Pretest Nclex

The nurse has provided self-care activity instructions to a client after insertion of an implanted cardioverter-defibrillator (ICD). The nurse determines that further instruction is needed if the client makes which statement?

"I can perform activities such as swimming, driving, or operating heavy equipment as I need to."

A health care provider has prescribed transvaginal ultrasonography for a client in the first trimester of pregnancy, and the client asks the nurse about the procedure. How should the nurse respond to the client?

"The probe that will be inserted into the vagina will be covered with a disposable cover and coated with a gel."

The nurse determines that the client understands the basis of the diagnosis of obsessive-compulsive disorder after making which statement?

"My rituals are ways for me to control unpleasant thoughts or feelings."

The nursing student is assigned to care for a child with hemophilia. The nursing instructor reviews the plan of care with the student. Which intervention on the stude

Blood transfusion of packed red blood cells

The client diagnosed with alcoholism has been prescribed medication therapy to assist in the maintenance of sobriety. The nurse will provide the client with education focused on which medication that will most likely be prescribed?Disulfiram

Disulfiram

A 6-month-old infant is admitted to the hospital. The nurse weighs the infant and notes that the infant's weight is 14 pounds. Which statement by the mother indicates that further teaching is needed?

"I will have to increase his milk intake because he is not gaining enough weight."

The home care nurse is preparing to visit a client with a diagnosis of trigeminal neuralgia (tic douloureux). When performing the assessment, the nurse should plan to ask the client which question to elicit the most specific information regarding this disorder?

"Is the pain experienced a stabbing type of pain?

The nurse is counseling the young mother of a small child recently diagnosed with impetigo. The nurse should make which statement that provides the best information about impetigo?

"You will need to prevent any of the fluid from the blisters from coming into contact with your other children."

A client with a history of gastrointestinal upset has been diagnosed with acute diverticulitis. The nurse should anticipate a prescription from the health care provider for which type of diet for this client?

A low-fiber diet

A client is being admitted to the hospital for treatment of acute cellulitis of the lower left leg. During the admission assessment, the nurse expects to note which finding?

A skin infection of the dermis and underlying hypodermis

The nurse is assessing a client who has been admitted to the coronary care unit. The client seems to fluctuate in the ability to focus during the day. On the basis of this assessment, which client problem should the nurse suspect?

Acute confusion as a result of hospital-induced psychosis

The nurse is performing a skin assessment on a client diagnosed with malignant melanoma. The nurse should expect to note which characteristic of this type of skin lesion?

An irregularly shaped lesion

The nurse arrives at work and is told to report (float) to the intensive care unit (ICU) for the day because the ICU is understaffed and needs additional nurses to care for the clients. The nurse has never worked in the ICU. The nurse should take which best action?

Clarify with the team leader to make a safe ICU client assignment.

A quantitative 72-hour fecal fat collection is prescribed by the health care provider. How should the nurse instruct the client to prepare for the specimen collection?Consume a high-fat diet for 3 days before the test.

Consume a high-fat diet for 3 days before the test.

The nurse is caring for a client receiving morphine sulfate for pain. Because this medication has been prescribed for this client, which nursing action should be included in the plan of care?

Encourage the client to cough and deep breathe

To prevent postoperative atelectasis in a client recovering from an open cholecystectomy, what should the nurse do first?

Ensure that the client is experiencing adequate pain control.

A client is receiving a continuous intravenous infusion of heparin sodium to treat deep vein thrombosis. The client's activated partial thromboplastin time (aPTT) is 65 seconds. The nurse anticipates that which action is needed?

Leaving the rate of the heparin infusion as is

A thymectomy accomplished via a median sternotomy approach is performed in a client with a diagnosis of myasthenia gravis. The nurse creates a postoperative plan of care for the client that should include which intervention?

Monitor the chest tube drainage.

Home History Help Calculator Review ModeQuestion 3 of 75QN: 4894 | ID: 2347 | file: Pediatric_Part_1 Previous Go Next Stop Bookmark Rationale Strategy Reference(s) Submit The nurse is caring for a child with a head injury. The nurse observes decerebrate posturing. What is the nurse's best action?

Notify the health care provider.

