NCLEX Assignment 1

After the nurse provides education about all-terrain vehicle (ATV) safety for a parent of a 11-year-old child, which statement made by the parent indicates an understanding of the information?

"I will make sure my child does not get on an ATV."

The nurse concludes that the teaching about sickle cell anemia has been understood when an adolescent with the disorder makes which statement?

"I'll start to have symptoms when I drink less fluid."

The home health nurse provides education for a client with cancer of the tongue who will begin gastrostomy feedings at home. Which client statement indicates effective teaching?

"Before I start the procedure, I will measure the residual volume."

Nitroglycerin sublingual tablets are prescribed for a client with the diagnosis of angina. The nurse advises the client to anticipate pain relief will begin within which period of time?

1-3 minutes.

Scald injuries could be cause by contact with which item?

Hot liquids or steam

Which part of the female reproductive system produces testosterone?

Ovary

The nurse explains to the parents of a 6-year-old child with pinworm infestation how pinworms are transmitted. Which statement indicates that the teaching has been understood?

"She needs to wash her hands before eating anything."

A client has been receiving digoxin. The client calls the clinic and complains of "yellow vision." Which response would the nurse provide?

"The medication may need to be discontinued. Come to the clinic this afternoon."

An adolescent was recently diagnosed with type 2 diabetes mellitus. Which information will the nurse include when providing education to the family?

"The most important interventions are good nutrition and portion control."

A client asks the nurse how psychotropic medications work. How would the nurse reply?

"These medications affect the chemicals used in communication between nerve cells."

Which is the maximum volume of an intramuscular injection recommended for a preschool-aged child?

1.0mL

Which actions transmit the human immunodeficiency virus (HIV)? Select all that apply

Sharing syringe needles Breast-feeding a newborn Anal intercourse

Which amount is the normal value of a client's inspiratory reserve volume?

3.0 L

The nurse is planning to provide self-care health information to several clients. Which client would the nurse anticipate will be MOST motivated to learn?

A 56-year-old client who had a heart attack last week and is requesting information about exercising.

Which education would the nurse provide the parent of a preschool-age child about how preschoolers view death?

A form of sleep.

Which procedure is shown in the picture?

A thoracentesis

Which disorder would the nurse classify as neurodevelopmental?

ADHD

According to Kubler-Ross' theory of death and dying, which stage is a terminally ill client displaying by gradually moving towards resolution of feelings about impending death?

Acceptance stage

The spouse of a client with pulmonary tuberculosis (TB) received a tuberculin skin test. The nurse examined the skin test and identified an area of induration greater than 10mm. Which response to this finding would the nurse implement?

Additional tests are necessary to determine infection status.

A client is scheduled for an adrenalectomy. Which action would the nurse expect in the plan of care?

Administer parenteral corticosteroids.

Which action would the nurse take for a client with an obsessive-compulsive disorder who continually walks up and down the hall, touching every other chair and becomes upset if interrupted?

Allow the behavior to continue for a specified time, letting the client help set the time limits to be imposed.

Which term would the nurse use in a report to describe the absence of menstrual periods in a 35-year-old nonpregnant client?

Amenorrhea

During the administration of an antibiotic, the client becomes restless and flushed, and begins to wheeze. Which action will the nurse take after stopping the antibiotic infustion?

Assess the client's respiratory status.

Which complications would the nurse monitor in a client who sustained a transection of the spinal cord, but no other injuries?

Autonomic hyperreflexia

Which type of joint permits movement in any direction?

Ball-and-socket

An adolescent who has had a leg amputated because of bone cancer begins to experience phantom limb sensations. How would the nurse respond to complaints of pain?

By acknowledging that the pain is real and administering medication to relieve it.

Which statement is true regarding antipsychotic medications?

Clozapine is more effective than other second generation antipsychotics.

A client with schizophrenia who is receiving an antipsychotic medication begins to exhibit a shuffling gait and tremors. The primary health care provider prescribes the anticholinergic medication benztropine, 2 mg daily. The nurse should inquire about which symptom when assessing the client?

Constipation

The nurse assesses a client's IV site. Which clinical finding leads the nurse to conclude that the IV has infiltrated, rather than caused inflammation?

Coolness

Which disorder is caused by the deficiency of antidiuretic hormone?

Diabetes Insipidus

Which step would the nurse take when preparing to administer Rho(D) immune globulin to a postpartum client?

Ensure that the client is Rh negative and the neonate is Rh positive.

When the nurse revises the care plan because the goals have not been met, which phase of the nursing process is being applied?

Evaluation

A client who takes rifampin tells the nurse, "My urine looks orange." Which action would the nurse take?

Explain that this is expected.

The parent of an infant with heart failure questions the necessity of weighing the baby every morning. Which would the nurse say that this daily information is important in determining?

Fluid retention

Which injection is caused due to fungus?

Folliculitis

To keep the client with Alzheimer disease who has hyperorality safe, which parameter would the nurse have the staff closely monitor?

For attempts at eating inedible objects.

Which surgery will a client undergo if pituitary gland must be removed?

Hypophysectomy

A client is admitted to the hospital for an adrenalectomy. Before the client's replacement steroid therapy is regulated fully, the nurse will monitor the client for which complication?

Hypotension.

