NCLEX
You are reviewing the CBC for a patient who has been admitted for knee arthroscopy. Which value is most important to report to the provider before prepping the patient for surgery? A. Hct of 33% B. Hgb of 10.9g/dL C. Plt count 426,00/mm³ D. WBCs of 16,000/mm³
D. WBCs of 16,000/mm³ Reason: All are abnormal, but increased WBCs may indicate an active infection.
Nurses teach infant care and safety classes to assist parents in appropriately preparing to take their neonates home. Which statement about automobile restraints for infants is correct? a) An infant should ride in a front-facing car seat until he weighs 20 lb (9.1 kg) and is 1 year old. b) An infant should ride in a rear-facing car seat until he weighs 25 lb (11.3 kg) or is 1 year old. c) An infant should ride in a front-facing car seat until he weighs 30 lb (13.6 kg) or is 2 years old. d) An infant should ride in a rear-facing car seat until he weighs 20 lb and is 1 year old.
d) An infant should ride in a rear-facing car seat until he weighs 20 lb and is 1 year old. Reason: Until the infant weighs 20 lb and is 1 year old, he should ride in a rear-facing car seat.
The wife of a 67-year-old client who has been taking imipramine (Tofranil) for 3 days asks the nurse why her husband isn't better. The nurse should tell the wife: a)"It takes 2 to 4 weeks before the full therapeutic effects are experienced." b)"Your husband may need an increase in dosage." c)"A different antidepressant may be necessary." d)"It can take 6 weeks to see if the medication will help your husband."
a) "It takes 2 to 4 weeks before the full therapeutic effects are experienced." Reason: Imipramine, a tricyclic antidepressant, typically requires 2 to 4 weeks of therapy before the full therapeutic effects are experienced. Because the client has been taking the drug for only 3 days, it is too soon to determine if the current dosage of imipramine is effective. It is also too soon to consider taking another antidepressant.
A client is scheduled for surgery under general anesthesia. The night before surgery, the client tells the nurse, "I can't wait to have breakfast tomorrow." Based on this statement, which nursing diagnosis should be the nurse's priority? a)Deficient knowledge related to food restrictions associated with anesthesia b)Fear related to surgery c)Risk for impaired skin integrity related to upcoming surgery d)Ineffective coping related to the stress of surgery
a) Deficient knowledge related to food restrictions associated with anesthesia Reason: The client's statement reveals a Deficient knowledge related to food restrictions associated with general anesthesia. Fear related to surgery, Risk for impaired skin integrity related to upcoming surgery, and Ineffective coping related to the stress of surgery may be applicable nursing diagnoses but they aren't related to the client's statement.
A client with a bleeding ulcer is vomiting bright red blood. The nurse should assess the client for which of the following indicators of early shock?a)Tachycardia. b)Dry, flushed skin. c)Increased urine output. d)Loss of consciousness
a) Tachycardia. Reason: In early shock, the body attempts to meet its perfusion needs through tachycardia, vasoconstriction, and fluid conservation. The skin becomes cool and clammy. Urine output in early shock may be normal or slightly decreased. The client may experience increased restlessness and anxiety from hypoxia, but loss of consciousness is a late sign of shock.
A client with an incomplete small-bowel obstruction is to be treated with a Cantor tube. Which of the following measures would most likely be included in the client's care once the Cantor tube has passed into the duodenum? a)Maintain bed rest with bathroom privileges. b)Advance the tube 2 to 4 inches at specified times. c)Avoid frequent mouth care. d)Provide ice chips for the client to suck
b) Advance the tube 2 to 4 inches at specified times. Reason: Once the intestinal tube has passed into the duodenum, it is usually advanced as ordered 2 to 4 inches every 30 to 60 minutes. This, along with gravity and peristalsis, enables passage of the tube forward. The client is encouraged to walk, which also facilitates tube progression. A client with an intestinal tube needs frequent mouth care to stimulate saliva secretion, to maintain a healthy oral cavity, and to promote comfort regardless of where the tube is placed in the intestine. Ice chips are contraindicated because hypotonic fluid will draw extra fluid into an already distended bowel.
When measuring the fundal height of a primigravid client at 20 weeks' gestation, the nurse will locate the fundal height at which of the following points? a)Halfway between the client's symphysis pubis and umbilicus. b)At about the level of the client's umbilicus. c)Between the client's umbilicus and xiphoid process. d)Near the client's xiphoid process and compressing the diaphragm.
b) At about the level of the client's umbilicus. Reason: Measurement of the client's fundal height is a gross estimate of fetal gestational age. At 20 weeks' gestation, the fundal height should be at about the level of the client's umbilicus. The fundus typically is over the symphysis pubis at 12 weeks. A fundal height measurement between these two areas would suggest a fetus with a gestational age between 12 and 20 weeks. The fundal height increases approximately 1 cm/week after 20 weeks' gestation. The fundus typically reaches the xiphoid process at approximately 36 weeks' gestation. A fundal height between the umbilicus and the xiphoid process would suggest a fetus with a gestational age between 20 and 36 weeks. The fundus then commonly returns to about 4 cm below the xiphoid owing to lightening at 40 weeks. Additionally, pressure on the diaphragm occurs late in pregnancy. Therefore, a fundal height measurement near the xiphoid process with diaphragmatic compression suggests a fetus near the gestational age of 36 weeks or older.
