nclex pass point set 3

A nurse is evaluating an external fetal monitoring strip. Identify the area on this strip that causes her to be concerned about uteroplacental insufficiency.

Explanation: This fetal monitoring strip illustrates a late deceleration. The decrease in fetal heart rate begins at the end of the contraction and doesn't return to baseline until the contraction is over. Late decelerations are associated with uteroplacental insufficiency, shock, or fetal metabolic acidosis.

A client is unable to get out of bed and get dressed unless a nurse prompts every step. This is an example of which behavior? word salad tangential perseveration avolition

avolition Explanation: Avolition refers to impairment in the ability to initiate goal-directed activity. Word salad is a behavior in which a group of words are put together in a random fashion without logical connection. A person exhibiting tangential behavior never gets to the point of the communication. In perseveration, a person repeats the same word or idea in response to different questions.

A client with antisocial personality disorder smokes in prohibited areas and refuses to follow other unit and facility rules. The client persuades others to do the client's laundry and other personal chores, splits the staff, and will work only with certain nurses. The care plan for this client should focus primarily on: consistently enforcing unit rules and facility policy. isolating the client to decrease contact with easily manipulated clients. engaging in power struggles with the client to minimize manipulative behavior. using behavior modification to decrease negative behavior by using negative reinforcement.

consistently enforcing unit rules and facility policy. Explanation: Firmness and consistency regarding rules are the hallmarks of a care plan for a client with a personality disorder. Isolation is inappropriate and violates the client's rights. Power struggles should be avoided because the client may try to manipulate people through them. Behavior modification usually fails because of staff inconsistency and client manipulation.

A primigravid client admitted to the labor area in early labor tells the nurse that her brother was born with cystic fibrosis and she wonders if her baby will also have the disease. The nurse can tell the client that cystic fibrosis is: X-linked recessive and the disease will only occur if the baby is a boy. X-linked dominant and there is no likelihood of the baby having cystic fibrosis. Autosomal recessive and that unless the baby's father has the gene, the baby will not have the disease. Autosomal dominant and there is a 50 per cent chance of the baby having the disease.

Autosomal recessive and that unless the baby's father has the gene, the baby will not have the disease. Explanation: Cystic fibrosis and other inborn errors of metabolism are inherited as autosomal recessive traits. Such diseases do not occur unless there are two genes for the disease present. If one of the parents does not have the gene, the child will not have the disease. X-linked recessive genes can result in hemophilia A or color blindness. X-linked recessive genes are present only on the X chromosome and are typically manifested in the male child. X-linked dominant genes, which are located on and transmitted only by the female sex chromosome, can result in hypophosphatemia, an inborn error of metabolism marked by abnormally low serum alkaline phosphatase activity and excretion of phosphoethanolamine in the urine. This disorder is manifested as rickets in infants and children. Autosomal dominant gene disorders can result in muscular dystrophy, Marfan's syndrome, and osteogenesis imperfecta (brittle bone disease). Typically, a dominant gene for the disease trait is present along with a corresponding healthy recessive gene.

The nurse is teaching a new parent about the feeding patterns of a newborn infant. Which of the following statements by the parent would the nurse recognize as the correct description of a feeding pattern for a formula-fed infant? "Formula-fed infants experience shorter periods between feedings." "Formula-fed infants digest their milk more rapidly." "Formula-fed infants demand to feed every 1.5 to 3 hours." "Formula-fed infants usually feed every 3 to 4 hours."

"Formula-fed infants usually feed every 3 to 4 hours." Explanation: Formula is harder to digest than breast milk and therefore, babies typically feed less frequently than breastfed babies. Formula-fed infants should demand feedings every 3 to 4 hours compared to every 2 to 3 hours for breastfed babies.

A nurse is caring for a client after internal fixation of a compound fracture in the tibia. The nurse finds that the client has not had dinner, seems restless, and is tossing on the bed. What is the most appropriate response by the nurse? "Are you having pain in your leg?" "Tell me what you are feeling." "Do you need pain medication?" "Are you feeling all right?"

"Tell me what you are feeling." Explanation: The nurse should ask the client to tell the nurse what they are feeling. Asking open-ended questions would encourage the client to verbalize pain. Some clients may not demonstrate their feelings or readily discuss their symptoms due to factors related to cultural norms. Closed-ended questions like "Are you having pain?", "Do you need pain medication?", and "Are you feeling all right?" may block communication.

