nclex!!!!

Position for LIVER BIOPSY?

Right lateral Decubitus ( lying on the right side. The client is placed on the right side post liver biopsy to reduce bleeding by compressing the liver capsule to the puncture site. )

The nurse is obtaining a health assessment from the preoperative client scheduled for hip replacement surgery. Which statement by the client would be most important for the nurse to report to the primary healthcare provider?

"I had rheumatic fever when I was 10 years old." (After having rheumatic fever, a client would need to be pre-medicated with antibiotics prior to any surgical or dental procedure to prevent a recurrence.)

A case manager is assessing an unresponsive client diagnosed with terminal hepatic encephalopathy to determine equipment needs upon discharge to home for hospice care. Which equipment should the case manager obtain for this client? 1. Alternating pressure mattress 2. Hospital bed 3. Walker 4. Suction equipment 5. Oxygen

1. Alternating pressure mattress 2. Hospital bed 4. Suction equipment 5. Oxygen Correct: An alternating pressure mattress will help to prevent pressure ulcers. A hospital bed is needed so that the head of the client's bed can be elevated to 30 degrees to ease respirations and decrease the work of breathing. The unresponsive client may need suction equipment for suctioning if unable to clear secretions from the oropharynx. The client at the end stages of liver disease will be hypoxemic, so oxygen therapy is provided. 3. Incorrect: The unresponsive client will not need a walker.

A homebound client lives alone, has a history of poorly controlled diabetes, and has an open wound on the left heel. The home health nurse is concerned about the client's condition and the possible need for a referral. Which intervention should the nurse initiate for this client? 1. Ask the primary healthcare provider to prescribe a diabetes educator consult. 2. Increase home health visits to monitor the healing process of the open wound. 3. Suggest nursing home placement to the family until wound has healed. 4. Suggest that the client's family hire sitters to assist with hygiene care.

1. Ask the primary healthcare provider to prescribe a diabetes educator consult. (Referrals to appropriate agencies or departments are often made by the home care nurse. Client needs must be met in the most efficient way while utilizing appropriate expertise. This client has poorly controlled diabetes resulting in a wound. A diabetes educator can help develop a plan to prevent further complications of diabetes.)

Which tasks would be appropriate for the nurse to assign to an LPN/VN? 1. Changing a colostomy bag. 2. Administer antibiotic via intravenous piggyback (IVPB). 3. Teach insulin self administration to a diabetic client. 4. Administer IV pain medication to a two day post op client. 5. Check for urinary retention. 6. Remove wound sutures.

1. Changing a colostomy bag. 2. Administer antibiotic via intravenous piggyback (IVPB). 5. Check for urinary retention. 6. Remove wound sutures. These tasks are within the PNs practice scope. The PN can change a colostomy bag, administer antibiotics by IVPB, monitor for urinary retention and remove wound sutures. 3. Incorrect: The RN is responsible for teaching. The PN can reinforce teaching once taught by the RN. 4. Incorrect: The RN must give IV pain meds to clients. The PN can monitor the effectiveness of the medication after given by the RN and can report any problems if necessary.

A quality assurance (QA) manager plans to evaluate performance improvement regarding the implementation of fall precautions for at risk clients. What steps should the QA manager include in this evaluation? 1. Chart review for fall precaution documentation. 2. Direct observation of unit staff. 3. Poll staff to identify what fall precautions are implemented for at risk clients. 4. Identify at risk clients on unit. 5. Make unannounced visits to the unit for evaluating staff performance.

1. Chart review for fall precaution documentation. 2. Direct observation of unit staff. 4. Identify at risk clients on unit. 5. Make unannounced visits to the unit for evaluating staff performance. (The QA manager is responsible for evaluating performance improvement plans to ensure that staff are providing appropriate care. The QA manager can do chart reviews to see if staff are documenting fall precaution for a client. Direct observation of unit staff will let the QA manager know if staff are performing proper precautions while caring for clients. The first step is to identify what clients are at risk for falls and then see if the staff have identified these clients as at risk as well. Monitoring should be at unpredictable intervals, so staff do not comply just for a scheduled evaluation.)

A client tells the nurse, "I am dying from cancer. I have told my primary healthcare provider that I do not want to be revived if my heart stops beating or I stop breathing." What action should the nurse take first to assure that the client's request is respected? 1. Ensure a do-not-resuscitate prescription has been provided. 2. Report client wishes during the end-of-shift report. 3. Have the client sign an advanced directive. 4. Ask the client who holds the durable power of attorney for health care decisions.

