NCLEX - PN (6/27/2020)

The nurse knows that in the initial stages of Alzheimer's disease the client and family try to hide deficits in memory. Which are some of the defense mechanisms related to the progression of the disease?

- Denial - Confabulation - Perserveration - Avoidance of questions Rationale: Denial occurs fairly early in the disease process. Confabulation is the creation of stories or answers in place of actual memories to maintain self-esteem. Perservation is the repetition or phrases or behavior. Avoidance of questions also helps the client to maintain self-esteem.

The nursing student is assigned to care for an adolescent female client in the health care clinic who has the potential diagnosis of gonorrhea. Which signs/symptoms if found in the client supports this diagnosis?

- Edematous labia - Acute severe pelvic pain - Presence of a greenish-yellow purulent endocervical discharge Rationale: Gonorrhea can be asymptomatic, if S&S occur, the client may experience edema of the labia, chronic or acute severe pelvic or lower abdominal pain, a greenish-yellow purulent endocervical discharge, and menstrual irregularities.

A post-op client has been receiving morphine sulfate every 3-4 hours for pain. The nurse should be sure to implement which measures to reduce the risk of adverse effects from this medication?

- Encourage fluids when not NPO - Encourage coughing and deep breathing - Monitor the number of BMs Rationale: morphine sulfate suppressed the respiratory and cough reflex. Narcotics also slow down peristalsis and lead to constipation. Encouraging liquids will help liquefy secretions for coughing and prevent constipation.

The nurse is monitoring a newborn who was born to a drug-addicted mother. Which findings should the nurse expect to note during data collection of the newborn?

- Irritable - Cries incessantly - Difficult to console - Hyperextends and postures Rationale: A newborn born to woman using drugs is irritable and is easily overloaded by sensory stimulation.

The nurse is caring for a client with an eating disorder and knows that which S&S indicate that the client is dealing with anorexia nervosa?

- Lanugo - Amenorrhea Rationale: S&S of anorexia nervosa include lanugo, amenorrhea, low weight, yellow skin, cold extremities, and constipation.

A client diagnosed with schizophrenia is experiencing an acute dystonic reaction. Which interventions should the LPN initiate?

- Monitor airway - Notify the RN - Remain with the client to provide support - Administer a prescribed IM antiparkinson medication Rationale: an acute dystonic reaction is an often painful, sustained contraction of muscles, usually of the head and neck, which typically occurs from 2 to 5 days after the introduction of antipsychotic meds.

A client has been diagnosed with metabolic alkalosis. Which lab values are most important for the nurse to monitor for this client?

- Serum electrolytes - ABGs Rationale: Metabolic alkalosis occurs when the pH is greater than 7.45, and the HCO3 is greater than 26 mEq/L. The client with metabolic acid-base imbalances are prone to alterations in potassium as well.

The nurse understands that which lab requisition data will be needed by the lab for adequate evaluation of the ABG specimen?

- The client's temperature - The date the specimen was drawn - The time the specimen was drawn - Any supplemental oxygen the client is receiving Rationale: An ABG requisition usually contains information about the date and time the specimen was drawn, the client's temperature, whether the specimen was drawn with the client using room air or supplemental oxygen and the vent settings if the client is on a mechanical ventilator.

Which are the most important interventions that can help reduce the incidence of hospital-acquired urinary catheter infections?

- Use indwelling urinary catheters judiciously - Remove indwelling catheters when no longer needed - Use strict aseptic technique when inserting all urinary catheters

Which intervention should be implemented for the older client with presbycusis who has a hearing loss?

Use low-pitched tones Rationale: Presbycusis is age-related, irreversible, degenerative changes of the inner ear. The older client has a decreased response to high-frequency sounds as a result.

The nurse notes a client with hypothyroidism is taking a maintenance dose of levothyroxine. The nurse is reviewing instructions concerning taking levothyroxine with the client. There is a need for further instruction when the client makes which statement?

"I will take the pill with milk to keep from upsetting my stomach." Rationale: Levothyroxine should be taken on an empty stomach because many medications, and foods, especially those rich in iron, fiber, calcium, or soy interfere with absorption. It should be taken the same time each day, morning is usually recommended.

