NCLEX PRACTICE Level 3

What is one disadvantage of using the rectal route for drug administration? You Selected:

It can result in incomplete drug absorption.

The nurse prepares to administer a client's morning medication. Which action should the nurse take first?

Perform hand hygiene

The nurse is caring for a child with a seizure disorder. Which nursing intervention would be included to support the goal of avoiding injury, respiratory distress, or aspiration during a seizure?

Place a hand under the child's head for support.

The spouse of a client diagnosed with vascular dementia asks the nurse if this is the same as having Alzheimer's disease (AD). Which response by the nurse is most appropriate?

There are similarities in the conditions but they are not the same condition.

A client who is on airborne precautions asks the nurse "Can you please leave the door to my room open?" What is the best response by the nurse?

"I must keep your door closed to prevent the spread of infection. I'll open the curtains so that you don't feel so closed in."

The parent of a 16-year-old child calls the emergency department, suspecting their child's abdominal pain may be appendicitis. In addition to pain, the child has a fever of 100° F (37.8° C) and has vomited twice. What would be appropriate advice for the nurse to give the parent?

"Immediately bring your child into the emergency department.

The nurse is preparing to give a 9-year-old client a preoperative I.M. injection. Which size needle should the nurse use?

22G, 1"

A nurse is teaching a women's group about ovarian cancer. Which client is at the highest risk for this disease?

45-year-old client who has never been pregnant

A nurse is completing an intake and output record for a client who is receiving continuous bladder irrigation after transurethral resection of the prostate (TURP). How many milliliters of urine should the nurse record as output for his or her shift if the client received 1,800 mL of normal saline irrigating solution and the output in the urine drainage bag is 2,400 mL? Record your answer as a whole number.

600

The parents of a child diagnosed with hypopituitarism tells the nurse they feel guilty because they should have recognized this disorder. Which statement by the nurse about children with hypopituitarism would be the most helpful?"

They're usually of normal size for gestational age at birth."

When reinforcing teaching the parents of a toddler with congenital heart disease, the nurse should explain all medical treatments and emphasize which instruction?

Try to maintain your child's usual lifestyle to promote normal development.

When caring for a 2-year-old child, the nurse should offer choices, when appropriate, about some aspects of care. According to Erikson, doing this helps the child achieve:

autonomy.

While looking out the window, a client with schizophrenia remarks, "That school across the street has creatures in it that are waiting for me." Which nursing action is the most appropriate for this client?

Acknowledge the client's fears and insecurities.

A client on an inpatient psychiatric unit has been taking a tricyclic antidepressant (TCA) without satisfactory results, so the health care provider changes the medication to a monoamine oxidase inhibitor (MAOI). Prior to administering the medication, what should the nurse be sure to check?

Adequate time has elapsed between discontinuing the first medication and beginning the second.

A client is found sitting on the floor of the bathroom in the day treatment clinic with moderate lacerations on both wrists. Surrounded by broken glass, she sits staring blankly at her bleeding wrists while staff members call for an ambulance. Which of the following approaches should the nurse initially utilize?

Approach her slowly while speaking in a calm voice, calling her name, and telling her that the nurse is here to help her.

A nurse needs assistance in getting an older adult client with confusion back into bed from the chair. The nurse leaves the client sitting alone in the room while going to find someone to assist with the transfer. While the nurse is gone, the client gets out of the chair, falls, and sustains an injury. What did the nurse fail to do?

Arrange for continual care of the client.

A nurse is monitoring the progress of a client with acute respiratory distress syndrome (ARDS). Which data best indicate that the client's condition is improving?

Arterial blood gas (ABG) values are normal.

A client tells the nurse she has never had an orgasm and her partner is upset that he can't meet her needs. Which nursing intervention is most appropriate?

Assess the couple's perception of the problem.

How can a nurse best protect herself after she experiences a minor allergic reaction to latex?

Avoid use of all latex products.

A nurse caring for a client during the fourth stage of labor observes that the client has changed pads four times in the past hour and is reporting dizziness. What initial actions should the nurse take? Select all that apply.

Check vital signs. Check the fundal height. Notify the RN.

A client's blood glucose level is 45 mg/dl. The nurse should be alert for which signs and symptoms?

Coma, anxiety, confusion, headache, and cool, moist skin

A nursing home resident is admitted to the hospital for evaluation and treatment of chronic diarrhea. The nurse plans to place the client on isolation precautions. Which type of isolation precautions should be observed with this client? Select all that apply.

Contact Standard

A nurse is obtaining data for a client admitted to the clinic with a paraphilic disorder. Which interventions best demonstrate the appropriate care of this client? Select all that apply.

Demonstrate a nonjudgmental attitude. Institute safety precautions as needed according to facility protocol. Encourage the client to identify feelings.

A client is receiving antibiotic drug therapy. Which aspect of implementation related to drug therapy would the nurse utilize?