1. Ensure a do-not-resuscitate prescription has been provided. (The nurse should check the medical record for a DNR order. By law, a person who does not have a do-not-resuscitate (DNR) prescription, must be provided CPR in the event of a cardiac/respiratory arrest. This action will ensure the client's end-of-life wishes have been communicated and will honor the client's wishes.)

The public health nurse is planning to participate in local forums regarding the placement of a factory that is known to produce pollution through discharge of chemical by-products into the air. What actions demonstrate ethical nursing practice in the public health arena? Speaking up for the underrepresented, such as the poor and uneducated persons. 2. Encouraging community leaders to accept placement of the factory. 3. Requesting that forums be held throughout the community at various times of the day or evening. 4. Asking for information regarding the health status of people in other factory locations. 5. Requesting information from individuals in areas where the factories are currently located.

1. Speaking up for the underrepresented, such as the poor and uneducated persons. 3. Requesting that forums be held throughout the community at various times of the day or evening. 4. Asking for information regarding the health status of people in other factory locations. 5. Requesting information from individuals in areas where the factories are currently located. (Many times factories are placed in communities where people are not aware of the hazards. The underrepresented and poor need the nurse as their advocate. Forums encourage wider participation of all community members and give the community more information about the consequences of the pollution. The public health nurse advocates for the health of the entire community. Individuals in the communities where factories are located could give first-hand information about health or other issues related to the factory placement. Printed reports, depending on the source, may contain false information.)

A nurse from the neonatal unit is transferred to the adult medical-surgical unit. Which client should the charge nurse assign to the neonatal nurse? 1. Undergoing surgery for placement of a central venous catheter. 2. Diagnosed with leukemia, hospitalized for induction of high-dose chemotherapy. 3. Receiving IV heparin for left leg thrombosis. 4. Admitted with a cerebrovascular accident.

1. Undergoing surgery for placement of a central venous catheter. (This is the most stable client to give to the nurse who was transferred from the neonatal unit. A neonatal nurse cares for central lines daily in this specialty area and can transfer this knowledge to the adult client.)

A nurse is calling the primary healthcare provider about a client who is experiencing dyspnea and chest pain two days post total knee replacement. Which statements by the nurse are appropriate according to the communication tool SBAR (Situation, Background, Assessment and Recommendation)? 1. "Hello Dr, I am calling about one of your clients." 2. "Jane Doe is having increasing dyspnea and is reporting chest pain." 3. "Jane Doe had a total knee replacement two days ago. Pulse is 120, BP 128/54, Resp 32. She is restless." 4. "From my assessment, I think she may be having a cardiac event or a pulmonary embolism."

2. "Jane Doe is having increasing dyspnea and is reporting chest pain." 3. "Jane Doe had a total knee replacement two days ago. Pulse is 120, BP 128/54, Resp 32. She is restless." 4. "From my assessment, I think she may be having a cardiac event or a pulmonary embolism." 5. "I recommend that you see the client immediately and that we start oxygen stat. Do you agree?" First, the nurse should identify self, agency, and client calling about. Then deliver SBAR. The Situation, Background, Assessment and Recommendation (SBAR) technique has become the Joint Commission's stated industry best practice for standardized communication in healthcare, effortlessly structuring critical information primarily for spoken delivery. Each of these statements fulfills appropriate SBAR requirements. 1. Incorrect. The nurse should identify the primary healthcare provider by name and should then identify self, the agency the nurse is calling from and the client by name. For instance: "Dr. Smith, this is nurse Adams, RN. I am calling about your client, Jane Doe, at ABC hospital."

A 13 year old, found unresponsive in the park, is brought into the emergency department. The nurse sees a medical alert bracelet stating "Diabetic", and notes a fruity smell to the breath. There are no family members available to obtain consent for treatment and an attempt to call them has been unsuccessful. What action should the nurse take? 1. Obtain consent from the social worker on duty in the emergency department. 2. Begin treatment by inserting two large bore IVs of Normal Saline. 3. Give glucogon IM and wait for the arrival of a parent to consent to further treatment. 4. Withhold treatment until a parent arrives to the emergency department.

2. Begin treatment by inserting two large bore IVs of Normal Saline. In emergencies, if it is impossible to obtain consent from the client or an authorized person, a health care provider may perform a procedure required to benefit the client or save a life without liability for failure to obtain consent. In such cases the law assumes that the client would wish to be treated. Begin treatment for diabetic ketoacidosis (DKA).

A client has been admitted with a diagnosis of septic shock and has been successfully intubated. The nurse performs and documents a rapid assessment. Which information from the assessment requires the most immediate action by the nurse? Blood pressure 90/40 mm Hg Heart rate 112 beats/min Respiratory rate 32 breaths/min Temperature 103deg;F (39.4deg;C) axillary O2 saturation 94% 1. Lung assessment finding. 2. Blood pressure reading. 3. Elevated temperature 4. Urine description and output.

