NCLEX Review Exam 2

A nurse is teaching a patient who has mastitis that is breastfeeding. Which of the following statements should the nurse include in the education? "Nurse the infant only on the unaffected breast until resolved." "Completely empty each breast at each feeding or use a pump." "Limit the amount of time the infant nurses on each breast." "Wear a tight-fitting bra until lactation has ceased."

"Completely empty each breast at each feeding or use a pump."

A nurse is caring for a client who has named a person to serve as his health care proxy. The client states he needs clarification about this type of advance directives. Which of the following statements by the client indicates a need for clarification? "I can change who I designate as my health care proxy at any time." "If I become incapacitated, end-of-life choices will be made by my proxy." "I have to choose a family member as my health proxy." "The health care proxy does not go into effect until I am incapable of making decisions."

"I have to choose a family member as my health proxy." Answer Rationale: The client should choose someone he trusts and knows about his wishes for day-to-day and end-of-life care. It can be a family member, but it does not have to be a family member.

A nurse is reviewing information about the Health Insurance Portability and Accountability Act (HIPAA) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates a need for further teaching? "Information about a client can be disclosed to family members at any time." "HIPAA established regulations of individually identifiable health information in verbal, electronic, or written form." "A client's address would be an example of personally identifiable information." "HIPAA is a federal law, not a state law."

"Information about a client can be disclosed to family members at any time." Answer Rationale: This statement reflects a need for further teaching. Privacy relates to the client's rights over the use and disclosure of his or her own personal health information.

A nurse is preparing to perform hand hygiene. Which of the following actions should the nurse take? Apply 4 to 5 mL of liquid soap to the hands. Adjust the water temperature to feel hot. Hold the hands higher than the elbows. Rub hands and arms to dry.

Apply 4 to 5 mL of liquid soap to the hands. Answer Rationale: The nurse should apply 4 to 5 mL of liquid soap to the hands to ensure an adequate amount is available to produce lather and kill microorganisms.

A community health nurse is conducting an educational program on various environmental pollutants. The nurse should emphasize that clients who have which of the following disorders are especially vulnerable to ozone effects? Osteoarthritis Basal cell carcinoma Asthma Hypothyroidism

Asthma Answer Rationale: The ozone exerts its primary adverse effects on the respiratory system, reducing lung function and increasing the risk of respiratory infection. Clients who have respiratory disorders, such as asthma and COPD, are especially vulnerable.

A nurse is caring for a client who is 1 hr postpartum and observes a large amount of lochia rubra and several small clots on the client's perineal pad. The fundus is midline and firm at the umbilicus. Which of the following actions should the nurse take? Document the findings and continue to monitor the client. Notify the client's provider. Increase the frequency of fundal massage. Encourage the client to empty her bladder.

Document the findings and continue to monitor the client. Answer Rationale: These are expected findings. At 1 hr postpartum, lochia rubra should be intermittent and associated with uterine contractions. The volume of lochia resembles that of a heavy menstrual period. Small clots are common. The nurse should document the findings and continue to monitor the client.

A nurse is planning interventions for migrant farm workers in a rural place. Which of the following should the nurse include as part of primary prevention? Establish food banks at locations throughout the community Provide employers handouts on recognizing pesticide toxicity. Partner with clinics to provide onsite care for acute injuries. Create handouts on identifying skin cancer in multiple languages.

Establish food banks at locations throughout the community

A nurse is caring for a client who recently had surgery for insertion of a permanent pacemaker. Which of the following prescriptions should the nurse clarify? Serum cardiac enzyme levels MRI of the chest Physical therapy Low-sodium diet

MRI of the chest Answer Rationale: A permanent pacemaker is a contraindication for MRI of the chest. The magnets in the machine can create electromagnetic interference and cause the pacemaker to malfunction.

A community health nurse in a pediatric clinic is reviewing the history of a 12-year-old client. Which of the following immunizations should the nurse expect to administer? Meningococcal conjugate Herpes zoster Rotavirus Pneumococcal polysaccharide

Meningococcal conjugate Answer Rationale: The CDC recommends administering the meningococcal vaccine to children who are 11 through 12 years old and then giving a booster dose at age 16. The nurse should prepare to administer this immunization.