After staying several hours with her 9-year-old daughter who is admitted to the hospital with an asthma attack, the mother leaves to attend to her other children. The child exhibits continued signs and symptoms of respiratory distress. Which of the following findings should lead the nurse to believe the child is experiencing anxiety?a)Not able to get comfortable. b)Frequent requests for someone to stay in the room. c)Inability to remember her exact address. d)Verbalization of a feeling of tightness in her chest
b) Frequent requests for someone to stay in the room. Reason: A 9-year-old child should be able to tolerate being alone. Frequently asking for someone to be in the room indicates a degree of psychological distress that, at this age, suggests anxiety. The inability to get comfortable is more characteristic of a child in pain. Inability to answer questions correctly may reflect a state of anoxia or a lack of knowledge. Tightness in the chest occurs as a result of bronchial spasms.
The nurse has administered aminophylline to a client with emphysema. The medication is effective when there is: a)Relief from spasms of the diaphragm. b)Relaxation of smooth muscles in the bronchioles. c)Efficient pulmonary circulation. d)Stimulation of the medullary respiratory center.
b) Relaxation of smooth muscles in the bronchioles. Reason: Aminophylline, a bronchodilator that relaxes smooth muscles in the bronchioles, is used in the treatment of emphysema to improve ventilation by dilating the bronchioles. Aminophylline does not have an effect on the diaphragm or the medullary respiratory center and does not promote pulmonary circulation.
A primigravid client gives birth to a full-term girl. When teaching the client and her partner how to change their neonate's diaper, the nurse should instruct them to: a)fold a cloth diaper so that a double thickness covers the front. b)clean and dry the neonate's perineal area from front to back. c)place a disposable diaper over a cloth diaper to provide extra protection. d)position the neonate so that urine will fall to the back of the diaper.
b) clean and dry the neonate's perineal area from front to back. Reason: When changing a female neonate's diaper, the caregiver should clean the perineal area from front to back to prevent infection and then dry the area thoroughly to minimize skin breakdown. For a male, the caregiver should clean and dry under and around the scrotum. Because of anatomic factors, a female's diaper should have the double thickness toward the back. The diaper, not the neonate, should be positioned properly. Placing a disposable diaper over a cloth diaper isn't necessary. The direction of urine flow can't be ensured.
A nurse is helping a physician insert a subclavian central line. After the physician has gained access to the subclavian vein, he connects a 10-ml syringe to the catheter and withdraws a sample of blood. He then disconnects the syringe from the port. Suddenly, the client becomes confused, disoriented, and pale. The nurse suspects an air embolus. She should: a)place the client in a supine position and prepare to perform cardiopulmonary resuscitation. b)place the client in high-Fowler's position and administer supplemental oxygen. c)turn the client on his left side and place the bed in Trendelenburg's position. d)position the client in the shock position with his legs elevated.
c) turn the client on his left side and place the bed in Trendelenburg's position. Reason: A nurse who suspects an air embolism should place the client on his left side and in Trendelenburg's position. Doing so allows the air to collect in the right atrium rather than enter the pulmonary system. The supine position, high-Fowler's position, and the shock position are therapeutic for other situations but not for air embolism.
The client is taking risperidone (Risperdal) to treat the positive and negative symptoms of schizophrenia. Improvement of which of the following negative symptoms indicate the drug is effective?a)Abnormal thought form. b)Hallucinations and delusions. c)Bizarre behavior. d)Asocial behavior and anergia.
d) Asocial behavior and anergia. Reason: Asocial behavior, anergia, alogia, and affective flattening are some of the negative symptoms of schizophrenia that may improve with risperidone therapy. Abnormal thought form is a positive symptom of schizophrenia. Hallucinations and delusions are positive symptoms of schizophrenia. Bizarre behavior is a positive symptom of schizophrenia.
A client diagnosed with pain disorder is talking with the nurse about fishing when he suddenly reverts to talking about the pain in his arm. Which of the following should the nurse do next? a)Allow the client to talk about his pain. b)Ask the client if he needs more pain medication. c)Get up and leave the client. d)Redirect the interaction back to fishing.
d) Redirect the interaction back to fishing. Reason: The nurse should redirect the interaction back to fishing or another focus whenever the client begins to ruminate about physical symptoms or impairment. Doing so helps the client talk about topics that are more therapeutic and beneficial to recovery. Allowing the client to talk about his pain or asking if he needs additional pain medication is not therapeutic because it reinforces the client's need for the symptom. Getting up and leaving the client is not appropriate unless the nurse has set limits previously by saying, "I will get up and leave if you continue to talk about your pain."
A client with burns on his groin has developed blisters. As the client is bathing, a few blisters break. The best action for the nurse to take is to: a)remove the raised skin because the blister has already broken. b)wash the area with soap and water to disinfect it. c)apply a weakened alcohol solution to clean the area. d)clean the area with normal saline solution and cover it with a protective dressing.
d) clean the area with normal saline solution and cover it with a protective dressing. Reason: The nurse should clean the area with a mild solution such as normal saline, and then cover it with a protective dressing. Soap and water and alcohol are too harsh. The body's first line of defense broke when the blisters opened; removing the skin exposes a larger area to the risk of infection.
