nclex study feb 24 pt.2

The parents of a 2-month-old infant brought their child to the clinic due to fever, telling the nurse that the child had a Diphtheria, Tetanus, and Pertussis (DTaP) vaccination injection one week prior. The parents ask the nurse if the fever is related to the DTaP vaccination. What would be the nurse's most appropriate response?

"Fever after the DTaP injection is usually low-grade and appears within the first two days."

A pediatric nurse is caring for a 6-year-old child who underwent placement of a ventriculoperitoneal (VP) shunt for the management of hydrocephalus. Which of the following statements by the child's caregiver indicates an understanding of potential complications associated with the VP shunt?

"We need to monitor the child for signs of abdominal distention or discomfort."

The nurse has provided medication instruction to a client prescribed methadone for intravenous (IV) opioid use disorder. Which of the following statements, if made by the client, would indicate a correct understanding of the instructions? Select all that apply.

"I will need counseling while taking this medication." "I will need periodic blood tests while on this medication." "This medication may lower my risk for Hepatitis C." "I may get drowsy while taking this medication." methadone is an efficacious medication used in the treatment of opioid use disorder, chronic pain, and in the treatment of neonatal abstinence syndrome.

The nurse is teaching a continuing education course on communicable diseases. Which of the following statements should the nurse make about diphtheria? Select all that apply.

"The organism that causes this condition is Corynebacterium diphtheriae." "Vaccination is available starting at two months of age." "Transmission of the cutaneous diphtheria is via direct contact with the infected person."

A nurse is providing education to the parents of an infant diagnosed with microcephaly. Which statement by the parents indicates a need for further teaching?

"We know that microcephaly is always caused by genetic factors."

The nurse is teaching a patient who is scheduled for a thoracentesis. Which of the following information should the nurse include? "This procedure will require you to receive general anesthesia." "You will need to report any shortness of breath following the procedure." "You will need to empty your bladder before this procedure." "After the procedure, a follow-up chest x-ray will be done." "You will need to be on a clear liquid diet one day before the procedure."

"You will need to report any shortness of breath following the procedure." "After the procedure, a follow-up chest x-ray will be done." It would be inappropriate to advise that the client empty their bladder before the procedure.

The nurse is applying a prescribed 5% lidocaine patch to a client's lumbar back region. The nurse plans to remove this patch after how many hours following application?

12 hours

The nurse is preparing to administer an intramuscular (IM) injection to a neonate. Which gauge and size needle should the nurse use to administer the medication?

25 gauge, 5/8" (1.6 cm) needle

The emergency department (ED) nurse cares for a client with diabetes mellitus (type one) with diabetic ketoacidosis (DKA). Which assessment finding requires immediate follow-up? A. Pulse 112/minute B. Persistent nausea and vomiting C. Respiratory rate 21/minute D. Blood glucose 299 mg/dL

A A complication associated with DKA is hypovolemic shock. The client having tachycardia is demonstrating early signs of this type of shock.

The nurse is triaging clients in the emergency department (ED). Which client should the nurse recommend to the primary healthcare provider (PHCP) to be assigned to the intensive care unit (ICU)? A. 28-year-old admitted with S. pneumoniae meningitis and has a Glasgow Coma Scale of 13. B. 59-year-old admitted with decompensated heart failure receiving oxygen therapy and hospice services. C. 33-year-old admitted with cholecystitis and is receiving patient-controlled analgesia. D. 67-year-old admitted with intractable pain and vomiting secondary to metastatic ovarian cancer.

A S. pneumoniae meningitis is a life-threatening central nervous system infection.

The nurse is caring for a client who is a Native American. Which of the following actions would be necessary for the nurse to take?