A nurse is providing care for a surgeon on a medical-surgical unit. A nurse from another unit asks the nurse about the surgeon's medical diagnosis. The nurse responds that he is unable to provide the information requested. The nurse is displaying which of the following ethical principles? Autonomy Nonmaleficence Justice Beneficence

Nonmaleficence Answer Rationale: The nurse is obligated to protect the client's confidential information. A breach of confidentiality can place the client at risk of harm. Nonmaleficence is the ethical duty to prevent harm to the client.

The nurse provides instructions to a client who is taking levothyroxine. The nurse should tell the client to take the medication in which way? With food At bedtime with a snack At lunchtime On an empty stomach

On an empty stomach

A nurse is caring for a client who is at 36 weeks of gestation and who has a suspected placenta previa. Which of the following findings support this diagnosis? Abdominal pain with scant red vaginal bleeding Increasing abdominal pain with a nonrelaxed uterus Painless red vaginal bleeding Intermittent abdominal pain following passage of bloody mucus

Painless red vaginal bleeding Answer Rationale: Placenta previa is a condition of pregnancy when the placenta implants in the lower part of the uterus, partly or completely obstructing the cervical os (outlet to the vagina). Bright red, painless vaginal bleeding occurs in the second and third trimester.

A nurse is admitting a client who has acute pancreatitis. Which of the following provider prescriptions should the nurse anticipate? Initiate a low-residue diet. Pantoprazole 80 mg IV bolus twice daily Ambulate twice daily. Pancrelipase 500 units/kg PO three times daily with meals

Pantoprazole 80 mg IV bolus twice daily Answer Rationale: The nurse should anticipate a provider's prescription for a proton pump inhibitor to decrease gastric acid production, which ultimately decrease pancreatic secretions.

A nurse is caring for an adolescent who has hemophilia A and is scheduled for wisdom teeth extractions. Prior to the procedure, the nurse should anticipate that the client will receive which of the following products? Packed RBCs Prophylactic antibiotics Fresh frozen plasma Recombinant

Recombinant

A nurse is caring for a client who has active pulmonary tuberculosis (TB) and a new prescription for IV rifampin. The nurse should instruct the client that they should expect to experience which of the following manifestations while taking this medication? Constipation Black-colored stools Staining of teeth Red-colored urine

Red-colored urine Answer Rationale: Rifampin is used in combination with other medicines to treat TB. Rifampin will cause the urine, stool, saliva, sputum, sweat, and tears to turn reddish-orange to reddish-brown.

A client is suspected of having discoid lupus erythematosus (DLE). Which diagnostic test will primarily confirm the diagnosis? Anti-deoxyribonucleic acid (DNA) Extractable nuclear antigens Anti-Smith Test Skin biopsy

Skin biopsy

A nurse is establishing health promotion goals for a female client who smokes cigarettes, has hypertension, and has a BMI of 26. Which of the following goals should the nurse include? The client will list foods that are high in calcium, which should be avoided. The client will walk for 30 min 5 days a week. The client will increase calorie intake by 200 cal per day. The client will replace cigarettes with smokeless tobacco products.

The client will walk for 30 min 5 days a week. Answer Rationale: CDC recommendations include engaging in a moderate exercise, such as walking, for a total of 150 min each week.

A nurse is caring for patient diagnosed with anorexia nervosa. Which of the following demonstrates the nurse's ability to use interpersonal communication? The nurse presents an education session about anorexia nervosa to a large group of high school students. The nurse examines their own feelings about anorexia nervosa. The nurse asks the patient about their body image perception. The nurse discussed the patient's weight loss with the health care team.

The nurse asks the patient about their body image perception.

While caring for a client, the nurse experiences a needle stick injury. Which of the following actions should the nurse take first? Complete an incident report. Request the risk manager obtain consent for HIV testing from the client. Wash the site of injury with soap and water. Consent to postexposure treatment with antiretroviral medications.

Wash the site of injury with soap and water. Answer Rationale: The greatest risk to the nurse is infection transmission; therefore, the nurse should first wash the area with soap and water to reduce the risk of transmission.

A nurse is providing prenatal education to a patient that is 8 weeks gestation. The patient states, "I don't like milk." Which of the following would be a recommendation for a good source of calcium? dark, green leafy vegetables white breads and rice meat, poultry and fish deep red or orange vegetables

dark, green leafy vegetables