nclex

When teaching a client who is being started on imipramine hydrochloride, when should the nurse tell the client that the medication would have the desired effects?

Desired effects do not occur for 2 to 3 weeks of administration

A client with cancer has received a course of chemotherapy with fluorouracil. The nurse should plan to reinforce which instructions?

"Do not get any immunizations without primary health care provider approval."

The mother of an infant newly diagnosed with cystic fibrosis is being taught proper nutritional needs for the infant. The nurse determines that the mother understands nutritional needs when the mother gives which response?

"I know I need to monitor my infant's stools, and if there are more than four stools a day, I will increase the pancreatic enzyme.

A pilocarpine ocular system is prescribed for the client with glaucoma. The nurse reinforces instructions to the client regarding the medication. Which statement by the client indicates an understanding of the use of this medication?

"I should check my eye each morning to make sure that the medication system is in place."

The nurse reinforces home care instructions to a client diagnosed with systemic lupus erythematosus and instructs the client about methods to manage fatigue. Which statement by the client indicates a need for further teaching?

"I should take hot baths because they are relaxing

The nurse provides homecare instructions to the parents of a child with heart failure regarding the procedure for the administration of digoxin. Which statement by a parent indicates the need for further teaching?

"If my child vomits after medication administration, I will repeat the dose.

A primary health care provider prescribes morphine 6 mg intramuscularly for a client in pain. The medication label states, morphine 10 mg per mL. How many milliliters will the nurse administer to the client? Fill in the blank. Record the answer to one decimal place.

0.06

A primary health care provider's prescription reads "meperidine hydrochloride 125 mg by the intramuscular route stat." The medication vial reads 100 mg/mL. How many milliliters of the medication should the nurse draw into the syringe for injection? Fill in the blank. Record answer to two decimal places.

1.25

The nurse volunteering at the health screening clinic reinforces instructions to a 22-year-old client that diet and exercise should be used as tools to keep the total cholesterol level under at least which level?

130

A client arrives at the birthing center in active labor. Her membranes are still intact and the nurse-midwife performs an amniotomy. The nurse explains to the client that this procedure will most likely have which effect?

2. Amniotomy can be used to induce labor when the condition of the cervix is favorable (ripe) or to augment labor if the process begins to slow. Rupturing of membranes allows the fetal head to contact the cervix more directly and may increase the efficiency of contractions.

The nurse is assisting with preparing a teaching plan for the client with diabetes mellitus regarding proper foot care. Which instruction should be included in the plan of care?

3.Apply a moisturizing lotion to dry feet, but not between the toes

Which clients are at risk for developing skin breakdown? Select all that apply.

A client who is underweight,A client diagnosed with heart failure,A client diagnosed with spinal cord injury

The nurse is assisting in reviewing the critical paths of the clients on the nursing unit. In performing a variance analysis, which indicates the need for further action and analysis?

A postoperative client who develops a cough and a fever

The nurse is reinforcing instructions to a group of adults about the seven warning signs of cancer. The nurse determines that a member of the group needs further teaching if the member states which sign/symptom is a warning sign?

Absence or decreased frequency of menses

A client who has undergone a colostomy several days ago is reluctant to leave the hospital and has not yet looked at the ostomy site. Which measures will most likely promote coping? Select all that apply.

Ask a member of the local ostomy club to visit with the client before discharge.2. Ask the enterostomal nurse specialist to consult with the client before discharge.5. Ask the client to begin doing one part of the ostomy care and increase tasks daily.

A nurse is reinforcing instructions to a client in the first trimester of pregnancy about measures to help with morning sickness. Which should the nurse include in the instructions? Select all that apply.

Avoid milk. 2.Eat a low-fat diet. 3.Stop or decrease smoking. 4.Eat smaller, more frequent meals. 5.Consume adequate fluid between meals

A postpartum nurse has reinforced instructions to a new mother on how to bathe her newborn. The nurse demonstrates the procedure to the mother and on the following day asks the mother to perform the procedure. Which observation made by the nurse indicates that the mother is performing the procedure correctly?

Begin with the eyes and face.

A client with breast cancer is being treated with cyclophosphamide. The nurse plans care, knowing that this medication fits which classification?

Cell cycle phase nonspecific

The nurse is assessing the skin on a client who is immobile and notes the presence of a stage 2 pressure injury in the sacral area. Which nursing actions will encourage healing of a stage 2 pressure injury? Select all that apply.

Clean with mild soap and water.Encourage adequate nutritional intake.Apply a dressing that allows oxygen to pass through.

The nurse enters a client's room, and the client immediately demands to be released from the hospital. During review of the client's record, the nurse notes that the client was admitted 2 days ago for the treatment of an anxiety disorder and that the admission was a voluntary one. The nurse reports the findings to the registered nurse (RN) and expects that the RN will take which action?

Contact the health care provider (HCP).

The nurse has reinforced client instructions regarding crutch safety. Which comment by the client would indicate a need for further teaching?

Crutch tips will not slip, even when wet."