The nurse is about to administer lithium carbonate to a client with bipolar disorder in a mania state. What is the nurse's action after assessing the client's lithium level to be 1.0 mEq/L (mmol/L)? Notify the healthcare provider. Hold the lithium carbonate. Administer the lithium carbonate. Repeat the lithium level.

Administer the lithium carbonate. Explanation: To treat acute mania, the client's serum lithium level should be between 0.6 and 1.2 mEq/L (mmol/L). The serum lithium level shouldn't exceed 2 mEq/L (mmol/L). The nurse must monitor the client continuously for signs and symptoms of lithium toxicity, such as diarrhea, vomiting, drowsiness, muscular weakness, ataxia, stupor, and lethargy. The nurse must also keep in mind that even a normal lithium level can become toxic. Notifying the healthcare provider of the normal level with a client in mania is not appropriate. There are no signs and symptoms of toxicity, so the medication should not be held. There is no reason to repeat the level.

A client with a history of drug abuse gives birth to a low-birth-weight neonate who is experiencing drug withdrawal. Which intervention is helpful for this neonate? Place the isolette in a quiet area of the nursery. Withhold medications until liver function improves. Dress the neonate in loose-fitting clothing. Place the isolette close to the nurse's station.

Place the isolette in a quiet area of the nursery. Explanation: The neonate experiencing drug withdrawal should be placed in a quiet area of the nursery to minimize stimuli; the nurses' station is typically not a quiet area. The neonate should be swaddled to prevent him from stimulating himself with movement. Medications should be administered as needed.

A 25-year-old client tells the nurse that she would like to become pregnant, but she has been diagnosed with blocked fallopian tubes due to pelvic inflammatory disease. When helping the client explore infertility treatment options, what is most appropriate for this client? gamete intrafallopian transfer zygote intrafallopian transfer menotropin therapy in vitro fertilization

in vitro fertilization Explanation: Because this client's tubes are blocked, in vitro fertilization would be the most appropriate. After ova are removed surgically from the client and fertilized outside the uterus, the fertilized ova are introduced vaginally through a special tube through the cervix to the uterus for implantation, completely bypassing the fallopian tubes. Gamete intrafallopian transfer, the transfer of ova into a patent fallopian tube for fertilization, would be inappropriate for client with blocked fallopian tubes. Zygote intrafallopian transfer involves oocyte retrieval then fertilization. After fertilization, the fertilized eggs are transferred into the client's fallopian tubes. This is not an option for a client who has blocked tubes. Menotropin therapy would be appropriate if the client was experiencing ovarian dysfunction.

The nurse is planning care for a toddler with a seizure disorder. Which item in the care plan should the nurse revise? padded side rails oxygen mask and bag system at bedside padded tongue blade at the bedside lorazepam for seizure lasting longer than 5 minutes

padded tongue blade at the bedside Explanation: The nurse should revise a care plan that includes padded tongue blades. Nothing should be placed in the mouth during a seizure. Padded side rails will protect the child from injury during a seizure. The bag and mask system should be present in case the child needs oxygen during a seizure. Most seizures resolve in under 5 minutes. If they do not, then a dose of lorazepam can be administered. The healthcare provider will prescribe the correct dosage for weight and the parameters for administering.

A client makes a routine visit to the prenatal clinic. Although the client is 14 weeks pregnant, the size of her uterus approximates an 18- to 20-week pregnancy. The physician diagnoses gestational trophoblastic disease and orders ultrasonography. The nurse expects ultrasonography to reveal: an empty gestational sac. grapelike clusters. a severely malformed fetus. an extrauterine pregnancy.

grapelike clusters. Explanation: In a client with gestational trophoblastic disease, an ultrasound performed after the third month shows grapelike clusters of transparent vesicles rather than a fetus. The vesicles contain a clear fluid and may involve all or part of the decidual lining of the uterus. Usually no embryo (and therefore no fetus) is present because it has been absorbed. Because there is no fetus, there can be no extrauterine pregnancy. An extrauterine pregnancy occurs with an ectopic pregnancy.

On the second postpartum day after a cesarean birth, the client reports having gas pains. What should the nurse should instruct the client to do? Ask the primary care provider for a simethicone prescription. Chew on some ice chips. Drink some hot coffee. Ambulate more often.

