nclex 7

a nurse is preparing to administer phenytoin IV to a client who has a seizure disorder. Which of the following actions should the nurse plan to take?

Administer a saline solution after injection

A nurse working on an orthopedic unit is caring for 4 client. Which of the following clients should the nurse identify as being greatest risk for skin breakdown

an older adult who has a hip fracture and is in bucks traction

a nurse is preparing to perfrom a cranial nerve examination on a client. Which of the following actions should the nurse take to check cranial nerve XII

ask the client to stick out their tongue and observe if its midline

a nurse is assessing a client who has parkinsons dz. which of the following manifestations should the nurse expect

bradykinesia; a difficulty moving

A nurse is modifying the diet of a client who has Parkinson's disease and is prescribed selegiline, an MAOI. Which of the following foods should the nurse eliminate?

cheddar cheese

A nurse is performing a home safety assessment for a client who has experienced a stroke. which of the following findings are a safety hazard

dim lighting, hot water, medications in a clear bag, area rugs

A nurse is teaching about risk factors for developing a stroke with a group of older adult clients. which of the following nonmodifiable risk factors should the nurse include

genetics

A nurse is preparing to perform a cranial nerve examination on a client. which of the following actions should the nurse take to check cranial nerve I

have the client identify specific smells

A nurse is teaching a class about expected changes to the skin in older adults. which of the following information should the nurse include

increase in skin thinning, decrease in subcutaneous tissue. decrease in skin hydration

A nurse is caring for a client who has a pressure injury

increased redness at wound borders, temperature, WBC

A nurse is caring for a client who has right sided paralysis following a stroke

joint contracture, passive ROM, right heal with pressure injury

A nurse is caring for a confused client who has alzheimers dz. which of the following actions should the nurse take

keep familiar personal items at the bedside

A nurse in a long term care facility is caring for a client who has alzheimers disease. Which of the following action should the nurse include in the plan of care

provide a consistent daily routine

A nurse is in a clients room when the client begins having a tonic clonic seizure. which of the following actions should the nurse take first

turn the clients head to the side

A charge nurse is making a room assignment for a client who has scabies. In which of the following rooms should the nurse place the client

a private room

a nurse is observing a newly licensed nurse set up a sterile field. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure

inspects the sterile package

A nurse is assigning a client who has a stage 2 pressure injury. Which of the following findings should the nurse expect?

partial thickness skin loss with red tissue in wound bed

A nurse enters a clients room and finds the client on the floor having a seizure. Which of the following actions should the nurse take?

place the client on his side

A nurse is providing teaching to the family of a client who has parkinsons dz. which of the following information should the nurse include in the teaching

provide client supervision

a nurse in the providers office is caring for a child

seizure; phenytoin level

A nurse is caring for a client who has aphasia following a stroke. A family member asks the nurse how she should communicate with the client. Which of the following responses by the nurse is appropriate?

incorporate nonverbal cues

a nurse is providing teaching to a client who has a new diagnosis of parkinsons dz. on which of the following medications should the nurse prepare to instruct

levodopa/ carbidopa

A nurse is caring for a client who is experiencing a seizure. which of the following actions should the nurse take

loosen restrictive clothing and place a pillow under the clients head

A nurse is caring for a client who has had a hemorrhagic stroke following a ruptured cerebral aneurysm. which of the following manifestations should the nurse expect

manifestations precede by a severe headache

A nurse is teaching a class about the function of cells in the epidermis. the nurse should include that which of the following are receptor cells that detect light touch

merkel cells

a nurse is caring for a client following an abdominal surgery. the client has a prescription for a dressing changes q4hrs and PRN. which of the following objects should the nurse use to reduce skin ittitaion around the incision area

montgomery straps

A nurse is preparing to perform a cranial nerve examination on a client. Which of the following actions should the nurse take to check cranial nerve VII

observe for facial symmetry while the client smiles.

A nurse is preparing to perform a cranial nerve examination for a client. Which of the following actions should the nurse take to check cranial nerve XI

observe the ability of the client to turn their head to the side

a nurse working on a medical unit is caring for a client who is prescribed seizure precautions. which of the following interventions should the nurse include in the clients plan of care

obtain iv access

for each client finding, click to specify if the finding is consistent with parkinsons, stoke, or multiple sclerosis.

orientation status: all. Ambulation: parkinsons Muscle movement: parkinsons Speech: all facial: parkinsons

A nurse is caring for a client who has pruritus following treatment for scabies. WHich of the following actions should the nurse take

provide mittens

a nurse is caring for a client who is at risk for pressure injury. which of the following actions should the nurse take?

provide the client with a high-calorie diet

A nurse is reviewing the medical record of a client who has moderate alzheimers dz

record strict nutritional content; continue bowel training program

A nurse is caring for a group of clients. which of the following clients should the nurse identify is at highest risk for developing pressure injury

a client who is unresponsive to verbal commands and changes position occasionally.

