NCLEX Assessments

The nurse is reviewing the primary health care provider's documentation in the record of a child admitted with a diagnosis of intussusception. The nurse expects to note that the primary health care provider has documented which manifestation? 1.Scleral jaundice 2.Projectile vomiting 3.Currant jelly-like stools 4.Pale-colored and hard stools

3.Currant jelly-like stools Rationale: In the child with intussusception, bright red blood and mucus are passed through the rectum, resulting in what is commonly described as currant jelly stools. The child classically presents with severe abdominal pain that is crampy and intermittent, causing the child to draw the knees in to the chest. Vomiting may be present but not projectile. Scleral jaundice and pale-colored, hard stools are not manifestations of this disorder.

The nurse is providing instructions to the mother of a child with croup regarding treatment measures if an acute spasmodic episode occurs. Which statement made by the mother indicates a need for further teaching? 1."I should place a steam vaporizer in my child's room." 2."I will take my child out into the cool, humid night air." 3."I could place a cool-mist humidifier in my child's room." 4."I will have my child inhale the steam from warm running water."

*1."I should place a steam vaporizer in my child's room." Rationale: Steam from running water in a closed bathroom will assist in keeping secretions thin so that they can be easily expectorated. Steam from a vaporizer however can present a danger of scald burns because of the more direct effect than that provided from steam from running water. A cool mist from a bedside humidifier may be effective in reducing mucosal edema. Cool-mist humidifiers are recommended over steam vaporizers. Taking the child out into the cool, humid night air may also relieve mucosal swelling.

The primary health care provider prescribes hydromorphone 1 mg intravenously for a client in pain. The medication label states hydromorphone 2 mg/1 mL. The nurse should administer how many milliliters to the client? Fill in the blank.

0.5 mL

The nurse is reviewing a discharge teaching plan for a postcraniotomy client that was prepared by a nursing student. The nurse would intervene and provide teaching to the student if the student included which home care instruction? 1. Sounds will not be heard clearly unless they are loud. 2. Obtain assistance with ambulation if the client is lightheaded. 3. Tub bath or shower is permitted, but the scalp is kept dry until the sutures are removed. 4. Use a check-off system for administering anticonvulsant medications to avoid missing doses.

1. Sounds will not be heard clearly unless they are loud. Rationale: The postcraniotomy client typically is sensitive to loud noises and can find them excessively irritating. Control of environmental noise by others will be helpful for this client. Seizures are a potential complication that may occur for up to 1 year after surgery. For this reason, the client must diligently take anticonvulsant medications. The client and family are encouraged to keep track of the doses administered. The family should learn seizure precautions and should accompany the client during ambulation if dizziness or seizures tend to occur. The suture line is kept dry until sutures are removed to prevent infection.

The nurse is caring for a client diagnosed with tuberculosis (TB). Which assessments, if made by the nurse, are consistent with the usual clinical presentation of TB? Select all that apply. 1.Cough 2.Dyspnea 3.Weight gain 4.High-grade fever 5.Chills and night sweats

1.Cough 2.Dyspnea 5.Chills and night sweats Rationale: The client with TB usually experiences cough (productive or nonproductive), fatigue, anorexia, weight loss, dyspnea, hemoptysis, chest discomfort or pain, chills and sweats (which may occur at night), and a low-grade fever.

The nurse determines that a history of which mental health disorder would support the prescription of taking donepezil hydrochloride? 1.Dementia 2.Schizophrenia 3.Seizure disorder 4.Obsessive-compulsive disorder

1.Dementia Rationale:Donepezil hydrochloride is a cholinergic agent that is used in the treatment of mild to moderate dementia of the Alzheimer's type. It increases concentration of acetylcholine, which slows the progression of Alzheimer's disease. The other options are incorrect and are not indications for use of this medication.

A client is having a follow-up primary health care provider (PHCP) office visit after vein ligation and stripping. The client describes a sensation of "pins and needles" in the affected leg. Which would be an appropriate action by the nurse based on evaluation of the client's comment? 1.Report the complaint to the PHCP. 2.Instruct the client to apply warm packs. 3.Reassure the client that this is only temporary. 4.Advise the client to take acetaminophen until it is gone.

1.Report the complaint to the PHCP. Rationale: Hypersensitivity or a sensation of pins and needles in the surgical limb may indicate temporary or permanent nerve injury following surgery. The saphenous vein and saphenous nerve run close together in the distal third of the leg. Although complications from this surgery can occur, they are relatively rare so this symptom should be reported. The actions in the remaining options are incorrect and could be harmful; in addition, they delay the possible need for intervention about the client's complaint. Although nerve damage can occur and is usually temporary and minimal and resolves within a few months, it is not appropriate to tell the client that this occurrence is only temporary. The complaint needs to be further assessed.

A registered nurse who is orienting a new nursing graduate to the hospital emergency department instructs the new graduate to monitor a client for one-sided chest movement on the right side while the client is being intubated by the primary health care provider (PHCP). Which statement made by the new nursing graduate indicates understanding of the importance of this observation? 1."It will enter the left main bronchus if inserted too far." 2."It will enter the right main bronchus if inserted too far." 3."It may enter the left main bronchus if not inserted far enough." 4."It may enter the right main bronchus if not inserted far enough."

