Physiological Adaptation NCLEX-RN PassPoint

A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). Laboratory results reveal serum sodium level 130 mEq/L and urine specific gravity 1.030. Which nursing intervention helps prevent complications associated with SIADH?

restricting fluids to 800 ml/day

A nurse is performing an admission assessment on a client entering a long-term care facility. She notices a broken area of skin that extends into the dermis on the client's coccyx. How should the nurse document this wound?

stage II pressure ulcer

A nurse is helping to plan a teaching session for a client who will be discharged with a colostomy. Which statement to the client would the nurse use to describe a healthy stoma?

"At first, the stoma may bleed slightly when touched."

A diabetic postpartum client plans to breastfeed. The nurse determines that the client's understanding of breastfeeding instructions is sufficient when the client makes which statement?

"Breastfeeding will assist in lowering maternal blood glucose."

When determining the effectiveness of teaching a child's mother about sickle cell disease, which statement by the mother indicates the need for additional teaching?

"He's going to be playing on a soccer team when he's feeling better."

The nurse teaches the family of child with leukemia about preventing infections. How should the nurse explain to the parents why their child is at risk for infections?

"Immature white blood cells are incapable of handling an infectious process."

Which client statement should the nurse evaluate as indicating the client's correct understanding of the causes of coronary artery disease (CAD)?

"The leading cause of CAD is atherosclerosis."

Parents bring their infant to the emergency department because the child has stopped breathing. A nurse obtains a brief history of events occurring before and after the parents found the infant not breathing. Which question should the nurse ask the parents first?

"What did the infant look like when you found him?"

The nurse is assessing a client who had an episode of autonomic dysreflexia. The nurse should first assess the client for:

bladder distention.

For the client who is receiving intravenous magnesium sulfate for severe preeclampsia, which assessment findings would alert the nurse to suspect hypermagnesemia?

decreased deep tendon reflexes

A client reports abdominal pain and vomiting for 24 hours. The client's blood pressure is 98/48 mm Hg. The client is diagnosed with large-bowel obstruction. What is the priority nursing diagnosis for the client?

deficient fluid volume

An 80-year-old client comes to the clinic reporting shortness of breath. When listening to the client's lungs, the nurse hears crackles (intermittent, high- and low- pitched popping sounds in the lower bases of the lungs) during inspiration. In which conditions might the nurse auscultate crackles? Select all that apply.

-acute respiratory distress syndrome -pneumonia -pulmonary edema

A triage nurse in the emergency department admits a male client with second-degree burns on the anterior and posterior portions of both legs. Based on the Rule of Nines, what percentage of the body is burned? Record your answer using a whole number.

3

A client in the emergency department reported vomiting and diarrhea for the previous 24 hours. The client's blood pressure is 90/60 mm Hg, respiration is 20 breaths per minute, heart rate is 92 beats per minute, and temperature is 37.5° C (99.5° F). Which intervention will the nurse perform first?

Assess for dehydration.

Which action is most important when the nurse is planning pain management for a client after a lobectomy for lung cancer?

reassessing the client after administering pain medication

While assessing a 2-month-old infant's airway, the nurse finds that the infant is not breathing. After two unsuccessful attempts to establish an airway, which should the nurse do next?

Administer five back blows.

The nurse is preparing to defibrillate a client on a cardiac monitor who is in ventricular fibrillation (see photo). What should the nurse do?

After pressing the charge button and calling "all clear," push the shock button.

Which action should a nurse include in the care plan for a 2-month-old infant with heart failure?

Allow the infant to rest before feeding.

A school-age child is admitted to the hospital with newly diagnosed insulin-dependent diabetes mellitus. On admission at 1000, his blood glucose is 180 mg/dL (10 mmol/L). He receives 2 units of regular insulin subcutaneously at 1030. What should the nurse include in the plan of care?

Assess the child beginning at 1230 for shakiness, feelings of anxiety, or decreased level of consciousness.

The monitor technician informs the nurse that the client has started having premature ventricular contractions every other beat. What should the nurse do first?

Assess the client's orientation and vital signs.

The nurse notices redness, swelling, and induration at a surgical wound site. What is the nurse's next action?

Assess the client's temperature.

A nurse hears an irregular heart rate of 110 bpm when listening to a client's chest. After assessing the client and noting the new onset of shortness of breath, which action should the nurse take next?

Obtain a prescription for a stat electrocardiogram.

A client is admitted with full-thickness burns to 30% of the body, including both legs. After establishing a patent airway, which intervention is a priority?

replacing fluid and electrolytes

A client has arterial blood gas results of pH 7.32; PaCO2 50; HCO3 23; and SaO2 80%. These results indicate:

respiratory acidosis.

The daily white blood cell (WBC) count in a client with aplastic anemia drops overnight from 3,900 to 2,900/µl (3.9 to 2.9 X 109/L). Which is the appropriate nursing intervention?

Call the primary care provider, and request that the client be placed in reverse isolation.

During a routine checkup, a nurse assesses a client with acquired immunodeficiency syndrome (AIDS) for signs and symptoms of cancer. What is the most common AIDS-related cancer?

Kaposi's sarcoma

Which nursing diagnosis takes highest priority for a client with hyperthyroidism?

Imbalanced nutrition: Less than body requirements related to thyroid hormone excess

For a child with hemophilia, what is the most important nursing goal?

Preventing bleeding episodes

Which intervention should the nurse anticipate using when caring for a term neonate diagnosed with transient tachypnea at 2 hours after birth?

