NCLEX Daily Practice

A nurse prepares to discontinue an IV line on a client on the first postoperative day after abdominal surgery. What action is most important for the nurse to perform before discontinuing the line? a. evaluate oral intake b. clean the IV with antiseptic c. determine urinary output d. assess client pain

Evalue oral intake the client should be able to tolerate oral intake prior to discontinuing an IV line

The nurse provides education to a client who is newly diagnosed with asthma. Which client statement indicates to the nurse the need for additional teaching? a. I will seek emergency care if I have difficulty talking b. I don't need to worry about my diet c. I will take acetaminophen for headaches d. I will use my flow meter at least twice per day

I don't need to worry about my diet Food allergies, new or developing over time, can tigger asthma attacks

A pediatric client is brought to the emergency department with new onset laryngotracheobronchitis and stridor. Which nebulizer treatment does the nurse request be prescribed for this condition? a. salmeterol b. racemic epinephrine c. tiotropium d. theophylline

racemic epinephrine

The nurse provides care to a client who is hospitalized for atrial fibrillation. The clients CHADS2 (congestive heart failure, hypertension, age greater than 75, DM, and stroke) score for anticoagulant therapy is a 2. Which prescription does the nurse anticipate for this client based on this score? a. vitamin K therapy b. warfarin therapy c. traditional aspirin therapy d. low-dose aspirin therapy

warfarin therapy CHADS2 - scoring determines need for preventative anticoagulant therapy in clients with AF 0-1 = aspirin Comorbid conditions = stronger Score 2 or more = anticoagulants (heparin, enoxaparin, and warfarin)

A nurse is providing discharge instructions to a client who has a new laryngectomy. The nurse should tell the client to be careful while bathing to prevent which of the following complications? a. aspiration of water b. infection of the stoma c. bleeding around the stoma d. skin breakdown around the stoma

Aspiration of water A laryngectomy is a surgery to remove part or all of your larynx (voice box) - push button to speak - should use shower shield over the stoma

A client is scheduled for a liver biopsy to determine the exact etiology for a recent diagnosis of liver cirrhosis. Which assessment data indicates to the nurse that the client is at an increased risk for bleeding during this procedure? a. elevated serum globulin levels b. elevated serum aspartate aminotransferase level c. decreased serum protein level d. decreased serum platelet count level

Decreased serum platelet count level

A nurse is monitoring a client who has heart failure related to mitral stenosis. The client reports shortness of breath on exertion. Which of the following conditions should the nurse expect? a. increased cardiac output b. increased pulmonary congestion c. decreased left atrial pressure d. decreased pulmonary artery pressure

Increased pulmonary congestion Pulmonary congestion is a manifestation of mitral valve stenosis. Because of the defect in the mitral valve, the left atrial pressure rises and the left atrium dilated. The increased pressure results in a backflow of blood from the left atrium through the pulmonary vein and into the lungs resulting in pulmonary congestion.

A nurse plans to care for a client admitted with sickle cell crisis. After beginning hydration and oxygen supplementation, which is the priority intervention? a. request an evaluation by the physical therapist to limit loss of function b. use standardized scales to assess the client for signs of depression c. monitor weight and provide high protein snacks between meals as needed d. instruct the client in the use of a client-controlled analgesia pump

Instruct the client in the use of a client-controlled analgesia pump During sickle cell crisis, pain should be managed continuously and aggressively

A nurse is discussing exercise activities with an acute care client who has schizophrenia and is overweight due to psychotropic medication. The client refuses to participate in an aerobic exercise class and instead requests to walk in the facility's gym. Which of the following responses should the nurse make? a. can you tell me why you do not want to participate in the planned group acitivty? b. do you understand that psychotropic medications cause weight gain c. the aerobics class will be more effective at burning calories than walking d. it sounds like you have come up with an alternative exercise that works for you

It sounds like you have come up with an alternative exercise that works for you The nurse is using therapeutic techniques of acceptance, giving recognition, and encouragement by supporting the client's idea of a way to exercise

A nurse is caring for a client who is receiving brachytherapy. Which of the following measures should the nurse include in the client's plan of care? a. plan to spend extra time with the client to provide emotional support b. ensure that chemotherapy medications do not extravasate into the client's tissues c. keep the door to the client's room closed d. encourage family members and friends to visit for at least 1 hr per day

Keep the door to the client's room closed Brachytherapy is a cancer treatment in which radioactive (meaning it can be hazardous to others) material sealed inside a seed, pellet, wire, or capsule is implanted in the body using a needle or catheter. The radiation given off by this source damages the DNA of nearby cancer cells

A hospice nurse is caring for a client who has cancer and is taking naproxen 250 mg 3 times daily PO and gabapentin 1,800 mg 3 times daily PO to manage pain. The client tells the nurse "I am having pain that keeps me from doing what I'd like most of the time". Which of the following additions should the nurse anticipate to the client's medication regimen? a. oral meperidine b. parenteral naloxone c. parenteral diazepam d. oral oxycodone