2. Blood pressure reading. (The low blood pressure indicates that systemic tissue perfusion will not be adequate. The blood pressure needs to be improved rapidly.)

An elderly Asian woman has been in the hospital for three weeks, and it seems that her condition is such that nursing home placement is in the client's best interest. The family is against placing their relative in the nursing home. How should the nurse respond to this? 1. Encourage the family to accept nursing home placement as the best option for their loved one. 2. Listen to the family's concerns and report those to the primary healthcare provider. 3. Ask the client what she wants and tell the family to abide by the client's wishes. 4. Realize that the nurse does not need to be involved in this decision.

2. Listen to the family's concerns and report those to the primary healthcare provider. (The nurse should listen to the concerns of the family. The Asian culture tends to be opposed to nursing home placement and see it as their duty to care for their elders in the home. The nurse should listen and serve as an advocate.)

Which nursing tasks can the RN delegate to an unlicensed assistive personnel (UAP)? 1. Tell a female client who has recurrent urinary tract infections how to wipe after urinating. 2. Obtain blood pressure of client diagnosed with nephrotic syndrome. 3. Collects a urine specimen from an indwelling catheter tubing. 4. Document the intake and output of a client in acute renal failure. 5. Irrigate the foley catheter of a client who has had transurethral resection of the prostate (TURP). 6. Perform perineal care of a client who has urinary incontinence.

2. Obtain blood pressure of client diagnosed with nephrotic syndrome. 4. Document the intake and output of a client in acute renal failure. 6. Perform perineal care of a client who has urinary incontinence.

The nurse is performing the admission assessment on a client who is having a breast augmentation. Which client information would be most important for the nurse to report to the surgeon before surgery? 1. Client is concerned about who will care for her two children while she recovers. 2. There is a history of postoperative dehiscence after a previous C-section. 3. Client's last menstrual period was 8 weeks ago. 4. Client is concerned over pain control postoperatively.

3. Client's last menstrual period was 8 weeks ago. (The client may be pregnant, so a pregnancy test will need to be completed prior to administering anesthetic agents. As you look at these options they are all possible but only one is a priority and in this case life threatening.)

Intervention to REDUCE risk of skin irritation due to frequent large abd dressing?

Secure the dressing with MONTGOMERY straps. (Montgomery straps will allow the dressing to be held in place without the use of tape. The adhesive on the ends of the straps is the only adhesive used.)

The charge nurse has received report from the emergency department about a client diagnosed with Cushing's disease being admitted to the unit. Which client in a semi-private room would be appropriate for the charge nurse to have this client share? 1. Client who has leukemia. 2. Client diagnosed with gastroenteritis. 3. Client who has a fractured hip. 4. Client diagnosed with bronchitis.

3. Client who has a fractured hip. (The client with Cushing's disease could go in the room with the client who has a fractured hip, as this client does not have an infection. )

Which client requires immediate intervention by the nurse? 1. Client diagnosed with Crohn's disease reporting frequent bloody diarrhea and abdominal cramping. 2. Client with renal calculi who reports no pain relief from ketorolac administered 30 minutes ago. 3. Client with a fractured femur reporting sharp chest pain of 4/10. 4. Client admitted with cholelithiasis reporting right-sided abdominal pain of 8/10.

3. Client with a fractured femur reporting sharp chest pain of 4/10. (Sharp chest pain after a fractured femur could indicate a pulmonary embolus (PE) or a fat embolus and requires immediate intervention by the nurse.)

What is priority for the nurse to determine about a client who is scheduled for a tubal ligation in the outpatient surgical center? 1. Client's prior experiences with outpatient surgery. 2. Medical plan and the extent of insurance coverage for outpatient surgery. 3. Client's plan for transportation and care at home. 4. Client's plan to spend the night at the surgical center.

3. Client's plan for transportation and care at home. (After outpatient surgery, the client should not be allowed to drive home. A driver and assistance at home are necessary prior to discharge.)

Which pediatric client should the nurse see first? 1. Six year old with a femur fracture. 2. Two year old with a fever of 102 ° F (38.8 ° C) 3. Three year old with wheezes in right lower lobe. 4. Two year old whose gastrostomy tube came out.

3. Three year old with wheezes in right lower lobe. (The child having respiratory difficulty should be seen first. This is an example of using Maslow to set priorities. Airway will always be first followed by breathing and circulation. This client is not stable.)