Ambulate more often. Explanation: During the first few days postpartum, the accumulation of gas in the intestines may cause discomfort. This is relieved by measures such as increasing activity, doing leg exercises, avoiding carbonated or very hot or cold beverages, avoiding using ice or straws, and maintaining a high-protein liquid diet for the first 24 to 48 hours. A rectal tube also may be used. A gastric or intestinal tube is sometimes used when other measures fail.Simethicone tablets may provide some relief, but the nurse, not the client, should ask the primary care provider for this medication.Chewing on ice chips or using a straw may actually increase gas accumulation.Drinking hot coffee should be avoided because very hot or cold beverages increase gas accumulation.

When developing a care plan for a hospitalized client, the nurse knows that children in which age-group are most likely to view illness as a punishment for misdeeds? infancy preschool age school age adolescence

preschool age Explanation: Preschool-age children are most likely to view illness as a punishment for misdeeds. Separation anxiety, although seen in all age-groups, is most common in older infants. Fear of death is typical of older school-age children and adolescents. Adolescents also fear mutilation.

A nurse is attending a seminar at the local senior center. The nurse knows the presenter has a good understanding of genitourinary changes in the elderly when the presenter makes which statement? "Urinary incontinence is a normal part of aging." "It is best not to have any fluids after the lunch meal, so that you don't need to void at night." "You should leave a light on in your bathroom at night." "Stress incontinence only occurs in people diagnosed with dementia or Alzheimer's disease."

"You should leave a light on in your bathroom at night." Explanation: Urinary incontinence, although common in the elderly is not a normal part of aging. Not drinking after lunch can lead to dehydration. Stress incontinence is related to detrusor muscle weakness and not dementia or Alzheimer's disease. Leaving a light on in the bathroom at night appropriately addresses possible safety/fall concerns.

A nurse suspects that a coworker is taking and using narcotics from the medication cart. What would the nurse do first? Monitor the coworker's behaviors. Report the suspicion to the nurse manager. Discuss the suspicion directly with the coworker. Keep track of the quantity of medications in the cart throughout the shift.

Report the suspicion to the nurse manager. Explanation: The nurse should report the suspicion to the nurse manager. The American Nurses Association does not advise confronting coworkers in these situations. Monitoring the coworker's behavior or keeping track of the quantity of medications in the cart do not solve these problem. These actions allow the coworker to continue working with clients while possibly under the influence of drugs, which is not safe.

The nurse is working as charge nurse on a medical-surgical unit. The nurse is providing orientation for a newly hired RN. Which action by the new RN requires immediate attention? teaching a newly admitted burn client about the use of pressure garments discussing the use of herpes zoster vaccine with a young adult administering oral tetracycline with milk to a client with cellulitis obtaining an anaerobic culture specimen from a superficial burn wound

administering oral tetracycline with milk to a client with cellulitis Explanation: Dairy products inhibit the absorption of tetracycline, decreasing the effectiveness of the antibiotic. All the other activities are not appropriate, but would not cause as much potential harm as the administration of tetracycline with milk. Anaerobic bacteria would not likely grow in a superficial wound. Herpes zoster vaccine is recommended for clients who are older adults (60 years or older). Pressure garments are used after graft wounds heal and during the rehabilitation phase after a burn injury, and should be discussed when the client is ready for rehabilitation, not when the client is admitted.

A client is 4 days postoperative from a tibia fracture and has a long leg cast. The nurse is conducting initial teaching for walking with crutches. What is the most important activity for the nurse to encourage the client to do prior to discharge from the hospital? sit up straight in a chair to develop the back muscles, as this will help the client walk with crutches. keep the affected limb in extension and abduction at all times. conduct exercises in bed to strengthen the upper extremities, as this will assist the client in crutch use. while walking, do weight bearing on the cast to increase balance.

conduct exercises in bed to strengthen the upper extremities, as this will assist the client in crutch use. Explanation: When walking with crutches, the client engages the triceps, trapezius, and latissimus muscles. A client who has been immobilized may need to implement an exercise program to strengthen these shoulder and upper arm muscles before initiating crutch walking. The other choices are incorrect based on functionality and muscle use.