Avoid excessive direct eye contact

You are caring for a 65-year-old client who received a fecal diversion ostomy two days ago. Since then, the nursing staff has provided total care for the client and their ostomy, including irrigation and the application of the collection pouch. You have planned the education and training for this client to begin ostomy self-care; however, when you tell the client that you will be teaching them how to do this after discharge, the client states, "I do not want to even look at it. I will have my spouse care for it when I get home." Which of the following is the most appropriate nursing diagnosis which should be prioritized for this client? A. Risk for disturbed body image related to an ostomy B. Disturbed body image related to a fecal diversion ostomy C. Deficient knowledge related to the importance of self-care D. Deficient knowledge related to ostomy self-care

B

A client in the medical ward developed sudden hypotension, difficulty breathing, and cyanosis shortly after receiving an intravenous penicillin infusion. Based on the nurses' understanding of anaphylactic reactions, what can the nurse conclude is the cause of this reaction? A. Potent antibodies formed when the antibiotic was infused into the client during this infusion. B. The client was previously exposed to penicillin, enabling their body to produce antibodies. C. The client developed passive immunity to penicillin. D. Atopic sensitization occurred.

B anaphylaxis is an acute, potentially life-threatening, IgE-mediated allergic reaction occurring in previously sensitized clients following reexposure to the sensitizing antigen.

The nurse is assessing a client in the immediate postpartum period. Which of the following signs or symptoms would indicate the client is experiencing subinvolution? Boggy uterus. Board-like abdomen. Decreased fundal height. Increased bleeding. Hyporeflexia. Persistent lochial discharge.

Boggy uterus. Increased bleeding. Persistent lochial discharge. subinvolution refers to a womb that is not firm and contracting as expected to in the postpartum stage

The nurse in the mental health unit is preparing to establish a new group therapy session. Which client would be most appropriate for group therapy? A client A. in the acute phase of schizophrenia. B. with bipolar I disorder experiencing a mixed episode of depression and mania. C. with post-traumatic stress disorder having difficulty sleeping because of night terrors. D. experiencing delirium tremens associated with alcohol withdrawal.

C

The nurse is working in the NICU for the morning shift. While assessing four neonates less than 6-hours old, which neonate warrants additional attention from the nurse? A. A neonate with a molded head and overriding sutures. B. A neonate with cyanotic hands and feet that has not passed meconium. C. A neonate that is spitting up excessive mucus, with a temperature of 36.1 °C (97°F), and is dusky in appearance. D. A neonate with abdominal respirations and intermittent tremors of the extremities.

C

A nurse is caring for a client with diabetes insipidus who is receiving vasopressin (ADH) therapy. Which of the following assessments should the nurse prioritize when monitoring the client's response to vasopressin? A. Blood glucose levels B. Serum sodium levels C. Urine output D. Heart rate

C Urine output is the most direct and immediate indicator of vasopressin's effectiveness in reducing polyuria, a characteristic symptom of diabetes insipidus.

The nurse is assessing a female client with syphilis. Which of the following would be an expected finding?

Chancre lesion

The nurse has been made aware of the following client situations. The nurse should first assess the client A. with chronic obstructive pulmonary disease (COPD) who has an oxygen saturation of 90%. B. being treated for hypertension and has a blood pressure of 151/95 mm Hg and complaints of a headache. C. with a urinary catheter in place who is experiencing fever and chills. D. with a chest tube attached to a closed-chest drainage system that reports the onset of dyspnea.

D

The intensive care nurse (ICU) cares for a group of assigned clients. The nurse should initially follow-up with the client who is A. mechanically ventilated and not taking spontaneous breaths while in the assist-control (AC) mode. B. being treated for a flail chest, reporting chest pain with inhalation. C. noted to have gentle bubbling in the water seal chamber of their chest tube when coughing. D. receiving intravenous (IV) dopamine via a peripheral vascular access device and reports pain at the IV site

D Dopamine is a vasopressor and is indicated in the treatment of shock. Dopamine is a vesicant, and a significant adverse effect of dopamine is that it can extravasate and cause severe tissue damage

The nurse is discharging a client that has been admitted due to subarachnoid hemorrhage. The client still has some speech and balance deficits. Which referral would the nurse expect for this client? A. Refer the client to hospice care. B. Refer the client to speech therapy. C. Refer the client to physical therapy. D. Refer the client to a home health agency.