Oral oxycodone WHO analgesic ladder for cancer pain management: 1. nonopioid analgesic (naproxen) 2. adjuvant medication for neuropathic pain (gabapentin) 3. opioid for moderate pain (oxycodone) Meperidine = opioid analgesic not indicated for cancer pain because severe toxic effects when given in multiple doses Naloxone = opioid antagonsit not indicated for cancer pain - it is for clients with opioid overdose Diazepam - no analgesic effects and can cause sedation interfering with daily activities

A nurse cares for a client taking moxifloxacin for the treatment of endocarditis. The nurse monitors the client's heart rhythm for which unwanted effect of quinolone therapy? a. ST elevation b. QT prolongation c. QRS widening

QT prolongation QT for Quinolone Therapy Quinolone therapy can cause QT lengthening. The risk increases if the client takes antidysrhythmic medications or has an electrolyte imbalance. Drug-Induced QT Prolongation: ABCDE Antiarrhythmics antiBiotics antipsyChotics antiDepressants antiEmetics

A nurse provides care for a client with thrombocytopenia who has developed epistaxis. The nurse assists the client into which position? a. sitting upright with neck hyperextended b. standing erect with arms raised above the head c. lying supine with neck extended d. sitting upright and leaning forward

Sitting upright and leaning forward sitting upright and leaning forward to prevent aspiration Thrombocytopenia = low platelet count Epistaxis = nosebleeds

A client with emphysema is short of breath. The nurse assists the client into which position? a. leaning back in a recliner b. sitting upright and leaning forward c. lying to the left side d. supine with pillow under the legs

Sitting upright and leaning forward tripod position assists dyspneic clients to maximize lung volume (High Fowlers Position)

The nurse receives report for a client receiving end-of-life care prescribed parenteral opioids. The client demonstrates poor pain control, restlessness, and tachypnea despite the off-going nurse documenting numerous high doses of opioid on the previous shift. For which possible causes of the client's presentation should the nurse assess? Select all that apply a. opioid withdrawal b. opioid overdose c. drug diversion by previous nurse d. acute onset liver failure e. increasing opioid tolerance

a. opioid withdrawal c. drug diversion by previous nurse e. increasing opioid tolerance

A nurse provides discharge instructions to a client with HIV. Which instruction does the nurse provide? (select all that apply) a. use condoms consistently and correctly for vaginal or anal sex b. do not share your shaving razor or nail clippers with anyone c. avoid sharing drinks or utensils with healthy family members d. avoid being around individuals with symptoms of contagious infections e. sexual partners should be tested for HIV

a. use condoms consistently and correctly for vaginal or anal sex b. do not share your shaving razor or nail clippers with anyone d. avoid being around individuals with symptoms of contagious infections e. sexual partners should be tested for HIV HIV should avoid razors, get tested, use condoms, take precautions against infections

A nurse is caring for a client who has peptic ulcer disease and reports a headache. Which of the following medications should the nurse plan to administer? a. ibuprofen b. naproxen c. aspirin d. acetaminophen

acetaminophen (doesn't affect blood coagulation and does not increase the risk of GI bleeding) Ibuprofen, Naproxen and Aspirin are NSAIDS contraindicated due to reduced platelet aggregation

A nurse is caring for a client who is undergoing electroconvulsive therapy (ECT) to treat major depression. Following the procedure, which of the following actions should the nurse take? a. administer oxygen b. administer an anticonvulsant c. administer an opioid antagonist d. administer IV fluids

administer oxygen in preparation for ECT, the anesthesiologist administers succinylcholine, which paralyzes respiratory muscles.

A nurse administers ceftriaxone IV as prescribed to a client. Twenty minutes after initiation, the client develops a generalized red, itchy rash. The nurse discontinues the infusion and contacts the healthcare provider. Which additional actions does the nurse take? Select all that apply a. inform the client this is a normal side effect of the medication b. document the client's reaction to medication in the client's health record c. discontinue the IV line and restart at a new site d. add a new allergy to the client's permanent health record e. complete an adverse drug reaction report per facility protocol

b. document the client's reaction to medication in the client's health record d. add a new allergy to the client's permanent health record e. complete an adverse drug reaction report per facility protocol

A nurse prepares to give handoff report on a client at 1900 and realizes the client did not receive a scheduled dose of 60mg enoxaparin subcut at 0900 which is prescribed BID after an acute ST-elevation myocardial infarction (STEMI). Which actino does the nurse take? a. administer the correct dose of the missed medication b. adjust the medication schedule based on the new administration time c. contact the healthcare provider regarding the missed medication dosage d. document the time the medication was administered

contact the healthcare provider regarding the missed medication dosage

A nurse is assessing the skin of a client who has frostbite. The client has small blisters that contain blood, and the skin of the affected area does not blanch. THe nurse should classify this injury as which of the following? a. first degree frostbite b. second degree frostbite c. third degree frostbite d. fourth degree frostbite

third degree frostbite blanch = that do not turn white (blanch) when you push on them