NCLEX PREP 429

Which instruction is a nurse least likely to give to a mother to promote oral hygiene in a preschooler? 1 "You should use a round soft-bristle toothbrush for your child." 2 "You should change your child's toothbrush every three months." 3 "You should teach your child to brush all teeth surfaces thoroughly." 4 "You should have your child use fluoride rinses if he or she tends to get cavities."

"You should have your child use fluoride rinses if he or she tends to get cavities."

A client is to receive 0.25 mg of digoxin intramuscularly. The ampule is labeled 0.5 mg = 2 mL. How many mL should the nurse administer? Record your answer using a whole number. ___ mL

1 mL

A client has an IV of D5W 250 mL to which 100 mg of morphine is added. The healthcare provider prescribes 14 mg of morphine per hour for end of life palliative treatment of a client . At how many mL per hour should the nurse set the intravenous pump? Record your answer using a whole number. ___mL/hr

35 ml/hr

Which diseases can be transmitted from client to client by droplet infection? Select all that apply. 1 Scabies 2 Shingles 3 Measles 4 Pertussis 5 Diphtheria

4 Pertussis 5 Diphtheria

At the start of the nursing shift, there were 200 mL in a client's intravenous (IV) bag. The nurse took the bag down when there were 50 mL still in the bag and hung a new 1000-mL IV bag. The client received two intravenous piggybacks (IVPBs) during the shift; each contained 100 mL. When calculating the intake and output at the end of the shift, the nurse looks at the IV bag. Refer to the illustration. How many mL of IV fluid did the client receive during the shift? Record the answer as a whole number. ___ mL

950 mL

A 9-year-old child who has cerebral palsy and scoliosis also is mentally challenged and blind. The child is incontinent, has contractures of the elbows and wrists, and sits in a customized wheelchair most of the day. One goal of nursing care is for the child's skin integrity to remain intact. Which nursing action will best achieve this goal? 1 Padding the child's lower extremities 2 Repositioning the child every 4 hours 3 Replacing the bed linens with sterile linens 4 Changing disposable diapers every 2 to 3 hours

Changing disposable diapers every 2 to 3 hours

A nurse is preparing to administer an intravenous piggyback medication to a client who is receiving a continuous infusion of intravenous (IV) fluids. What is the priority nursing intervention? 1 Get an additional IV infusion pump for the medication. 2 Check the compatibility of the medication and the continuous IV solution. 3 Disconnect the continuous IV solution while administering the piggyback medication. 4 Flush the client's venous access device to ensure patency.

Check the compatibility of the medication and the continuous IV solution.

A client who had been receiving palliative care for cancer has deteriorated and now needs end-of-life care. The nurse identifies that which types of care will now be removed from the treatment plan? Select all that apply. Chemotherapy Repositioning Regular oral care Blood transfusion Radiation therapy

Chemotherapy Blood transfusion Radiation therapy

The registered nurse is teaching a group of nursing students about the characteristics of the five percussion notes. Which statements made by a student nurse indicate effective learning? Select all that apply. 1 "Resonance indicates the presence of trapped air." 2 "Dullness can be percussed over a consolidated lung." 3 "Hyperresonance is characteristic of normal lung tissue." 4 "Tympanic notes over the lung usually indicate a large pneumothorax." 5 "Flatness percussed over the lung fields indicates massive pleural effusion."

Correct2 "Dullness can be percussed over a consolidated lung." Correct4 "Tympanic notes over the lung usually indicate a large pneumothorax." Correct5 "Flatness percussed over the lung fields indicates massive pleural effusion."

A nursing instructor asks a nursing student about tips for examining a 4-year-old sick child. Which statements made by the nurse indicate adequate teaching? Select all that apply. 1 "I should call the child as 'Mr.' or 'Ms.'" 2 "I should give the child time to play around." 3 "I should start the examination with the child's fingers and hands." 4 "I should gather all information related to the child's sickness from the parents." 5 "I should make judgments when parents share the details of their child's sickness."

Correct2 "I should give the child time to play around." Correct3 "I should start the examination with the child's fingers and hands." Correct4 "I should gather all information related to the child's sickness from the parents."

A client with a suspected kidney disorder reports flank pain. Which nursing interventions should be conducted while performing flank assessment? Select all that apply. 1 Percussing the tender flank first 2 Forming both hands into a clenched fist 3 Asking the client to assume a sitting position 4 Placing one hand flat on costovertebral angle (CVA) 5 Delivering a firm hand thump over the lower abdomen

Correct3 Asking the client to assume a sitting position Correct4 Placing one hand flat on costovertebral angle (CVA)

The nurse is performing an abdominal assessment on a client. Where on the abdomen should the nurse assess for McBurney point?