A perinatal client with a history of heart disease has been instructed on care at home. Which statement indicated the need for further instruction?

"It is best to rest on my right side." Rationale: It is best to rest on the left side to promote blood return.

An older adult confides to the visiting nurse the fear of falling while going to the bathroom at night. Consider the visual changes of the older client, what recommendation should the nurse make?

"Keep a red light on in the bathroom at night" Rationale: Eyes adapt to the dark by using the rod receptors, which are sensitive to short blue-green wavelengths. Red wavelengths are longer and perceived by the cones.

The nurse is gathering data from a client in crisis. When determining the client's perception of the precipitating event that led to the crisis, which is the most appropriate question to ask?

"What leads you to seek help now?" Rationale: The nurse's initial task when gathering date from a client in crisis is to assess the individual or family and the problem. The more clearly the problem can be defined, the better the chance a solution can be found.

The nurse is providing discharge teaching regarding skin care to a new mother of a 2 day old infant. Which statements by the mother demonstrate an understanding of how to care for the infant's skin?

- "We will apply ointments containing zinc oxide to the baby's bottom to prevent diaper rash." - "To prevent diaper rash, we will change our baby's diaper as soon as he has pooped or peed." Rationale: Diaper rash is common in children who wear diapers. It is caused by irritation of the skin caused by contact with urine and feces. Both interventions will help protect the baby's skin from the damaging effects of urine and feces.

A client has been diagnosed with bacterial conjunctivitis. Which clinical manifestations of bacterial conjunctivitis should the nurse expect to note?

- Swollen lids - Inflamed conjunctiva - Crusting on eyelids, especially in the morning

The client has been prescribed nitrofurantoin sodium. The nurse determines the therapy is effective if which result is noted?

Absence of dysuria Rationale: an antibacterial agent that is used to treat acute urinary tract infection or as a chronic suppressive treatment for UTIs.

The nurse is caring for a child with a fracture is placed in skeletal traction. The nurse monitors for the most serious complication associated with this type of traction by checking for which?

An elevated temperature Rationale: Most serious complication associated with skeletal traction is osteomyelitis (an infection involving the bone). S&S include complaints of localized pain, swelling, warmth, tenderness, an unusual odor from fracture site, and an elevated temperature.

The nurse collects a urine specimen from a preop child with epispadias who is scheduled for surgical repair. Which lab result of the urine test would the nurse most likely expect to note?

Bacteriuria Rationale: Epispadias is a congenital defect that involves the abnormal placement of the urethral orifice of the penis. The urethral orifice is located anywhere on the dorsum of the penis. This characteristic leads to easy access of the bacterial entry into the urine.

A child is admitted to the hospital with a diagnosis of suspected bacterial endocarditis. The nurse prepares the child for which diagnostic test that will confirm the diagnosis?

Blood cultures Rationale: A definitive diagnosis is achieved through blood cultures. A negative blood culture does not rule it out, it just indicated a lesser likelihood of its existence.

A client has a long leg plaster cast. During evening rounds, the nurse notes that the capillary refill is greater than 3 seconds and the toes are edematous and dusky. The client states the pain medication is not working and the right foot feels like it is asleep. The nurse analyzes the date and determines the client's S&S indication which complication?

Compartment Syndrome Rationale: As pressure within the fascia compartment increases, nerves and blood vessels are occluded, resulting in ischemia and unrelieved pain. In this situation, the edema and cast are compressing the structures within the leg.

The nurse is assigned to care for a child after a myringotomy with the insertion of tympanostomy tubes. The nurse notes a small amount of reddish drained from the child's ear after the surgery. What action should the nurse take?

Document the findings Rationale: A small amount of reddish drainage is normal during the first few days after surgery. However, any heavy bleeding or bleeding that occurs after 3 days should be reported.

After an eye exam, a client has been diagnosed with acute angle-closure glaucoma. What sign/symptom of the client accompanies the history?

Eye pain Rationale: S&S of acute angle-closure glaucoma are blurred vision, severe pain, and vision loss.

The nurse is caring for a client who has a history of opioid abuse and is monitoring the client for signs of withdrawal. What signs and symptoms are associated with withdrawal from opioids?

Fever, yawning, irritability, diaphoresis, and diarrhea.