The nurse used a secure access code to obtain a morphine 2 mg/ml vial from the computerized automated dispensing cabinet (ADC). Before exiting the system, the nurse is prompted to count the remaining vials. The nurse counts 10 remaining vials, but the system reads 9 remaining vials. What is the next action by the nurse? Ask another nurse to assist with following the procedure to resolve the discrepancy. Change the number on the ADC to read 10 remaining vials. Administer the medication then contact the pharmacy to report the discrepancy. Remove the extra vial and ask another nurse to witness the waste.

Ask another nurse to assist with following the procedure to resolve the discrepancy. Explanation: Morphine is a controlled substance. Federal law requires an accurate record for each controlled substance administered to prevent diversion and misuse. Accurate counts of vials are an important part of maintaining this accurate record. In the event of a discrepancy, the nurse should ask another nurse to act as a witness and follow the facility procedure for resolving a discrepancy. Resolving the discrepancy is a priority and should happen before medicating the client. The nurse should not change the number or waste the extra vial because this will not maintain an accurate record of the controlled substance administration as required by law.

The nurse reviewed laboratory values for a client with type 1 diabetes mellitus. The client's hemoglobin A1c (HbA1c) is 9 percent. What is the priority action for the nurse? Obtain a fasting serum glucose level Assess the client's baseline knowledge about their treatment regimen Assess the home log of blood glucose levels Tell the client the test result shows that the client's blood sugars are not under control

Assess the client's baseline knowledge about their treatment regimen Explanation: A hemoglobin A1c level or glycosylated hemoglobin gives the nurse data about the average blood glucose concentration over 2 to 3 months, providing a picture of the client's overall glucose control. The nurse should determine the client's knowledge about insulin, diet, and exercise program because of the above normal result. Telling the client that their blood sugars are not under control is confrontational and is not therapeutic. A fasting serum glucose level gives a picture of the client's recent glucose level, not the overall effectiveness of the therapeutic regimen. A 1-week diet recall is not always accurate. A home log may provide some information about overall control and compliance, the log may not have all of the glucose levels recorded, and would be lacking diet and exercise information.

The nurse is preparing to administer propranolol to a client for control of migraine headaches. The client also has a prescription for sumatriptan as needed for a headache. The client's pulse rate is 56 bpm. What should the nurse do next? Contact the health care provider (HCP). Assess blood pressure. Administer oxygen. Administer sumatriptan.

Correct response: Assess blood pressure. Explanation: One of the actions of propranolol, a drug used in the treatment of migraine headaches, is to inhibit arterial vasodilation. The nurse should assess the client's blood pressure to evaluate overall circulatory response to the medication. Until the nurse determines the client's blood pressure, there is no immediate need to contact the HCP. There is no immediate need to administer oxygen. The client has not indicated pain; it is not necessary to administer the sumatriptan at this time.

A client with colorectal cancer has been presented with her treatment options but wishes to defer any decisions to her uncle, who acts in the role of a family patriarch within the client's culture. What best protects the client's right to self-determination? respecting the client's desire to have the uncle make choices on her behalf revisiting the decision when the uncle is not present at the bedside teaching the client about her right to autonomy holding a family meeting and encouraging the client to speak on her own behalf

Correct response: respecting the client's desire to have the uncle make choices on her behalf Explanation: The right to self-determination (autonomy) means that decision-making should never be forced on anyone. The client has the autonomous right to defer her decision making to another individual if she freely chooses to do so.

A client with suspected severe acute respiratory syndrome (SARS) comes to the emergency department. Which physician order should the nurse implement first? Institute isolation precautions. Begin an I.V. infusion of dextrose 5% in half-normal saline solution at 100 ml/hour. Obtain a nasopharyngeal specimen for reverse-transcription polymerase chain reaction testing. Obtain a sputum specimen for enzyme immunoassay testing.

Institute isolation precautions. Explanation: SARS, a highly contagious viral respiratory illness, is spread by close person-to-person contact. Contained in airborne respiratory droplets, the virus is easily transmitted by touching surfaces and objects contaminated with infectious droplets. The nurse should give top priority to instituting infection-control measures to prevent the spread of infection to emergency department staff and clients. After isolation measures are carried out, the nurse can begin an I.V. infusion of dextrose 5% in half-normal saline and obtain nasopharyngeal and sputum specimens.

