NCLEX study

A client who has been in a coma for two months is being maintained on bed rest. The nurse concludes that to prevent the effects of shearing force, the head of the bed should be maintained at an angle of?

30 degrees. Shearing force occurs when two surfaces move against each other, when the bed is at an angle greater than 30 degrees, the torso tends to slide and causes this phenomenon.

An older adult client is demonstrating mild confusion after surgical repair of a hernia. What should the nurse do to provide for this clients safety?

Activate the position-sensitive bed alarm.

A nurse performs postoperative teaching for a client who is to have cataract surgery. Which is the most important for the nurse to include concerning what the client should do after surgery?

Avoid bending from the waist because this increases intraocular pressure.

Daily Humulin R insulin has been prescribed for a client with type 1 diabetes. The nurse administers the insulin at 8 AM. When should the nurse monitor the client for a potential insulin reaction?

Before lunch- because regular insulin is short acting and peaks in 2-4 hours.

Six hours after major abdominal surgery, a client complains of severe abdominal pain and feeling faint. The nurse identifies a thready, rapid pulse. The nurse checks the Physiological Aspects of Care record and determines that the client can receive another injection of pain medication in an hour. What is the most appropriate action by the nurse?

Call the health care provider, report the clients symptoms, and obtain further prescriptions because the clients signs and symptoms suggest the possibility of shock.

A client who was recently diagnosed with diagnosed with emphysema develops a malignancy in the right lower lobe of the lung, and a lobectomy is performed. After surgery, the client is receiving oxygen by nasal cannula at 2 L per minute. Blood gas results demonstrate respiratory acidosis. What should be the initial nursing intervention?

Encourage deep breathing

The nurse is caring for a client who is experiencing signs and symptoms of a cardiac dysrhythmia who is scheduled to wear a Holter monitor for 24 hours. During the test, the client should be instructed to?

Keep a diary of activities because the purpose of a Holter monitor is to correlate dysrhythmia with the clients reported activity.

Tha nurse is caring for a client who is experiencing signs and symptoms of a cardiac dysrhythmia who is scheduled to wear a Holter monitor for 24 hours. During the test, the client should be instructed to?

Keep a diary of activities to correlate the clients dsyrhymthmia to their activities.

The nurse is teaching the client with obstructive pulmonary disease to use pursed lip breathing because this is beneficial for the client through which mechanism?

Prolonged exhalation to decrease air trapping

A client is admitted to the hospital with a diagnosis of pneumonia. The clients pulse rate increases from 88 beats per minute on admission to 120-140 beats per minute on the second day of hospitalization. The client is more restless, complains of a headache, and is diaphoretic. What would the nurse want to check?

The arterial blood gases

A client is admitted into the hospital for a laparoscopic cholecystectomy. What should the nurse encourage the client to add to the diet to help normalize bowel function after surgery?

Whole bran because it provides bulk that promotes intestinal motility and a regular bowel movement.

After an amputation of a limb, a client begins to experience extreme discomfort in the area where the limb once was. The nurses greatest concern at this time is?

Addressing the pain

A client is scheduled for a transurethral resection of the prostate. What should the nurse tell the client to expect after surgery?

An indwelling urinary catheter is required for at least a day.

A client who is receiving total parenteral nutrition (TPN) reports experiencing nausea, thirst, and a headache. Which clinical factor should the nurse monitor initially to further assess the client's status?

Blood glucose because the client is exhibiting classic signs of hyperglycemia.

A client with emphysema is admitted to the hospital with pneumonia. On the third hospital day, the client complains of a sharp pain in the right side of the chest. The nurse suspects a pneumothorax. What breath sound is most likely to be present when the nurse assesses the clients right side?

Decreased breath sounds

A client with a history of closed-angle glaucoma is scheduled for abdominal surgery. Because the client is extremely anxious, surgery is to be performed under general anesthesia. What should the nurse teach the client to do to prevent respiratory complications postoperatively?

Deep-breathing techniques

A client is scheduled to receive intravenous fluids to be delivered at 80 ml/hr. To adjust the drip rate when administering the IV via gravity, the nurse must determine the?