The nurse is assisting a post op client who had a pneumonectomy. The nurse monitors the client for which adverse sign/symptom indicating acute pulmonary edema?

Frothy sputum Rationale: The client developing pulmonary edema after pneumonectomy demonstrates dyspnea, cough, frothy sputum crackles, and possibly cyanosis.

The nurse asks the client about current prescribed medications, the client tells the nurse that amprenavir is prescribed twice daily. Based on this finding, the nurse should elicit data from the client regarding the presence of which condition?

HIV Rationale: Amprenavir is an antiretroviral agent, classified as a protease inhibitor. Its used to treat HIV infection.

The nurse is asked to assist the PHCP in performing Leopold's maneuvers on a client. Which nursing intervention should be implemented before this procedure is performed?

Have the client empty her bladder. Rationale: An empty bladder contributes to woman's comfort during the examination. Leopold's maneuvers are often performed to aid the examiner in locating fetal heart tones.

The nurse has a prescription to give a client a scheduled dose of digoxin. Before administering the medication, the nurse screens for which S&S that could indicate early signs of digoxin toxicity?

Loss of appetite, nausea, and vomiting Rationale: These are early signs of digoxin toxicity. Other signs include bradycardia, visual alterations, confusion, diarrhea.

The nurse is observing the mother administering ear drops to her infant and determines that the mother is performing the procedure correctly if the mother performs which action?

Pulls down and back on the earlobe and directs the solution toward the wall of the canal

The nurse is reading the results of a CSF analysis performed on an adult client who underwent a lumbar puncture. The nurse knows that a reported value of 0 is normal for which substance in CSF?

Red blood cells Rationale: The adult with normal CSF has no RBCs in the CSF. The client may have small numbers of WBCs (0 to 3 cells/mm3), protein (15 to 45 mg/dL), and glucose (40 to 80 mg/dL) are normally present in CSF.

The nurse is assisting in caring for a client in the telemetry unit and is monitoring the client for cardiac change indicative of hypokalemia. Which occurrence noted on the cardiac monitor indicated the presence of hypokalemia?

ST-segment depression Rationale: in the client with hypokalemia, the nurse would note ST-segment depression on a cardiac monitor. The client may also exhibit a flat T wave.

A client's vision is tested with a Snellen chart. The results of the test are documented as 20/60. How should the nurse interpret this result?

The client can read at a distance of 20 feet what a client with normal vision can read at 60 feet. Rationale: Vision that is 20/20 is normal; that is, the client can read from 20 feet what a person with normal vision can read from 20 feet.

The nurse is reviewing the lab studies of a client receiving epoetin alfa. When should the nurse expect to note a therapeutic effect of this medication on the Hgb and Hct?

Two months after therapy Rationale: initial effects are noted within 1 to 2 weeks, Hct levels reach normal levels in 2 to 3 months.

The nurse is emphasizing discharge instructions to the mother of the child who has been prescribed tetracycline hydrochloride. The nurse should most appropriately stress the importance of which instruction?

Use a straw when the child is taking the medication Rationale: tetracycline hydrochloride can stain the teeth and the mouth should be rinsed after administration. The medications should be administered 1 hour before or 2 hours after the administration of milk.

When performing CPR, the nurse should deliver how many breaths per minute to an adult client?

10 Rationale: During CPR, the nurse would deliver 10 breaths per minute to an adult client. 30 chest compressions, 2 breaths, 5 times within 1 minute.

The nurse is caring for a client diagnosed with SLE, that is affected the hematopoietic system. Which data regarding the S&S should the nurse anticipate collecting?

- Anemia - Splengomegaly - Lymphadenopathy Rationale: Hematology is the study of blood and blood-forming tissues, which include the bone marrow, blood, spleen, and lymph system. Anemia is a hematological system issue and often occurs in SLE. Lymphadenopathy (enlarged lymph nodes) and splenomegaly (enlarged spleen) also can occur with SLE.

The nurse is caring for a cardiac client who has atrial fibrillation. Which actions by the nurse are most appropriate?

- Check all telemetry leads - Check blood pressure - Obtain STAT ECG - Assess client's LOC Rationale: Check the leads to confirm the rhythm, check the BP and LOC, and then obtain a STAT ECG.