Unit 3 NCLEX

The nurse is assigned to assist with caring for a client with esophageal varices who had a Sengstaken-Blakemore tube inserted because other treatment measures were unsuccessful. The nurse should check the client's room to ensure that which priority item is at the bedside?

A pair of scissors - When the client has a Sengstaken-Blakemore tube, a pair of scissors must be kept at the client's bedside at all times. The client needs to be observed for sudden respiratory distress, which occurs if the gastric balloon ruptures and the entire tube moves upward. If this occurs, the registered nurse is notified immediately and the balloon lumens will be cut.

The nurse notes documentation that a client has conductive hearing loss. The nurse understands that which is a cause of this type of hearing loss?

A physical obstruction to the transmission of sound waves

The nurse enters a client's room and finds that the wastebasket is on fire. The nurse immediately assists the client out of the room. Which is the next nursing action?

Activate fire alarm

The nurse is preparing to administer medication through a nasogastric (NG) tube that is connected to suction. Which indicates the accurate procedure for medication administration?

Clamp the NG tube for 30 minutes after medication administration

The nurse is reading the health care provider's (HCP's) progress notes in the client's record and sees that the HCP has documented "insensible fluid loss of approximately 800 mL daily." Which client is at risk for this loss?

Client with a fast respiratory rate - Insensible losses may occur without the person's awareness. Insensible losses occur daily through the skin and the lungs.

An older client has been prescribed digoxin (Lanoxin). The nurse understands that which age-related change would place the client at risk for digoxin toxicity?

Decreased lean body mass and glomerular filtration rate

The nurse is preparing to administer an intermittent tube feeding to a client with a nasogastric tube. The nurse checks the residual and obtains an amount of 200 mL. Which action should the nurse take?

Hold the feeding - When 200 mL of residual formula are obtained, the feeding is held and the registered nurse is notified because this is an indication that the feeding is not being absorbed. If the residual is less than 100 mL, the feeding is usually administered. Large-volume aspirates indicate delayed gastric emptying and place the client at risk for aspiration. In addition, the nurse should always check the health care provider's prescriptions and agency policy regarding residual amounts.

The nurse is caring for a client with leukemia and notes that the client has poor skin turgor and flat neck and hand veins. The nurse suspects hyponatremia. Which additional signs/symptoms should the nurse expect to note in this client if hyponatremia is present?

Postural blood pressure changes

The nurse reviews the client's serum calcium level and notes that the level is 8.0 mg/dL. The nurse understands which condition causes this serum calcium level?

Prolonged bed rest

The nurse is preparing to administer an intermittent tube feeding to a client. The nurse aspirates 90 mL of residual from the tube. What should the nurse do with the aspirated residual?

Reinstill the residual and administer the feeding - Unless otherwise instructed or if the residual contents appear abnormal, an amount of less than 100 mL may be reinstituted; then a normal amount of prescribed tube feeding is administered. It is important to return the contents to the stomach to prevent electrolyte imbalances.

The nurse is reviewing the health records of assigned clients. The nurse should plan care knowing that which client is at risk for a potassium deficit?

The client receiving nasogastric suction

The nurse monitors the postoperative client frequently, knowing that accumulated secretions can lead to which problem?

pneumonia

The parents of a 4-year-old child tell the nurse that they are concerned because the child has been masturbating. Which is the appropriate response by the nurse?

"This is a normal behavior at this age." - According to Freud's psychosexual stages of development, the child is in the phallic stage between the ages of 3 and 6 years. At this time, the child devotes much energy to examining his or her genitalia, masturbating, and expressing interest in sexual concerns.

The nurse is caring for a client with respiratory insufficiency. The arterial blood gas results indicate a pH of 7.50 and a PCo2 of 30 mm Hg, and the nurse is told that the client is experiencing respiratory alkalosis. Which additional laboratory value should the nurse expect to note?

A potassium level of 3.2 mEq/L - Signs/symptoms of respiratory alkalosis include tachypnea, mental status changes, dizziness, pallor around the mouth, spasms of the muscles of the hands, and hypokalemia. The remaining options identify normal laboratory results.

The nurse reviews a client's electrolyte results and notes a potassium level of 5.5 mEq/L. The nurse understands that a potassium value at this level should be noted with which condition?

A traumatic burn - serum potassium level that exceeds 5.0 mEq/L is indicative of hyperkalemia. Clients who experience the cellular shifting of potassium, as in the early stages of massive cell destruction (i.e., with trauma, burns, sepsis, or metabolic or respiratory acidosis), are at risk for hyperkalemia.

The nurse is collecting data from a client who is scheduled for surgery in 1 week in the ambulatory care surgical center. The nurse notes that the client has a history of arthritis and has been taking acetylsalicylic acid (aspirin). The nurse reports the information to the health care provider and anticipates that the provider will prescribe which?

D/C the aspirin 48 hours before the scheduled surgery.

The nurse is developing a plan of care for a client who is scheduled for surgery. The nurse should include which activity in the nursing care plan for the client on the day of surgery?

Have the client void immediately before surgery.

The nurse is caring for a client with diabetic ketoacidosis and observes that the client is experiencing abnormally deep, regular, rapid respirations. How should the nurse correctly document this observation in the medical record?

Kussmaul's respirations observed

The nurse is turning a postoperative client who had extensive spinal surgery on the previous day. Which turning intervention or position would be best for repositioning this client?

Logrolling

The nurse is administering a cleansing enema to a client with a fecal impaction. Before administering the enema, the nurse should assist the client to which position?

Left Sims' position, with the head of the bed flat