Correct3 Right lower quadrant (RLQ)

Which nursing intervention should the nurse consider to be a priority for clients with fluid overload? 1 Ensuring client safety 2 Providing drug therapy 3 Providing nutritional therapy 4 Preventing future fluid overload

Ensuring client safety

Which cranial nerves assist with both sensory and motor functioning in a client? Select all that apply. 1 Optic 2 Facial 3 Trochlear 4 Accessory 5 Trigeminal

Facial Trigeminal

A client is started on a clear liquid diet after surgery. Which items should the nurse offer the client? Select all that apply. 1 Gelatin 2 Broth 3 Yogurt 4 Ice milk 5 Ginger ale

Gelatin Broth Ginger ale

When completing a neurologic assessment, the nurse determines that a client has a positive Romberg test. Which finding supports the nurse's conclusion? 1 Inability to stand with feet together when eyes are closed 2 Fanning of toes when the sole of the foot is firmly stroked 3 Dilation of pupils when focusing on an object in the distance 4 Movement of eyes toward the opposite side when head is turned

Inability to stand with feet together when eyes are closed

An arterial blood gas report indicates the client's pH is 7.25, PCO2 is 35 mm Hg, and HCO3 is 20 mEq/L. Which disturbance should the nurse identify based on these results? 1 Metabolic acidosis 2 Metabolic alkalosis 3 Respiratory acidosis 4 Respiratory alkalosis

Metabolic acidosis

Which assessment finding in a client signifies a mild form of hypocalcemia? 1 Seizures 2 Hand spasms 3 Severe muscle cramps 4 Numbness around the mouth

Numbness around the mouth

The nurse is teaching the parents of a toddler-age client who is prescribed iron supplements for iron-deficiency anemia. Which food should the nurse encourage the parents to provide to enhance absorption of iron? 1 Cereal 2 Spinach 3 Whole milk 4 Orange juice

Orange juice

Which action is the least likely to prevent sleep disturbances? 1 Avoiding reading, writing, and eating in bed 2 Getting out of bed if unable to fall sleep after 20 minutes 3 Performing strenuous exercise within an hour before going to bed 4 Lowering the temperature of the bedroom and keeping it dark and quiet

Performing strenuous exercise within an hour before going to bed

The nurse should monitor for which involuntary physiologic response in a client who is experiencing pain? 1 Crying 2 Splinting 3 Perspiring 4 Grimacing

Perspiring

While caring for a client with advanced muscular dystrophy who suffered respiratory distress, the nurse frequently repositions the client to prevent the development of pneumonia. Which other complication can be prevented through this nursing intervention? 1 Renal calculi 2 Disorientation 3 Pressure ulcers 4 Urinary infection

Pressure ulcers

The nurse is preparing to give grief counseling to a client who lost his or her partner recently. Which intervention does the nurse include as a priority action in the care plan? 1 Giving essential information honestly 2 Inquiring about the client's spiritual beliefs 3 Knowing the reason why the loss happened in his or her family 4 Providing an environment for the client to express his or her feelings

Providing an environment for the client to express his or her feelings

A nurse is caring for a client with pain due to muscle spasm. Which nursing action is beneficial for the client? 1 Providing heat compresses at the site 2 Providing a massage to the affected area 3 Encouraging the client to perform isometric exercises 4 Encouraging the client to do active-passive range-of-motion (ROM) exercises

Providing heat compresses at the site

A client with a fractured tibia and fibula is to be discharged from the emergency department with a right leg cast and crutches. In addition to the technical aspects of crutch walking, the nurse should teach the client to do what? 1 Double the intake of vitamin C. 2 Remove loose rugs from the environment. 3 Avoid taking showers until the cast is removed. 4 Increase weight bearing on the injured leg gradually.

Remove loose rugs from the environment.

Which intervention would be most beneficial in preventing a catheter-associated urinary tract infection in a postoperative client? 1 Pouring warm water over the perineum 2 Ensuring the patency of the catheter 3 Removing the catheter within 24 hours 4 Cleaning the catheter insertion site

Removing the catheter within 24 hours

A client's serum potassium level has increased to 5.8 mEq/L (5.8 mmol/L). What action should the nurse implement first? 1 Call the laboratory to repeat the test. 2 Take vital signs and notify the healthcare provider. 3 Inform the cardiac arrest team to place them on alert. 4 Take an electrocardiogram and have lidocaine available.

Take vital signs and notify the healthcare provider.

A nurse performs a Rinne test during physical assessment of a client. The client indicates that the sound is louder when the vibrating tuning fork is placed against the mastoid bone than when held closely to the ear. What conclusion should the nurse make about these results? 1 This represents an expected finding. 2 The client may have a sensorineural deficit. 3 This is evidence of a conductive hearing loss. 4 The client has an inflammation of the mastoid.

This is evidence of a conductive hearing loss.

While preparing the client for a diagnostic procedure, the nurse positions the client upright with elbows on an overbed table and the feet supported. The nurse also instructs the client not to talk or cough during the procedure. Which diagnostic test is the client undergoing? 1 Lung biopsy 2 Thoracentesis 3 Mediastinoscopy 4 Ventilation-perfusion scan

Thoracentesis