2."It will enter the right main bronchus if inserted too far." Rationale: If the endotracheal tube is inserted too far into the client's trachea, the tube will enter the right main bronchus. This occurs because the right bronchus is shorter and wider than the left and extends downward in a more vertical plane. If the tube is not inserted far enough, no chest expansion at all will occur. The other options are incorrect.

Which client situation is most appropriate for the nurse to consult with the Rapid Response Team (RRT)? 1.A 56-year-old client, fourth hospital day after coronary artery bypass procedure, sore chest, pain with walking, temperature 97º F (36.1º C), heart rate 84 beats/min, respirations 22 breaths/min, blood pressure 122/78 mm Hg, bored with hospitalization 2.A 45-year-old client, 2 years after kidney transplant, second hospital day for treatment of pneumonia, no urine output for 6 hours, temperature 101.4º F (38.6º C), heart rate 98 beats/min, respirations 20 breaths/min, blood pressure 168/94 mm Hg 3.A 72-year-old client, 24 hours after removal of a chest tube that was used to drain pleural fluid (effusion), temperature 97.8º F (36.6º C), heart rate 92 beats/min, respirations 28 breaths/min, blood pressure 136/86 mm Hg, anxious about going home 4.An 86-year-old client, 48 hours after operative repair of fractured hip, alert, oriented, using patient-controlled analgesia pump, temperature 96.8º F (36º C), heart rate 60 beats/min, respirations 16 breaths/min, blood pressure 120/82 mm Hg, talking with daughter

2.A 45-year-old client, 2 years after kidney transplant, second hospital day for treatment of pneumonia, no urine output for 6 hours, temperature 101.4º F (38.6º C), heart rate 98 beats/min, respirations 20 breaths/min, blood pressure 168/94 mm Hg Rationale: The role of an RRT is to provide internal consultative services to staff nurses to detect client problems early. Absence of urine output and temperature and blood pressure elevation describe a client who may be rejecting a transplanted kidney. The constellation of symptoms described indicates possible rejection. Internal consultation could validate that assessment. The remaining options indicate expected characteristics of the clients described and provide no indication of need for RRT consultation.

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. 1.Bed rest as a necessary preventive measure may be prescribed. 2.Administration of subcutaneous heparin postdelivery as prescribed. 3.An overbed lift may be necessary if the client requires a cesarean section. 4.Less frequent cleansing of a cesarean incision, if present, may be prescribed. 5.Thromboembolism stockings or sequential compression devices may be prescribed.

2.Administration of subcutaneous heparin postdelivery as prescribed. 3.An overbed lift may be necessary if the client requires a cesarean section. 5.Thromboembolism stockings or sequential compression devices may be prescribed. Rationale: The obese pregnant client is at risk for complications such as venous thromboembolism and increased need for cesarean section. Additionally, the obese client requires special considerations pertaining to nursing care. To prevent venous thromboembolism, particularly in the client who required cesarean section, frequent and early ambulation (not bed rest), prior to and after surgery, is recommended. Routine administration of prophylactic pharmacological venous thromboembolism medications such as heparin is also commonly prescribed. An overbed lift may be needed to transfer a client from a bed to an operating table if cesarean section is necessary. Increased monitoring and cleansing of a cesarean incision, if present, is necessary due to the increased risk for infection secondary to increased abdominal fat. Thromboembolism stockings or sequential compression devices will likely be prescribed because of the client's increased risk of blood clots.

The home care nurse is visiting an older client whose spouse died 6 months ago. Which behaviors by the client indicate effective coping? Select all that apply. 1.Neglecting personal grooming 2.Looking at old photographs of family 3.Participating in a senior citizens program 4.Visiting the spouse's grave once a month 5.Decorating a wall with the spouse's pictures and awards received

2.Looking at old photographs of family 3.Participating in a senior citizens program 4.Visiting the spouse's grave once a month 5.Decorating a wall with the spouse's pictures and awards received Rationale: Coping mechanisms are behaviors used to decrease stress and anxiety. In response to a death, ineffective coping is manifested by an extreme behavior that in some cases may be harmful to the individual physically or psychologically. Neglecting personal grooming is indicative of a behavior that identifies ineffective coping in the grieving process. The remaining options identify appropriate and effective coping mechanisms.

A client has a lithium level of 2.4 mEq/L. The nurse should immediately assess the client for which sign or symptom? 1.Diarrhea 2.Weakness 3.Blurred vision 4.Cardiac dysrhythmias

3.Blurred vision Rationale: At lithium levels of 2.0 to 2.5 mEq/L, the client will experience blurred vision, muscle twitching, severe hypotension, and persistent nausea and vomiting. With levels between 1.5 and 2.0 mEq/L, the client experiences vomiting, diarrhea, muscle weakness, ataxia, dizziness, slurred speech, and confusion. At lithium levels of 2.5 to 3.0 mEq/L or higher, urinary and fecal incontinence occurs, as well as seizures, cardiac dysrhythmias, peripheral vascular collapse, and death.

