to reduce itching in patients with measles

False, measles rashes are not typically pruritic , calamine lotion is effective for soothing pruritic rashes

True or false: Someone who currently has varicella-zoster virus infection (chickenpox) should receive the varicella virus vaccine in 30 days

False, the vaccine is not indicated for a patient who has already developed immunity after recovering from VZV infection

True or false: A patient is getting a chest tube removed. It is appropriate to premeditate the patient with an analgesic 30-60 minutes before the procedure to promote comfort as evidence indicates that most patients report significant pain during removal

True

True or false: During injection cap and tubing changes of a central venous catheter, the patient should be instructed to hold the breath to prevent air from entering the line, traveling the heart, and forming an air embolism.

True

True or false: Rh-positive patients can safely receive Rh-positive and Rh-negative blood.

True

True or false: Treatment for varicella-zoster virus infection (chickenpox) is supportive and may include cool oatmeal baths and topical antihistamines applied to lesions for itching

True

Testing vaginal secretions with a nitrazine pH test strip can help differentiate between amniotic fluid, which is alkaline, and normal vaginal fluids or urine, which are acidic. What colors suggest probable rupture of membranes?

a bluish color

Severe vomiting is a common cause of metabolic _________ due to loss of gastric acid.

alkalosis

How should a urine specimen from a foley catheter be collected ?

aseptically from the port located on the catheter tubing.

What is a form of disorganized thinking characterized by rapid, shifting ideas with little or no connection, patients are unaware that these topics or ideas are not connected?

associative looseness

The nurse is working on a busy medical-surgical unit and is responding to the patient call lights. Which statement would be the priority to assess first? A. A65-year-old female patient recently started on celecoxib says, "I am having some nausea and my upper back and shoulder are hurting a quiet bit." B. A patient's child says, "My parents has been here for 2 days without anything to eat or drink." C. A paraplegic patient with multiple stage 4 pressure ulcers says, "I have had a bowel movement and need to be cleaned up." D. A postoperative patient says, "I am very nauseous and just threw up. This pain medicine is making me really sick."

celecoxib has a black box warning for increased risk of cardiovascular complications, the patient may be showing signs of an MI

What is the onset of convulsions or seizures that cannot be attributed to other causes in a woman with preeclampsia?

eclampsia

What involves a pregnancy implant in one of many locations outside the uterine cavity, and as it outgrows its environment, it may rupture, cause life-threatening maternal hemorrhage ?

ectopic pregnancy

If extravasation is suspected and are some appropriate interventions?

elevate the affected extremity above the heart, immediately discontinue the infusion, leave the IV catheter in place to aspirate the medication and potentially administer an antidote, notify HCP, initiate new IV access in the unaffected extremity, administer pain medication

What is an acute manic episode characterized by?

excessive psychomotor activity, euphoric mood, poor impulse control, flight of ideas, non-stop talking, poor attention span

What occurs when a tissue-damaging medication leaks outside the vessel and into surrounding tissues?

extravasation

True or false: A UAP can feed a patient who has a stroke 24 hours after admission

false, a stroke is not considered stabilized until 48 hours have passed without changes, UAPs should only feed stable patients

True or false: The nurse performing post delivery care of a newborn should place the identification band on the newborn before beginning to dry off amniotic fluid

false, drying the newborn immediately following birth protects the newborn from heat loss by evaporation and should occur prior to or simultaneously with other interventions

The nurse dons personal protective equipment (PPE) before providing care for a patient in airborne transmission-based precautions. What is the appropriate order for these steps: hand hygiene, gown, gloves, goggles or face shield, mask or respirator?

hand hygiene, gown, mask or respirator, goggles or face shield, gloves

What is an opportunistic fungal infection that results when fungal spores from soil that contains bird or bat droppings is inhaled; this infection is usually asymptomatic or mild, but can result in widespread, life-threatening infection in immunocompromised individuals?

histoplasmosis

How often is an Apgar score repeated?

is repeated every 5 minutes for up to 20 minutes if the 5-minute Apgar score is <7

What are spots common in Asian infants, Hispanics, and Native Americans and often disappear in the first few years of life?

mongolian spots

What are some clinical manifestations of extravasation ?

pain, swelling, pallor, coolness, fluid-filled blisters around the IV site

What occurs when the newborn is delivered <3 hours after the onset of contractions ?

precipitous birth

What is a systemic disease characterized by HTN and proteinuria after the 20th gestational week with unknown etiology?

preeclampsia

What occurs when the umbilical cord precedes the presenting part of the fetus or protrudes through the cervix, which compresses the umbilical cord and prevents perfusion of the fetus?

prolapse of the umbilical cord

What is included in the care plan for a patient experiencing an acute manic episode ?

reduction of environmental stimuli, a structured schedule, physical activities to help relieve excess energy, providing high-protein/high-calories meals and snacks, setting limits on behavior

What are some risk factors for MRSA?

residence in long-term care facility, recent hospitalization/antibiotics, MRSA colonization, HIV, DM, IV drug use, hemodialysis, crowded quarters, sharing needles

How do you calculate a patient's pregnancy due date using nagele rule?

subtract 3 months and add 7 days

The water level in the water seal chamber rises and falls with inspiration and expiration, a process known as ________, this movement indicates that the system is functioning properly and maintaining appropriate negative pressure.

tidaling

ALL infusing medications (except vasopressors) must be paused before drawing blood to prevent what?

to prevent false interpretation of the patient's serum levels

Testing vaginal secretions with a nitrazine pH test strip can help differentiate between amniotic fluid, which is alkaline, and normal vaginal fluids or urine, which are acidic. What colors suggest amniotic membranes are intact?

yellow, olive, or green colors