D Referring the client to a home health agency can be a suitable choice as it encompasses a broader spectrum of care, including physical therapy (PT), occupational therapy (OT), and speech therapy, among others. These services can address the client's rehabilitation needs comprehensively, including both speech and balance deficits.

A home health nurse is providing educational information to a client with iron-deficiency anemia. Which meal selection by the client would indicate to the nurse that the client understood the educational information provided?

Egg salad on wheat bread, carrot sticks, kale salad, raisins

The nurse is caring for a newborn immediately following birth with an omphalocele. The nurse should take which action? Select all that apply. Obtain a prescription for an antibiotic Obtain a prescription for intravenous fluids Gently press the omphalocele back into the abdomen Wrap the omphalocele with gauze to keep it dry Monitor the rectal temperature frequently for hypothermia

Obtain a prescription for an antibiotic Obtain a prescription for intravenous fluids

The nurse is caring for a client who is receiving prescribed quetiapine. Which of the following findings would indicate the client has an adverse effect? Select all that apply.

Fever Stooped posture Shuffling gait

The nurse has received a prescription for rivaroxaban. The nurse understands that this medication is prescribed to treat which condition?

Venous Thromboembolism (VTE)

The nurse is discussing infiltration with a group of students. It would be appropriate for the nurse to describe this complication as

a non-vesicant drug entering subcutaneous tissue

The nurse educates a client with multiple calcium oxalate urinary calculi about appropriate dietary items. Which of the following foods low in calcium oxalate should the nurse recommend?

broccoli lettuce apples

The nurse is teaching a group of students on incident reports. Which of the following situations would require an incident report? Select all that apply. A client

complaining about poor care from a nurse. leaving against medical advice (AMA). threatening a nurse with bodily harm.

The nurse is counseling clients who want to lower their risk for head and neck cancer. The nurse should recommend Select all that apply.

human papillomavirus (HPV) vaccination. smoking cessation. regular visits with a dental professional. daily use of lip balm that contains sunscreen.

The nurse determines the total intake for a client diagnosed with acute kidney injury. The client received 650 mL of intravenous fluid, 6 ounces of water, and 8 ounces of chicken broth during the shift. The client's urinary output for the shift is 820 mL. What is the total intake the nurse will record for this client? Fill in the blank.

output does not matter do NOT subtract from intake

The charge nurse is orientating a newly hired nurse to the charge nurse role. Which observation by the charge nurse requires follow-up? The newly hired nurse Select all that apply. requests the unlicensed assistive personnel (UAP) transport a client with respiratory distress to radiology. asks the licensed practical/vocational nurse (LPN/VN) to witness informed consent for a client scheduled for surgery. instructs the licensed practical/vocational nurse (LPN/VN) to review orders just written by the physician. asks the unlicensed assistive personnel (UAP) to transport blood specimens to the lab. assigns a client immediately postoperative from cardiac catheterization to a licensed practical/vocational nurse (LPN/VN).

requests the unlicensed assistive personnel (UAP) transport a client with respiratory distress to radiology. assigns a client immediately postoperative from cardiac catheterization to a licensed practical/vocational nurse (LPN/VN).

The nurse is teaching a parent of a 7-month-old client about food choices that may be introduced into the diet. The nurse should recommend which dietary item?

soy-based yogurt

The nurse is performing a physical assessment on a child with suspected Kawasaki disease (KD). Which of the following assessment findings would support this diagnosis? Select all that apply. strawberry tongue fruity breath drooling fever bright red rash on the cheeks

strawberry tongue fever

The nurse is instructing a female client who is neutropenic. It would be appropriate for the nurse to recommend that she

use pads instead of tampons during the menstrual cycle.