Drops per milliliter delivered by the infusion set

A nurse is preparing to obtain a blood specimen for culture and sensitivity from a client with an elevated temperature for the last two days. What is the order of priority?

Explain the procedure to the client, collect the specimen according to protocol, send the specimen to the laboratory, and administer the first dose of antibiotics.

A nurse is providing teaching to a client with a newly prescribed proton pump inhibitor. The nurse determines that the teaching is effective when the client states that the medication is used for the treatment of?

Gastroesophageal reflux (GERD) because PPI's are effective in decreasing the secretion of gastric acid.

During change of shift report the night nurse indicates that a client cannot tolerate the prescribed intermittent tube feedings. The nurse receiving report should first?

Gather more data from the night nurse about the technique used because that will give the nurse the best indication of what solution to look for.

A client is concerned about contracting malaria while visiting relatives in Southeast Asia. What should the nurse teach the client to best avoid malaria?

Mosquito bites because malaria is caused by the protozoan Plasmodium falciparum which is carried by mosquitos.

A client with a cardiac dysrhythmia is receiving digoxin (Lanoxin) and Verapamil (Calan). Because of the combined effect of these two medications, the nurse assesses the client for?

Myocardial depression because both digoxin and verapamil decrease cardiac impulse conduction.

What criteria should the nurse consider when determining if an infection should be categorized as a health care- associated infection?

Occurred in conjunction with treatment for an illness

A healthcare provider prescribes daily sputum specimens to be collected from a client. When is the most appropriate time for the nurse to collect these specimens?

On awakening because during sleep, mucous secretions in the respiratory tract move slowly toward the throat.

When assessing a client who had abdominal surgery, the nurse determines that peristalsis has returned when the client?

Passes flatus because that indicates peristaltic movement.

A nurse is reviewing the laboratory reports of a client with a diagnosis of end stage renal disease. What test result should the nurse anticipate?

Potassium of 6.3 mEq/L because clients with end stage renal disease have impaired potassium excretion.

A client with scleroderma complains of difficulty with chewing and swallowing. When providing dietary counseling, the nurse should advise the client to?

Purée foods before eating because scleroderma causes chronic hardening and shrinking of the connective tissues of the body, including the esophagus and face. Puréed foods limit the need to chew.

A states Nurses Practice Act does not allow a registered nurse to suture wounds, but a primary health care provider offers to teach the RN, what should she do?

Refuse to suture the wounds

After flushing a clients arm with a saline lock, the patient complains about a painful and burning sensation at the site, what should the nurse do?

Remove the angiocatheter and saline lock and restart the IV in another site because the IV has been infiltrated.

A nurse observes that an unlicensed assistive personnel did not use a bag impervious to liquid for contaminated linen from a client who is on contact precautions. The nurses best way to handle this situation is to?

Review transmission based precautions with the UAP

Immediately after a storm has passed, the nurse is working with a rescue team that is searching for injured people. The nurse finds a victim lying next to a broken natural gas main. The victim is not breathing and is bleeding heavily from a wound on the foot. What should be the nurses first intervention?

Safely remove the victim from the immediate vicinity

A client has a thyroidectomy for cancer of the thyroid. To evaluate for nerve injury that may be a result of surgery-related trauma, the nurse assesses the clients ability to?

Speak- because the the laryngeal nerve is close to the operative site and can accidentally be damaged.

When caring for a client who has acute respiratory distress syndrome, the nurse would implement which measure to promote effective airway clearance?

Suction as needed

A client is newly diagnosed with multiple sclerosis. The client is obviously upset with the diagnosis and asks, "am I going to die?" The nurses best response is?

The prognosis is variable; most individuals experience remissions and exacerbations.

Before a transurethral resection of the prostate (TURP), a client asks about what to expect postoperatively. The most appropriate response by the nurse is?

There will be an indwelling urinary catheter and a continuous bladder irrigation in place.

The health care provider prescribes "bathroom privileges only" for a client with pulmonary edema. The client becomes irritable and asks the nurse why? What is the best way for the nurse to respond?

Using patient education by saying "rest helps your body direct energy to healing"