The weight of a 3-month-old infant with tetralogy of Fallot has declined from the 25th percentile to the 5th. Which mechanism would the nurse suspect is the reason for this inadequate weight gain?

Inadequate oxygen perfusion leading to activity intolerance, resulting in diminished energy to nurse.

Which is the cause of milk anemia in toddlers?

Increased milk intake

Fluoxetine is prescribed for a client with depression. Which precaution will the nurse consider when initiating treatment with this medication?

The blood level may be sufficient to cause noticeable improvement for 2-4 weeks.

Ranitidine has been prescribed to help treat a client's gastric ulcer. The nurse expects this medication to act specifically by which mechanism?

Inhibiting the histamine at H2 receptors

In the playroom of a pediatric unit, the nurse sees several toddlers seated at a table trying to copy the same picture from a book. They are not talking to each other or sharing their crayons. Which would the nurse conclude about this behavioral interaction?

It is typical expression of toddlers' social development.

The nurse is planning to teach the four-point alternate crutch gait to a 9-year-old child with cerebral palsy. How would the nurse explain this choice to the parents?

It provides for equal but partial weight bearing on each limb.

Which nursing objective would the nurse add to the plan of care for a child with attention-deficit/hyperactivity disorder (ADHD) who engages in self-destructive behavior?

Keeping the child from inflicting any self injury

Which part of the kidney senses changes in blood pressure?

Macula densa

Which structure is a component of the auditory ossicles?

Malleus

Which statement must the nurse emphasize to the family when preparing a school-aged child with persistent asthma for discharge?

Medications must be continued even when the child is asymptomatic.

A client in active labor who is 90% effaced, 7 cm dilated with the vertex presenting at 2+ station, complaining of pain and asks for medication. Which medication would the nurse anticipate causing respiratory depression in the newborn?

Meperidine

Which medication may be used to treat postpartum hemorrhage?

Methylergonovine

Which medication is the first choice of medication for the treatment of attention-deficit/hyperactivity disorder (ADHD)?

Methylphenidate

Which medication would the nurse identify as being used both for cervical ripening during labor and as a stomach protectant?

Misoprostol

Which nursing action would be included in the plan of care for a child with acute poststreptococcal glomerulonephritis?

Monitoring for seizures

Which type of immunity is acquired though the transfer of colostrum from the mother to the child?

Natural passive immunity

A client hospitalized for uncontrolled hypertension and chest pain was started on a daily diuretic 2 days ago upon admission, with prescriptions for daily basic metabolic panel. The client's potassium level this morning is 2.7 mEq/L (2.7 mmol/L). Which action will the nurse take next?

Notify the health care provider that the potassium level is below normal.

Which hormone would the nurse identify as causing ovulation and promoting lactation?

Oxytocin

Which term is used for the tip of a pyramid in the kidney?

Papilla

Which type of play do 2-year-old toddlers engage in?

Parallel

After a cerebrovascular accident, (CVA, also known as "brain attack"), a client is unable to differentiate between heat or cold and sharp or dull sensory stimulation. The nurse would conclude the CVA affected which lobe of the brain?

Parietal

A parent asks the nurse what to do when the toddler has temper tantrums. Which play materials would the nurse suggest that the child be offered as another means of expressing anger?

Pegs and pounding board

Why is a multiple-gestation pregnancy considered a high risk?

Perinatal mortality is 2-3 times more likely in multiple than in single births.

Which gland secretes melatonin?

Pineal Gland

Which step of the nursing process is directly affected if the nurse does not make a nursing diagnosis?

Planning

The nurse caring for a child who has an external fixation device on the leg. Which is the nurse's PRIORITY goal when providing pin care?

Preventing infection

Which health care team member is responsible for analyzing the knowledge and work of newly hired unlicensed assistive personnel before delegating a task?

Registered Nurse (RN)

A client with chronic obstructive pulmonary disease (COPD) has a blood pH of 7.25 and a partial pressure of carbon dioxide (PCO2) of mm Hg. Which complication would the nurse suspect the client is experiencing?

Respiratory acidosis

A client is diagnosed with Parkinson disease and receives a prescription for levodopa therapy. Which mechanism of action would the nurse identify for this medication?

Restores the dopamine levels in the brain

Which guideline would the nurse consider when planning care for a hospitalized older client with Alzheimer disease?

Routines provide stability for clients with neurocognitive disorders

An older client with Alzheimer type dementia, consistently sleeps in a semi-Fowler position in bed. Which area of the client's body would the nurse consider high risk for developing a pressure injury?

Sacrum

A recently hospitalized client with multiple sclerosis voices a concern about generalized weakness and fluctuating physical status. Which nursing intervention is the PRIORITY for this client?

Space activities throughout the day.

The nurse is developing a nursing diagnosis for a client after surgery. The nurse documents the "related to" factor as first-time surgery. Which assessment activity enabled the nurse to derive this conclusion?

The nurse asks the client to explain the surgery

Which statement is true for collaborative problems in a client?

They are identified by the nurse during the nursing diagnosis stage.

Which clinical indicator would the nurse monitor to determine if the client's simvastatin is effective?

Triglycerides

Which nutrients would the nurse teach the parents of a child with celiac disease to avoid?

Wheat and oat products.

When teaching a client about digoxin, which symptom will the nurse include as a reason to withhold the digoxin?

Yellow vision