A client admitted with a myocardial infarction has developed crackles in bilateral lung bases. Which prescription written by the primary healthcare provider should the nurse complete first? 1. Draw blood for arterial blood gases. 2. Place compression hose on legs. 3. Insert indwelling catheter for hourly urinary output. 4. Administer furosemide 20 mg intravenous push (IVP).

4. Administer furosemide 20 mg intravenous push (IVP). (The client is developing pulmonary edema or heart failure and needs to be diuresed to remove excess fluid. The question stem tells you that you have prescriptions for these four options so what are you going to do first. All prescriptions are possible but furosemide will fix the problem.)

Which client must the nurse assign to a private room? 1. Primiparous client who delivered twins at 28 weeks gestation two days ago 2. Postpartum client on IV Ampicillin and Gentamicin for chorioamnionitis 3. Postpartum client whose 2 hour old infant is being worked up for sepsis 4. Postpartum client 32 hours after delivery with a temperature of 101º F (38.05 ° C)

4. Postpartum client 32 hours after delivery with a temperature of 101º F (38.05 ° C) A temperature of 100.5° F (38.05° C) or greater in a client more than 24 hours postpartum is likely an indication of infection. This client should be kept separate from other mothers and babies. 1. Incorrect: The preterm twins are in the NICU and not in their mother's room (a client with term twins would need a private room because of space considerations). 2. Incorrect: Chorioamnionitis is not contagious. 3. Incorrect: The infant may have an infection and will remain in the NICU. The mother is not infected.

The nurse is working at the triage station. Which client should the nurse triage first? 1. A client with hepatitis A who states, "My arms and legs are itching." 2. A client with a cast on the right leg who states, "My right leg is killing me and nothing I do makes it stop hurting. " 3. A client with nausea and vomiting for two days states, "I am very weak and can't eat." 4. A client with hematuria and reports left flank pain.

A client with a cast on the right leg who states, "My right leg is killing me and nothing I do makes it stop hurting. " (The client who has a cast with unrelieved severe pain indicates compartment syndrome and requires immediate action. This client is at greatest risk for harm because untreated compartment syndrome can cause irreparable nerve, and muscle damage and can lead to amputation.)

A client arrives at the emergency department after sustaining partial and full-thickness burns over the anterior neck, chest, and right arm. Which interventions will the nurse initiate?

Administer oxygen Start two intravenous lines Remove necklace Elevate right arm (Burns over the anterior neck and chest mean that the client is likely to have inhalation burns, putting him/her at high risk for impaired gas exchange. The inhalation will cause edema of the airway. It goes back to Maslow's Hierarchy of Needs. Administer oxygen and start two IVs so that fluid resuscitation can begin. Metal continues to burn and swelling will occur, so remove the necklace or any jewelry. Elevate the arm to decrease swelling.)

points to include when teaching young women wishing to become pregnant.

Attain healthy weight Make sure immunizations are up to date Avoid drinking alcohol Learn family health history folic acid intake at 400mcg/day

While performing a vaginal examination on a client in labor, the nurse feels soft, squishy tissue instead of a head. What conclusion should the nurse make based on this assessment finding?

BREECH presentation (The nurse is palpating the buttocks of the fetus. The buttocks would be assessed as soft, squishy tissue. This is evidence of a breech presentation.)

Post thyroidectomy, the nurse assesses the client for complications by performing which assessment?

Check for a positive Chvostek's Assess swallowing reflex Monitor neck dressings for change in fit and comfort (A positive Chvostek's and Trousseau's is indicative of tetany (low calcium). This can occur when one or more of the parathyroids are accidently removed when the thyroid is removed. A weak, raspy voice, swallowing difficulty, and impaired respiratory status can be caused by nerve injury. Change in fit and comfort of the dressing can indicate possible neck swelling, which can affect the airway.)

Which activities can the nurse safely delegate to an unlicensed assistive personnel (UAP)?

Report a urinary output (UOP) less than 50 ml/hr on a post-op client. Assist a client with obtaining a clean catch urine sample. vitals on STABLE pt!!!

cesarean birth 2 days ago. teach to report what to doctor?

Fever >100.4 Calves with localized pain, redness and swelling. Burning with urination Feeling of apathy toward newborn lochia change from serosa to rubra(pink to red)(it should be rubra to serosa!)

diabetic in diabetic hyperosmolar hyperglycemic nonketotic (HHNK) state. What does the nurse anticipate for immediate tx plan?

IV adm. of isotonic saline (severly dehydrated)

what to teach pregnant pt who reports hemorrhoids & constipation?