A client is experiencing an acute exacerbation of rheumatoid arthritis. What should the nursing priority be? 1. providing comprehensive client teaching including symptoms of the disorder, treatment options, and expected outcomes 2. administering ordered analgesics and monitoring their effects 3. performing meticulous skin care 4. supplying adaptive devices, such as a zipper-pull, easy-to-open beverage cartons, lightweight cups, and unpackaged silverware

2. administering ordered analgesics and monitoring their effects Explanation: An acute exacerbation of rheumatoid arthritis can be very painful, and the nurse should make pain management the priority. Client teaching, skin care, and supplying adaptive devices are important, but these actions do not take priority over pain management.

The fire alarm sounds on the maternal-neonatal unit at 0200. How can a nurse best care for the unit's clients during a fire alarm? 1. Permit the mothers and their neonates to continue sleeping. 2. Immediately evacuate the unit. 3. Close all of the doors on the unit. 4. Do nothing because it's most likely a fire drill.

3. Close all of the doors on the unit. Explanation: The nurse should respond quickly by closing all of the doors on the unit. This action prevents the spread of smoke in case of a fire. The nurse shouldn't begin evacuating the unit until given notification to do so. The nurse shouldn't ignore the alarm because fire drills are necessary to prepare the staff for a fire. The mothers should be awakened in case evacuation is necessary.

Which question would the nurse ask to determine a client's coping abilities during a lengthy hospital stay? "What could you have done to prevent this illness?" "How is this illness impacting you and your family?" "How can we take away your worries while you are in the hospital?" "What are the worst challenges that you have faced?"

Correct response: "How is this illness impacting you and your family?" Explanation: This question helps address how illness affects the client as well as the family. This question seeks to assess the impact of the stressor and coping abilities. It also examines how the support system, the family, is responding. It is too late to address prevention issues. Taking away worries is not realistic because the client needs to work through concerns. Asking about worst challenges changes the topic of what the client is experiencing right now.

A nurse is caring for a client in her 34th week of pregnancy who wears an external monitor. Which statement by the client indicates an understanding of the nurse's teaching? "I'll need to lie perfectly still." "You won't need to come in and check on me while I'm wearing this monitor." "I can lie in any comfortable position, but I should stay off my back." "I know that the external monitor increases my risk of a uterine infection."

"I can lie in any comfortable position, but I should stay off my back." Explanation: The client demonstrates understanding of the nurse's teaching when she states that she should stay off her back. A woman with an external monitor should lie in the position that is most comfortable to her, but the supine position should be discouraged. It isn't necessary for the client to lie perfectly still. The client should be encouraged to change her position as often as necessary; however, the monitor may need to be repositioned after a position change. The nurse still needs to frequently assess and provide emotional support to a woman in labor who's wearing an external monitor. Because an external monitor isn't invasive and is worn around the abdomen, it doesn't increase the risk of uterine infection.

A client has been using Chinese herbs and acupuncture to maintain health. What is the best response by the nurse when asked if this practice could be continued during recuperation from a long illness? "Have you spoken to the physician about using the Chinese herbs and acupuncture?" "What do you want to accomplish by using these methods rather than researched practices?" "Once you have recovered from this illness, you can go back to your traditional ways." "Let's discuss your desire to integrate these practices with the physician and advocate on your behalf."

"Let's discuss your desire to integrate these practices with the physician and advocate on your behalf." Explanation: The client has a right to incorporate some of the traditional Chinese therapies. It is important to be respectful of cultural beliefs and to advocate for the client. Contacting the physician is important because there could be herbal-drug interactions. Each of the other choices does not respect cultural choices or explore the possibility of interactions. Openness with health care members is important because clients may choose to integrate these therapies without notifying the nurse or the physician.

These pediatric clients are in the triage area awaiting assessment. Which client will the nurse assess first? a crying 3-year-old whose parent is holding a cloth on the child's head covering a scalp laceration a lethargic 15-month-old with pink cheeks whose parent reported temperature of 38.4°C (101.2°F) a quiet 2-year-old with nasal flaring who is sitting in a tripod position a pale 6-month-old with a frequent cough and audible wheezing

a quiet 2-year-old with nasal flaring who is sitting in a tripod position Explanation: The nurse identifies the nasal flaring and particularly the tripod position as indications of respiratory distress. This pediatric client needs rapid assessment and intervention and will be seen first. The other pediatric clients are not in immediate danger and will be seen as soon as possible by a healthcare professional.