The nurse is examining a dark-skinned client for the presence of petechiae. The nurse will best observe these lesions in which body area?

Oral mucosa

Which additional daily dietary intake will most closely match the number of additional calories needed by the breast-feeding mother?Peanut butter and jelly sandwich and glass of 2% milk

Peanut butter and jelly sandwich and glass of 2% milk

The nurse is preparing to instruct a client on how to bathe a newborn. Which statement should the nurse include in the instruction?

"Begin with the eyes and face."

The nurse has provided instructions to a client with a diagnosis of rheumatoid arthritis about measures to protect the joints. Which statement by the client indicates a need for further instruction?

"Pain or fatigue is expected, and I should try to continue with the activity if this occurs."

A client is about to have arterial blood gases drawn, and the nurse explains what an Allen's test is. What comment shows that the client understands the nurse's explanation?

"This test is done to ensure adequate collateral circulation."

atorvastatin has been prescribed for a client, and the client asks the nurse about the side and adverse effects of the medication. What should the nurse tell the client is a frequent side effect of this medication?

Headache

A pregnant client who has human immunodeficiency virus (HIV) infection is being seen in the antenatal clinic. The nurse expects the health care provider (HCP) to initiate zidovudine at how many weeks of gestation?

14

The home care nurse visits a client with a diagnosis of unstable angina. The client is taking acetylsalicylic acid (aspirin) on a daily basis to reduce the risk of myocardial infarction (MI). Which medication dose would the nurse expect the client to be taking?

300 to 325 mg daily

A pregnant woman who is infected with the human immunodeficiency virus (HIV) delivers a newborn infant, and the nurse provides instructions to help the mother regarding care of the infant. Which statements by the client indicate the need for further instruction? Select all that apply.

I need to breast-feed, especially for the first 6 weeks postpartum." "My baby has no symptoms so it is not likely that he has gotten the infection from me."

The nurse is reinforcing instructions to the mother of a child who has a plaster cast applied to the left arm. Which statement by the mother indicates a need for further teaching?

I will have to use a heat lamp to help the cast dry."

The nurse assesses the sternotomy incision of a client on the third day after cardiac surgery. The incision shows some slight puffiness along the edges and is nonreddened, with no apparent drainage. The client's temperature is 99°F (37.2°C) orally. The white blood cell count is 7500 mm3 (7.5 × 109/L). How should the nurse interpret these findings?

Incision is slightly edematous but shows no active signs of infection.

A client with acute pyelonephritis who was started on antibiotic therapy 24 hours earlier is still complaining of burning with urination. The nurse should anticipate that the health care provider will prescribe which medication?

Phenazopyridine

A client is due for a dose of bumetanide. The nurse should temporarily withhold the dose and notify the health care provider (HCP) if which laboratory test result is noted?

Potassium 2.9 mEq/L (2.9 mmol/L)

The nurse is planning to admit a pregnant client who is obese. In planning care for this client, which potential client needs should the nurse anticipate? Select all that apply.

Routine administration of subcutaneous heparin may be prescribed. An overbed lift may be necessary if the client requires a cesarean section. Thromboembolism stockings or sequential compression devices may be prescribed.

A rubella titer is performed on a client who has just been told that she is pregnant. The results of the titer indicate that the client is not immune to rubella. Which should the nurse anticipate to be prescribed for this client?

Retesting rubella titer during pregnancy

The nurse reviews the health care provider's (HCP's) prescriptions for a child with a streptococcal infection. The HCP prescribes an antistreptolysin O titer. Based on this prescription, which diagnosis should the nurse suspect in the child?

Rheumatic fever (RF)

The health care provider (HCP) arrives on the nursing unit and deflates the esophageal balloon of a client's Sengstaken-Blakemore tube. The nurse should contact the HCP immediately if which occurs?

The client complains of nausea and vomits blood.

The nurse hears a client calling out for help, hurries down the hallway to the client's room, and finds the client lying on the floor. The nurse performs an assessment, assists the client back to bed, notifies the health care provider of the incident, and completes an incident report. Which statement should the nurse document on the incident report?

The client was found lying on the floor.