The nurse is collecting data on a pregnant client in the first trimester of pregnancy diagnosed with iron deficiency anemia. The nurse should monitor the client to detect which manifestation indicating that this problem has not yet resolved? 1.Pink mucous membranes 2.Increased vaginal secretions 3.Complaints of daily headaches and fatigue 4.Complaints of increased frequency of voiding

3.Complaints of daily headaches and fatigue Rationale: Anemia is one of the most common problems in pregnancy, and iron deficiency anemia and folic acid deficiency anemia are 2 of the most common types. It is estimated that between 20% and 60% of all women are anemic at some point during pregnancy, with hemoglobin concentration lower than 10.0 to 11.0 g/dL (100 to 110 mmol/L). Complaints of daily headaches and fatigue are abnormal findings and may reflect complications caused by decreased oxygen supply to vital organs, thus supporting laboratory findings. The incorrect options are expected findings in the first trimester of pregnancy.

A client is taking the prescribed dose of phenytoin to control seizures. Results of a phenytoin blood level study reveal a level of 35 mcg/mL (140 mcmol/L). Which finding would be expected as a result of this laboratory result? 1.Hypotension 2.Tachycardia 3.Slurred speech 4.No abnormal finding

3.Slurred speech Rationale: The therapeutic phenytoin level is 10 to 20 mcg/mL (40 to 79 mcmol/L). At a level higher than 20 mcg/mL, involuntary movements of the eyeballs (nystagmus) occur. At a level higher than 30 mcg/mL (120 mcmol/L), ataxia and slurred speech occur.

The nurse is assessing a client suspected of having meningitis for meningeal irritation and elicits a positive Brudzinski's sign. Which finding did the nurse observe? 1.The client rigidly extends the arms with pronated forearms and plantar flexion of the feet. 2.The client flexes a leg at the hip and knee and reports pain in the vertebral column when the leg is extended. 3.The client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column. 4.The client's upper arms are flexed and held tightly to the sides of the body and the legs are extended and internally rotated.

3.The client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column. Rationale: Brudzinski's sign is tested with the client in the supine position. The nurse flexes the client's head (gently moves the head to the chest), and there should be no reports of pain or resistance to the neck flexion. A positive Brudzinski's sign is observed if the client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column. Kernig's sign also tests for meningeal irritation and is positive when the client flexes the legs at the hip and knee and complains of pain along the vertebral column when the leg is extended. Decorticate posturing is abnormal flexion and is noted when the client's upper arms are flexed and held tightly to the sides of the body and the legs are extended and internally rotated. Decerebrate posturing is abnormal extension and occurs when the arms are fully extended, forearms pronated, wrists and fingers flexed, jaws clenched, neck extended, and feet plantar-flexed.

The nurse is planning the client assignments for the day. Which clients can be safely assigned to the assistive personnel (AP)? Select all that apply. 1.The client receiving a heparin infusion 2.The client receiving a blood transfusion 3.The client receiving continuous oxygen at 2 L/min 4.The client recovering from Guillain-Barré syndrome 5.The client who just returned from surgery for a hip repair 6.The client on isolation for methicillin-resistant Staphylococcus aureus

3.The client receiving continuous oxygen at 2 L/min 4.The client recovering from Guillain-Barré syndrome 6.The client on isolation for methicillin-resistant Staphylococcus aureus Rationale: APs cannot be assigned to a client requiring care that is more than basic. APs do not have the education to safely care for clients requiring more than basic care. Assigning a AP to these clients presents an unsafe situation. The client receiving a heparin infusion requires licensed personnel to monitor progress and for possible adverse reactions. The client receiving a blood transfusion requires monitoring for possible adverse reactions; licensed personnel are necessary. Unlicensed personnel cannot be assigned to a client who needs immediate postoperative assessment. These clients need to be cared for by a registered nurse (RN).

Which pre-electroconvulsive therapy intervention will the nurse implement for a hospitalized client with depression? 1.Restrict the client smoking for 12 hours. 2.Enforce nothing by mouth (NPO) status for 16 hours. 3.Limit the client's participation in unit activities for 24 hours. 4.Assure that an electrocardiogram is performed within 24 hours.

4.Assure that an electrocardiogram is performed within 24 hours. Rationale: Before electroconvulsive therapy (ECT), blood tests are performed and an electrocardiogram is done to determine a baseline status of the client. Maintaining NPO status for 6 to 8 hours before treatment is adequate. The remaining options are incorrect.

The nurse assists in the vaginal delivery of a newborn. Following the delivery, the nurse observes a spurt of blood from the vagina. The nurse should document this observation as signs of which condition? 1.Hematoma 2.Uterine atony 3.Placenta previa 4.Placental separation

4.Placental separation Rationale: As the placenta separates, it settles downward into the lower uterine segment. The umbilical cord lengthens, and a sudden trickle or spurt of blood appears. The other options are not characterized by these findings.