Provide warm, humidified oxygen in a warm environment.

The nurse is conducting a health assessment of an older adult. The client tells the nurse about cramping leg pain that occurs when walking for 15 minutes; the pain is relieved with rest. The lower extremities are slightly cool to touch, and pedal pulses are palpable +1. What should the nurse instruct the client to do?

Seek consultation from the health care provider.

When the nurse is assessing the client's abdomen, which finding best indicates that a client's peristaltic activity is returning to normal after surgery?

The client passes flatus.

A client arrives at a public health clinic worried that she has breast cancer after finding a lump in her breast. When assessing the breast, which assessment finding provides an indication that the lump is more typical of fibrocystic breast disease?

The lump is round and movable.

A client with pancreatic cancer, who has been bed-bound for 3 weeks, has just returned from having a left subclavian, long-term, tunneled catheter inserted for administration of analgesics. The nurse has not yet received radiographic results for confirmation of placement. The client becomes restless and dyspneic and has chest pain radiating to the middle of the back. Physical assessment reveals tachycardia and absent breath sounds in the left lung. What should the nurse further assess?

a pneumothorax

The nurse teaches the mother of a toddler who has had cleft palate repair that her child is at risk for developing which problem in the future?

a speech defect

A nurse is caring for a client with a central venous catheter and notices redness and tenderness at the catheter insertion site. Which assessment finding would indicate possible systemic infection?

respiratory rate of 32 breaths/minute

After cancer chemotherapy, a client experiences nausea and vomiting. The nurse should assign highest priority to which intervention?

administering metoclopramide and dexamethasone as ordered

A client with emphysema is receiving continuous oxygen therapy. Depressed ventilation is likely to occur unless the nurse ensures that the oxygen is administered in which way?

at a low flow rate

When the nurse is assessing an individual with peripheral artery disease, which clinical manifestation would indicate complete arterial obstruction in the lower left leg?

coldness of the left foot and ankle

Which findings indicate that a client has developed water intoxication secondary to treatment for diabetes insipidus?

confusion and seizures

A 56-year-old female client is currently receiving radiation therapy to the chest wall for recurrent breast cancer. She has pain while swallowing and burning and tightness in her chest. The nurse should further assess the client for indications of which health problem?

esophagitis

The mother of an infant with myelomeningocele asks if her baby is likely to have any other defects. The nurse responds based on the understanding that myelomeningocele is commonly associated with which disorder?

excessive cerebrospinal fluid within the cranial cavity

In presenting a workshop on parameters of cardiac function, which conditions should a nurse list as those most likely to lead to a decrease in preload?

hemorrhage, sepsis, and anaphylaxis

A child with type 1 diabetes develops diabetic ketoacidosis and receives a continuous insulin infusion. Which condition represents the greatest risk to this child?

hypokalemia

The nurse is admitting a toddler with the diagnosis of near-drowning in a neighbor's heated swimming pool to the emergency department. The nurse should assess the child for which complication?

hypoxia

The nurse interprets which finding as an early sign of acute respiratory distress syndrome (ARDS) in a client at risk?

hypoxia not responsive to oxygen therapy

A client in the cardiac step-down unit is experiencing supraventricular tachycardia. Which intervention should be attempted first?

immersing the client's hands in cold water

In a client with amyotrophic lateral sclerosis (ALS) and respiratory distress, which finding is the earliest sign of reduced oxygenation?

increased restlessness

A client is recovering from an ileostomy that was performed to treat inflammatory bowel disease. During discharge teaching, the nurse should stress the importance of

increasing fluid intake to prevent dehydration.

A preterm infant born 2 hours ago at 34 weeks' gestation is experiencing rapid respirations, grunting, no breath sounds on one side, and a shift in location of heart sounds. The nurse should prepare to assist with which procedure?

insertion of a chest tube into the neonate

The nurse is evaluating the laboratory results of a client who was recently admitted to the hospital. Which result indicates the presence of inflammation?

leukocytosis

A woman tells the nurse, "There has been a lot of cancer in my family." The nurse should instruct the client to report which possible sign of cervical cancer?

light bleeding or watery vaginal discharge

A client comes to the emergency department complaining of headache, malaise, chills, fever, and a stiff neck. Vital sign assessment reveals a temperature elevation, increased heart and respiratory rates, and normal blood pressure. On physical examination, the nurse notes confusion, a petechial rash, nuchal rigidity, Brudzinski's sign, and Kernig's sign. What do these manifestations indicate?

meningeal irritation

A nurse is assessing a 15-year-old adolescent who's being admitted for treatment of anorexia nervosa. Which clinical manifestation is the nurse most likely to find?

muscle weakness

A 44-year-old client has been experiencing spotting, nausea, vomiting, and fatigue. A positive pregnancy test and an ultrasound confirm a 13 week gestation. The client had three prior miscarriages with no term births. What does the nurse recognize as the greatest risk factor for the client at this time?

pregnancy loss

A client with AIDS develops a fever, severe headache, and stiff neck and begins to vomit. Family members state they have noticed that the client does not seem to be as alert and oriented as before. What is the nurse's priority intervention?

protecting the client's airway

The client with Hodgkin's disease undergoes an excisional cervical lymph node biopsy under local anesthesia. After the procedure, what does the nurse assess first?

the airway

What assessment findings in a term neonate would cause the nurse to notify the health care provider (HCP)?

unequally sized corneas