The nurse is caring for an Appalachian client. The nurse makes sure to have frequent contact with the client and to initiate many different conversations. What is the best reason why the nurse uses this approach?

The Appalachian client may prefer personal relationships with health care providers and a desire for frequent communication.

A battered wife says, "My husband is a bully and a womanizer and certainly doesn't provide for his family, but he's never beat me up, so I don't think I can say he's abusive." Which response by the nurse is therapeutic?

"Do you believe that there are other forms of abuse besides the physical kind?"

The nurse is caring for a client just admitted to the mental health unit and diagnosed with catatonic stupor. The client is lying on the bed in a fetal position. Which is the most appropriate nursing intervention?

Sit beside the client in silence with occasional open-ended questions.

A client is receiving acyclovir by the intravenous (IV) route for treatment of cytomegalovirus (CMV) infection. After reconstituting the powder dispensed by the pharmacy, the nurse should administer this medication via which method?

Slow IV infusion over 1 hour

The nurse is reviewing the assessment data of a client admitted to the mental health unit. The nurse notes that the admission nurse documented that the client is experiencing anxiety as a result of a situational crisis. The nurse plans care for the client, determining that this type of crisis could be caused by which event?

The death of a loved one

A mother brings her 3-week-old infant to a clinic for a phenylketonuria rescreening blood test. The test indicates a serum phenylalanine level of 1 mg/dL (60.5 mcmol/L). The nurse reviews this result and makes which interpretation?

it is negative

A 15-year-old pregnant, unwed client tells the nurse, "My life was unbearable before I met Bobby. My mother beats me every day, and my dad has sexually abused me since I was 10 years old!" Which response is appropriate for the nurse to make?

"It seems that you needed Bobby's help to separate from your family."

The client experiencing a great deal of stress and anxiety is being taught to use self-control therapy. Which statement by the client indicates a need for further teaching about the therapy?

"It provides a negative reinforcement when the stimulus is produced."

A client who had cardiac surgery 24 hours ago has had a urine output averaging 20 mL/hour for 2 hours. The client received a single bolus of 500 mL of intravenous fluid. Urine output for the subsequent hour was 25 mL. Daily laboratory results indicate that the blood urea nitrogen level is 45 mg/dL (16 mmol/L) and the serum creatinine level is 2.2 mg/dL (194 mcmol/L). On the basis of these findings, the nurse would anticipate that the client is at risk for which problem?

Acute kidney injury

a client who has been receiving total parenteral nutrition (TPN) by way of a central venous access device complains of shakiness and is diaphoretic. Based on these findings, the nurse should perform which assessment next?

Blood glucose level

A mother arrives at the emergency department with her 5-year-old child and states that the child fell off a bunk bed. A head injury is suspected. The nurse checks the child's airway status and assesses the child for early and late signs of increased intracranial pressure (ICP). Which is a late sign of increased ICP?

Bradycardia

The nurse is preparing to care for a child with a diagnosis of intussusception. The nurse reviews the child's record and expects to note which sign of this disorder documented?

Bright red blood and mucus in the stools

A client is scheduled to begin therapy with carbamazepine. The nurse should assess the results of which test(s) before administering the first dose of this medication to the client?

CBC

A hydrocolloid dressing is prescribed for a client with a leg ulcer. The home health nurse is preparing a plan of care for the client and should appropriately document which intervention?

Change the hydrocolloid dressing every 3 to 5 days.

A child is placed in skeletal traction for treatment of a fractured femur. The nurse creates a plan of care and should include which intervention?

Check the health care provider's (HCP's) prescriptions for the amount of weight to be applied.

The nurse is providing home care instructions to the mother of a child who is recovering from Reye's syndrome. Which instruction should the nurse provide to the mother?

Check the skin and eyes every day for a yellow discoloration.

the home health nurse is visiting a client with myasthenia gravis and is discussing methods to minimize the risk of aspiration during meals related to decreased muscle strength. Which suggestions should the nurse give to the client? Select all that apply.

Chew food thoroughly. Cut food into very small pieces Sit straight up in the chair while eating. Swallow when the chin is tipped slightly downward to the chest

The nurse is assisting to defibrillate a client in ventricular fibrillation. After placing the pad on the client's chest and before discharge, which intervention is a priority?