Documenting medications administered

After a stroke, a 75-year-old client is admitted to a health care facility. The client has left-sided weakness and an absent gag reflex. He's incontinent and has a tarry stool. His blood pressure is 90/50 mm Hg, and his hemoglobin is 10 g. Which action is a priority for this client?

Elevating the head of the bed to 30 degrees

The grandparents of a client with anorexia nervosa want to support the client, but are not sure what they should do. Which intervention is best?

Encourage positive expressions of affection.

A client with human immunodeficiency virus (HIV) infection is preparing for discharge from the hospital when he reports to a nurse that he continually feels weak. How should the nurse intervene?

Explain to the client that he should schedule periods of rest throughout the day.

Which information should the nurse include when reinforcing instructions regarding routine screening recommendations for colorectal cancer?

Guaiac-based fecal occult blood test (gFOBT) should begin at age 50 years.

The nurse is reinforcing teaching with a client how to take nitroglycerin to treat angina pectoris. Which statements indicate that the client understands the potential side effects of nitroglycerine? Select all that apply.

I may experience a pounding headache." "I may feel dizzy." "I may feel flushed."

he nurse is evaluating a child with acute poststreptococcal glomerulonephritis (APSGN) for signs of improvement. Which finding typically is the earliest sign of improvement?

Increased urine output

A client in labor tells the nurse, "I'm noticing that I have a clear, milky discharge from both of my breasts." Based on the client's statement, which action by the nurse would be most appropriate

Inform her that the discharge is colostrum, normally present after the fourth month of pregnancy.

Which documentation is most important when preparing a preschool-age child for surgery?

Informed consent

A teenager with heart failure who has been prescribed digoxin asks the nurse, "What will this drug do for my heart?" What is the best response by the nurse?

It will decrease the workload of the heart.

A client is prescribed metformin to control type 2 diabetes. The nurse should monitor for which life-threatening adverse reaction?

Lactic acidosis

A nurse is caring for an older adult client who was admitted with a hip fracture. The client is occasionally confused and has incidents of urinary incontinence. The nurse overhears the unlicensed assistive personnel state, "I am tired of changing that client's bed linen because she can't hold her urine. The client is with it mentally most of the time." Which response by the nurse is most appropriate?

Let's go to a private area so that we can talk more about your frustration."

A nurse is reviewing a client's chart and sees a health care practitioner's order for electroconvulsive therapy (ECT). Which following indication would the nurse expect to find that is the appropriate use for this therapy?

Major depression with psychotic features

A client in labor has been given an epidural anesthetic. When collecting data on the client immediately following the epidural administration, which finding would be most important for the nurse to report?

Maternal blood pressure decreases from 130/70 to 98/50 mm Hg.

The nurse is caring for a client whose first day of the last menstrual period (LMP) was July 29, 2016. When the client asks what the infant's due date is, which date would the nurse give if using the Naegle rule?

May 6, 2017

The mother of a preschooler recently diagnosed with type 1 diabetes mellitus makes an urgent call to the pediatrician's office. She says her child had an uncontrollable temper tantrum while playing and now is lethargic and hard to arouse. The nurse should instruct the mother to take which action first?

Measure the child's blood glucose level.

A client with amebiasis, an intestinal infection, is prescribed metronidazole. The nurse is providing information about adverse reactions of this drug. Which information should the nurse include in his or her teaching plan?

Metallic taste

A postpartum client with diabetes wants to breast-feed but is concerned about the effects of breast-feeding on her health. Which response would be most appropriate?

Mothers with diabetes may breast-feed; insulin requirements may decrease from breast-feeding.

A client recovering from back surgery tells a nurse that she's concerned about going home. She explains that she has many stairs to navigate and household responsibilities she must perform. How can the nurse help ease this client's concerns?

Notify the charge nurse of the client's concerns, and request a team meeting to discuss the client's discharge planning.

When preparing an in-service on adult respiratory distress syndrome (ARDS), which sign or symptom will the nurse educator identify as its hallmark?

Progressive hypoxemia despite supplemental oxygen therapy

A nurse is caring for a 17-year-old brought to the mental health facility by a family member who is concerned about the client's recent 20-lb (9 kg) weight loss, and weight loss total of 50 lb (22.7 kg) in the last year. What interventions are essential in the treatment of an adolescent diagnosed with an eating disorder? Select all that apply.

Provide a highly structured environment. Monitor the clients' weight, vitals, intake and output, caloric intake, and exercise. Assist the client in changing the negative perception to a positive one, and assist in setting realistic goals.

During chemotherapy, an oncology client has a nursing diagnosis of Impaired oral mucous membrane related to decreased nutrition and immuno suppression secondary to the cytotoxic effects of chemotherapy. Which nursing intervention is most likely to decrease the pain of stomatitis?

Providing a solution of hydrogen peroxide and water for use as a mouth rinse

A client with psoriasis visits the dermatology clinic. When inspecting the affected areas, the nurse expects to see which type of secondary lesion?