The nurse is suctioning a client through a tracheostomy tube. During the procedure, the client begins to cough, and the nurse notes the presence of an audible wheeze. The nurse attempts to remove the suction catheter from the client's trachea but is unable to do so. What is the nurse's priority response?

Disconnect the suction source from the catheter.

A primary health care provider places a Miller-Abbott tube in a client who has a diagnosed bowel obstruction. Six hours later, the nurse measures the length of the tube outside of the nares and notes that the tube has advanced 6 cm since it was first placed. Based on this finding, which action should the nurse take next?

Document the finding in the client's record.

Which interventions should the nurse implement for a child older than 2 years of age with type 1 diabetes mellitus who has a blood glucose level of 60 mg/dL? Select all that apply.

Give the child a teaspoon of honey and .repare to administer glucagon subcutaneously if unconsciousness occurs.

It has been determined that a client with hepatitis has contracted the infection from contaminated food. Which type of hepatitis is this client most likely experiencing?

Hepatitis A

The nurse is caring for a client with heart failure. The client suddenly becomes anxious and restless, has a sudden onset of breathlessness, and becomes cyanotic. The nurse suspects pulmonary edema and immediately places the client in which best position?

High-Fowler's

The client with diabetes mellitus receiving peritoneal dialysis asks the nurse why it is important to leave the dialysate infused only for a specific amount of time. The nurse responds that not adhering to the dwell time can increase the risk of the client experiencing which complication?

Hyperglycemia

A client is being discharged following treatment for left-sided heart failure. The nurse is reinforcing teaching the client the purpose, actions, adverse effects, and use of digoxin and hydrochlorothiazide prescribed for daily use. Which statement by the client indicates a need for further teaching?

I should decrease my intake of foods high in potassium, such as bananas

The nurse is reviewing the laboratory results of a client with leukemia who has received a regimen of chemotherapy. Which laboratory finding is indicative of the massive cell destruction that occurs with the chemotherapy?

Increased uric acid level

The nurse is collecting data on a client admitted to the hospital with a diagnosis of myxedema. Which data collection technique would provide data necessary to support the admitting diagnosis?

Inspection of facial features

A client is complaining about pain when voiding. The primary health care provider prescribes a clean-catch urine specimen. The nurse should instruct the client to perform which action first when obtaining this specimen?

Instruct the client to separate the labia and use the supplied cleanser to wipe each side of the urethra.

The nurse assists to prepare a teaching plan regarding the administration of eardrops for the parents of a 2-year-old child with otitis media. Which should be included in the plan?

Pull the earlobe down & back before instilling the eardrops

A woman who is 8 weeks pregnant complains to the nurse about nausea. Which advice should the nurse provide to this client about ways to assist with this problem? Select all that apply.

Refrain from eating anything for 2 to 3 hours after arising. Avoid greasy foods. Eat 5 to 6 small meals each day.

The registered nurse has written an outcome statement of, "Client will feel less anxious by the end of session," for a client with generalized anxiety disorder. Which interventions should the licensed practical nurse use to assist this client in meeting this goal? Select all that apply.

Stay with the client. Administer anxiolytics medications if prescribed. Ensure the client is in an environment with little stimuli.

he nurse is assisting in caring for a client in the telemetry unit who is receiving an intravenous infusion of 1000 mL 5% dextrose with 40 mEq of potassium chloride. Which occurrence observed on the cardiac monitor indicates the presence of hyperkalemia?

Tall, peaked T waves

The nurse is assisting in preparing a plan of care for a client with renal colic receiving meperidine hydrochloride for pain. The nurse includes in the plan of care to monitor for which side effect of this medication?

Urinary retention

The nurse is making a worksheet and listing the tasks that need to be performed for assigned adult clients during the shift. The nurse writes on the plan to check the intravenous (IV) of an assigned client who is receiving fluid replacement therapy how frequently?

every hour

The nurse is reinforcing discharge instructions to a client following right eye corneal transplantation surgery. The nurse determines that the client understands the instructions if the client makes which statement?

eye shield all time

The nurse is caring for a client with a diagnosis of aplastic anemia. Which are the most likely signs/symptoms associated with aplastic anemia? Select all that apply

fatigue, infection, petechiae - busted blood vessels shortness of breath

The nurse is present at a disaster scene and is participating in the triage of victims. Which color tag should be assigned to a victim with evidence of open pneumothorax?

red

The nurse reinforces instructions to a pregnant client regarding the administration of iron. The nurse determines that the teaching is effective if the client states that she will take the iron with which food items?

water

Which is the appropriate method to use to deliver the placenta after a precipitate delivery?

Gently guide the placenta out after a spontaneous separation.

The nurse evaluates that the older client has a need for further teaching on how to promote sleep when the client makes which statements? Select all that apply.

I drink hot chocolate before bedtime.

The nurse is teaching the client with angina pectoris about disease management and lifestyle changes that are necessary in order to control disease progression. Which statements by the client indicate a need for further teaching? Select all that apply.

It is best to exercise once a week for an hour."

The nurse is caring for a client following a total hip replacement. The client has been diagnosed with iron deficiency anemia. The nurse instructs the client to increase intake of which foods? Select all that apply.

Lean beef and chicken liverClams and mussels