Increased rectal pressure from the gravid uterus may result in hemorrhoids. Hormones decrease maternal GI motility, resulting in constipation the pt needs more fiber in the diet the pt needs to increase fluid intake

A client diagnosed with pancreatitis becomes increasingly restless, confused and has pulled out the NG tube and IV catheter. HR-128/min, BP 96/62. Oxygen saturation = 90%. Skin is cool and clammy to touch. Prioritize the actions that the nurse should take.

Initiate oxygen. Insert another IV line. Obtain blood sugar level. Insert NG tube. Repeat vital sign checks

A nurse has received the following arterial blood gas results on a client with a post bowel resection: pH 7.48; PCO2 30; HCO3 24. Which acid/base imbalance is the client experiencing?

Respiratory alkalosis (The pH is high, indicating alkalosis. The PCO2 is low, which coordinates with a high pH, indicating a lung problem. This client is in respiratory alkalosis, not acidosis. The bicarbonate is normal.)

The nurse is caring for a client with hyperparathyroidism. The nurse will monitor the client for which complications?

KIDNEY stones osteoporosis (because too much calcium in the blood equals too much calcium in the urine and increased risk of kidney stones. Increased parathyroid hormone (PTH) is pulling the calcium from the bones, leaving them weak.)

suggestions to help family reduce risk of injury of pt with mod cognitive impairment and whose family provides care for?

Lock up meds/ poisons and keep keys place locks high on door fram to make it difficult for the pt to have. Suggest that the family remove knobs from stove when not in use.

Which factor would most likely predispose a client to developing shock following a fracture of the femur?

Loss of blood into soft tissues surrounding the fracture (After a fracture, the factor that would most likely lead to shock is loss of blood into the soft tissue surrounding the fracture. When fractures occur, the ends of the bones can sever major arteries, causing loss of blood into the surrounding tissue.)

elderly pt Vomiting/Diarrhea for 3 days is receiving IV fluids at 200ml/hr. what is the PRIORITY action?

Lung assessments every 2-4hrs (200 mL/hr which is a rapid infusion rate for an elderly client. The lungs should be assessed every 2-4 hours to evaluate for potential fluid volume excess (FVE)

sympt of Hep A(contaminated by ingesting food/water that has feces)

Malaise Dark colored urine Jaundice

which type of chests drainage should the nurse anticipate pt will have after left total pneumonectomy for adenocarcinoma?

NO CHEST TUBE will be necessary (A total pneumonectomy means the excision of the entire lung. A drainage tube is not inserted, since the fluid and air must accumulate in the thoracic space. This is to prevent mediastinal shift to the left.)

what to expect when assessing a HEALTHY 65 yr old pt.

Presbyopia (As the lens becomes less flexible, the near point of focus gets further away. This condition, presbyopia, usually begins in the 40s. Reading glasses to magnify objects are required.)

Which assignment would be most appropriate for the charge nurse to assign to the LPN/VN in the Labor, Delivery, Recovery and Postpartum Unit (LDRP)? 1. Primipara needing assistance with breastfeeding. 2. Multipara reporting a headache and epigastric discomfort. 3. Primipara who is two days post op cesarean section. 4. Primipara who is preeclamptic in active labor. 5. Multipara post op cesarean section with a PCA pump.

Primipara needing assistance with breastfeeding. Primipara who is two days post op cesarean section. (These are stable clients whose care is within the scope of practice of an LPN/VN.)

36 weeks receiving mg sulfate for tx of preeclampsia. which findings require immediate action?

Urinary output of 100cc/4hrs (mg is excreted through kidneys, Adequate kidney function is vital to prevent magnesium toxicity. A urinary output of at least 30 mL/hr is the minimum standard to evaluate adequate kidney function)

A client has returned to the burn unit after an escharotomy of the forearm. What is the priority nursing intervention?

assess bilateral radial pulses (An escharotomy is an incision of the eschar of a burned arm to decrease the tension in the proximal tissue. This will result in increased circulation to the proximal tissue. The assessment of bilateral radial pulses needs to be compared for adequate circulation. )

interventions to keep school aged child safe?

encourage helmets with bicycle Teach children to swim at an early age Keep firearms in home locked/unloaded Teach "stop, drop, and roll"

what to doc. for pt,after ABGs, with hx of increasing dyspnea over past week that comes to the ED?

pt was on 2L of O2 by nassal canulla

teaching for pt with myasthenia gravis

setting alarm clock for medication times. (Medication must be taken on time. Too early can cause weakness and too late can cause extreme weakness to point of paralysis.)

need further investigation when pt's testes ?

when lump size of a piece of rice (most common symptoms of testicular cancer are a painless enlargement of one testis and the appearance of a palpable small hard lump on the front or side of the testicle)