Confirm that the rhythm is actually ventricular fibrillation.

A client who has had abdominal surgery complains of feeling as though "something gave way" in the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel protruding through the incision. Which interventions should the nurse take? Select all that apply.

Contact the surgeon. Instruct the client to remain quiet. Prepare the client for wound closure. Document the findings and actions taken.

the nurse is providing dietary instructions to a client with a diagnosis of irritable bowel syndrome. The nurse determines that education was effective if the client states the need to avoid which food?

Corn

The nurse manager has involved all staff members in the development of goals and decision making. Which leadership style has the unit manager exercised?

Democratic

Buspirone hydrochloride is prescribed for a client with an anxiety disorder. The nurse plans to include which teaching point when reviewing this medication with the client?

Dizziness and nervousness may occur.

The nurse caring for an Orthodox Jewish client plans a diet that adheres to the practices of the client's faith. When planning care, the nurse recognizes that which principles are consistent with dietary kosher laws? Select all that apply.

Eating fish with scales and fins is allowed. Unleavened bread is eaten during Passover week. Meat from animals that are vegetable eaters is allowed. Meat is allowed if the food animal is ritually slaughtered

The nurse is admitting a client with multiple trauma injuries to the nursing unit. The client has a leg fracture and had a plaster cast applied. Which position would be best for the casted leg?

Elevated on pillows continuously for 24 to 48 hours

The nurse is reviewing the laboratory test results for a client and notes that the serum sodium level is 150 mEq/L (150 mmol/L). The nurse understands that this value would be noted in which conditions?

Heart failure

The nurse is caring for a client with a diagnosis of right (nondominant) hemispheric stroke. The nurse notes that the client is alert and oriented to time and place. On the basis of these assessment findings, the nurse should make which interpretation?

Is likely to have perceptual and spatial disabilities

The nurse is performing an assessment on a client who was admitted with a diagnosis of carbon monoxide poisoning. Which assessment performed by the nurse would primarily elicit data related to a deterioration of the client's condition?

Level of consciousne

A client diagnosed with thrombophlebitis 1 day ago suddenly complains of chest pain and shortness of breath and is visibly anxious. Which complication should the nurse immediately assess the client for?

Pulmonary embolism

The purpose of a vaginal examination for a client in labor is to specifically assess the status of which findings? Select all that apply.

Station dilation efacement

After a tonsillectomy, the nurse reviews the health care provider's (HCP's) postoperative prescriptions. Which prescription should the nurse question?

Suction every 2 hours.

A client with tuberculosis receiving cycloserine orally twice daily must have blood drawn in 1 week to measure the serum concentration of the medication. The nurse prepares the client for this test by providing which information to the client?

Take the morning dose and have the blood drawn 2 hours after taking the dose.

A client has a prescription to take guaifenesin. The nurse should conclude that the client understands the most effective use of this medication if the client states that they need to take which action?

Take the tablet with a full glass of water.

The nurse provides instructions to a malnourished client regarding iron supplementation during pregnancy. Which statement, if made by the client, indicates an understanding of the instructions?

The iron is best absorbed if taken on an empty stomach.

The nurse is developing a plan of care for a client who believes the unit's food is being poisoned. Which strategy should the nurse plan to implement that will encourage the client to discuss feelings?

Use open-ended questions and silence.

The nurse has provided dietary instructions to a client with a diagnosis of hypoparathyroidism. The nurse should instruct the client that it is acceptable to include which item in the diet?

Vegetables

A client being admitted to the coronary care unit from the emergency department has a stat prescription to receive a dose of intravenous procainamide followed by a continuous infusion. Based on this prescription, the nurse should assess for which condition?

Ventricular ectopy

The nurse is preparing to administer eye drops. Which interventions should the nurse take to administer the drops? Select all that apply.

Wash hands. Put gloves on. Place the drop in the conjunctival sac. Pull the lower lid down against the cheekbone.

The nurse is providing dietary teaching to a client who is receiving a potassium-retaining diuretic about foods that are low in potassium. Which foods should the nurse include on a list of foods with low potassium content?

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