A nurse is caring for a client who reports frequent headaches. which of the following statements by the nurse uses holistic nursing?

are you feeling stressed before you have a headache

A nurse is performing discharge teaching for a client who has seizures and a new prescription for phenytoin. Which of the following statements by the client indicates a need for further teaching?

ill be glad when i can stop taking this medicine

a nurse is providing teaching to a client who has seizures and a new prescription for phenytoin. Which of the following information should the nurse provide

alcohol increases the chance of phenytoin toxicity.

a nurse is caring for a client who has impaired speech. which of the following actions should the nurse take

allow extra time to communicate with the client

a nurse is providing teaching to a client about preventing skin cancer. Which of the following client statements indicates a need for further teaching

eating a high fiber diet will reduce my risk

a nurse is caring for a client who has dementia due to alzheimers dz and was admitted to a longterm care facility following the death of her parrtner of 40 years. the client states, I want to go home; my husband is waiting for me to cook dinner." which of the following responses by the nurse is appropriate

tell me what you like to cook

A nurse is preparing a sterile field. Which of the following actions should the nurse identify as contaminating the field?

opening a sterile package over the middle of the sterile field

A nurse in an ED is caring for a client who has a seizure and became unresponsive after stating she had a sudden, severe headache and vomiting.

hemorrhagic stroke

A nurse is observing a newly licensed nurse prepare a sterile field. For which of the following actions should the nurse intervene?

Holds a bottle of solution with the label away from the palm of the hand

A nurse is caring for a client who has right sided paralysis from a stroke. Which of the following interventions should the nurse implement to prevent footdrop

apply a protective boot to the right ankle.

A nurse in an acute care facility is admitting an older adult client who has dementia due to alzheimers dz. the nurse notes that the clients partner appears exhausted. he states that he is findings it more and more difficulty to care for his wife. which of the following interventions is the nurses priority?

ask the partner to talk about his difficulties in caring for the client.

A nurse in the er is assessing a client who was brought in following a seizure. the nurse suspects the client may have meningococcal meningitis when assessment findings include nuchal rigidity and a petechial rash. After implementing droplet precautions, which of the following actions should the nurse initiate next?

assess the cranial nerves

A nurse is caring for a client who has late stage alzheimers dz and is hospitalized for treatment on pneumonia. During the night shift, the client is found climbing into the ed of another client who becomes upset and frightened. Which of the following actions should the nurse take

assist the client to the correct room.

during a routine physical examination, a nurse observes a 1 cm lesion on a client chest. The lesion is raised and flesh colored with pearly white borders. the nurse should recognize that this finding is suggestive of which of the following types of skin cancer

basal cell carcinoma

A nurse is caring for a client who reports a severe headache following a lumbar puncture. Which of the following actions should the nurse take

encourage oral fluids

A nurse is instructing a clients family members about feeding safety for a client who has dysphagia following a stroke. Which of the following instructions should the nurse include

encourage the client to take small bites

A nurse is providing teaching about lice to the parents of a school age child at a well child visit. Which of the following information should the nurse include in the teaching?

encourage your child to avoid sharing hats with other children.

A nurse at a community health clinic is caring for a client who reports a headache and stiff neck. Which of the following actions should the nurse take first

evaluate the clients neurological status

a nurse is caring for a client. identify if the finding is consistent with parkinsons, stroke, or multiple sclerosis

facial symmetry is stroke, htn is stroke, cognitive function is all, speech is all, mobility status is all

A nurse is developing a teaching plan for a client who has psoriasis. which of the following actions should the nurse include in the plan

identify effective stress reduction techniques

a nurse is assisting a provider with a sterile procedure and preapres to pour a solution onto a piece of gauze. Identify the sequence of steps the nurse should follow when pouring the solution

remove the bottle cap, place the bottle cap face up on a clean surface, pick up the bottle, pour 1-2 ml in a receptacle, pour the solution onto the gauze

A nurse is teaching a client who has a new prescription for sumatriptan tablets to treat migraine headaches. Which of the following instructions should the nurse include?

report swelling of eyelids after dosage

a home health nurse is planning care for a client who has alzheimers dz. the clients partner is her primary caregiver and reports not having enough time to complete his errands. which of the following referrals should the nurse plan to make

respite care

a nurse is assessing a client who has a new skin lesion that has a wavy border. the nurse should document the lesion using which of the following descriptions

serpiginous

A nurse is teaching the family of a client who has alzheimers dz about donepezil. Which of the following information should the nurse include in the teaching

syncope episodes may occur

A nurse on a long term care unit is creating a plan of care for a client who has alzheimers dz. which of the following interventions should the nurse include in the plan?

talk the client through tasks one step at a time

a nurse is teaching a client who has psoriasis about possible treatment options. Which of the following treatments should the nurse include in the teaching

tar preparations, corticosteroids, UV light therapy

a nurse is teaching a female client who has a new prescription for transdermal sumatriptan to treat migraine headaches. which of the following instructions should the nurse include

use contraception while taking this medication

A nurse is planning to perform a sterile dressing change for a client. Which of the following actions should the nurse plan to take?

use sterile forceps to move the sterile items on the sterile field