Scale

A client with schizophrenia becomes agitated and confronts the nurse with clenched fists. Which is the priority action of the nurse?

Speak to the client in a quiet voice and offer the client medication to help calm down.

After collecting a urine specimen, which action by the nurse is most appropriate?

Take the specimen to the laboratory immediately.

A client who is bleeding internally needs emergency surgery to stop the bleeding, but refuses treatment. Which are grounds for challenging a client's right to refuse treatment? Select all that apply.

The client is incompetent. Compelling reasons exist to overrule the client's wishes.

A nurse is caring for a client with anorexia nervosa. When assisting with the development of the client's plan of care, which goal would the nurse identify as the highest priority?

The client will establish adequate daily nutritional intake.

A client with a pulmonary embolism has received a thrombolytic medication. What is the most important concept the nurse should reinforce with this client and his family at this time?

The medication was given to break apart the blood clot blocking the pulmonary artery.

The nurse is observing the parents of a 4-year-old child who has been admitted to the hospital. Which actions indicate that the parents understand how to best minimize anxiety during their child's hospitalization? Select all that apply.

The parents bring the child's favorite toy to the hospital. The parents remain at the child's side during the hospitalization. The parents bring the child's siblings for a brief visit.

A nurse is caring for several neonates in a busy nursery. When weighing a neonate, which action should the nurse take?

Weigh the neonate at the same time each day for accuracy.

A child tests positive for the sickle cell trait, and the parents ask the nurse what this means. Which response by the nurse would be most appropriate?

Your child is a carrier but doesn't have the disease."

A nurse is taking care of four clients. Which client should the nurse see first? a 17-year-old client 24 hours postappendectomy a 33-year-old client with a recent diagnosis of Guillain-Barré syndrome a 50-year-old client 3 days post-myocardial infarction (MI) a 50-year-old client with diverticulitis

a 33-year-old client with a recent diagnosis of Guillain-Barré syndrome ascending paralysis and potential respiratory failure.

A few minutes after beginning a blood transfusion, the nurse notes that the client has chills, dyspnea, and urticaria. The nurse reports this to the physician immediately because the client probably is experiencing:

a hemolytic allergic reaction caused by an antigen reaction

Which plan is most appropriate for a discharge home visit to parents who lost an infant to sudden infant death syndrome (SIDS)?

as soon after death as possible

A mother brings her 2-month-old infant to the clinic for a well-baby checkup. To best assess the interaction between the mother and infant, the nurse should observe them:

as the mother feeds the infant.

A child with tetralogy of Fallot has clubbing of the fingers and toes. The nurse understands that this finding is related to which condition?

chronic hypoxia

The nurse is caring for a 14-year-old child in skeletal traction for treatment of a fractured femur. The child is expected to be hospitalized for several weeks. When planning care, the nurse should take into account the client's need to achieve what developmental milestone?

identity

A nurse is providing fluid replacement for a client with burns on 35% of the body that occurred 12 hours previously. The client's blood pressure is 85/60 mm Hg, pulse is 124 beats/minute, and urine output was 25 mL during the past hour. What prescription should the nurse expect to receive from the health care provider?

increase the IV fluid infusion rate

The nurse is caring for a client who suffered third-degree burns over 50% of the body. Which medication would the nurse anticipate using to prevent infection in this clien

mafenide acetate

A medication nurse is preparing to administer 9 a.m. medications to a client with liver cancer. Which consideration is the nurse's highest priority?

metabolism of the medication

A nurse is interviewing the parent of a 7-year-old child. Which symptom reported by the parent would most lead the nurse to suspect that the child has type 1 diabetes?

recent bed-wetting Polyuria

Continual assessment is an important component in cardiopulmonary resuscitation (CPR). Before initiating CPR, the nurse should always assess for:

responsiveness.

During an examination of a 5-month-old infant, a flat, dull pink macular lesion is noted on the infant's forehead. The nurse suspects which condition?

salmon patch flat, dull pink macular lesion

The nurse is assigned to care for a postoperative client who has diabetes mellitus. During data collection, the client reports that he's impotent and says he's concerned about its effect on his marriage. In planning this client's care, the most appropriate intervention would be to

suggest referral to a sex counselor or other appropriate professional

The nurse is assigned to care for a postoperative client who has diabetes mellitus. During data collection, the client reports that he's impotent and says he's concerned about its effect on his marriage. In planning this client's care, the most appropriate intervention would be to:

suggest referral to a sex counselor or other appropriate professional.

When providing care for a school-age child with diabetes insipidus, the nurse recognizes that which behavior might be difficult related to this child's growth and development?

taking the medication at school

A nurse reviews the laboratory results for a client reporting right lower quadrant abdominal pain. Which laboratory finding should the nurse report to the health care provider immediately?

white blood cell (WBC) count of 22.8/mm