NCLEX prep - Passpoint

A client has impaired skin integrity related to compromised circulation. What should the nurse include in the teaching plan regarding nutritional considerations?

adequate intake of vitamins A and C, protein, and zinc -For clients with a risk for impaired skin integrity related to compromised circulation, good nutrition in the form of adequate intake of vitamins A and C, protein, and zinc is recommended. Only clients who are overweight or obese need a diet that helps with weight reduction. Research does not support that supplementation with vitamins and antioxidants prevents vascular disease. There is no need to eliminate carbohydrates and fats from someone's diet.

The health care provider (HCP) has prescribed a sterile urine specimen for a 3-year-old boy with a history of recurrent urinary tract infections. The family is upset because the last time the child was catheterized, the procedure was very painful and traumatic. What is the nurse's best response?

"I'll get a prescription for a numbing lubricant to make the procedure more comfortable." -

A client has a tumor of the posterior pituitary gland. The nurse planning the client's care would include which interventions? Select all that apply.

. Tumors of the posterior pituitary gland can lead to diabetes insipidus because of deficiency of vasopressin, also called antidiuretic hormone (ADH). Decreased ADH reduces the kidneys' ability to concentrate urine, resulting in excessive urination, thirst, and fluid intake. To monitor fluid balance, the nurse would weigh the client daily, measure urine specific gravity, and monitor intake and output. The nurse would also encourage fluids to keep intake equal to output and prevent dehydration. The posterior pituitary does not have food or caloric implications; thus, a calorie-restricted diet is not needed.

A client has been admitted with severe abdominal pain that has lasted for the past 4 hours. Place in chronological order the correct sequence for conducting an abdominal assessment. All options must be used.

Ask the client to urinate. Auscultate the client's abdomen. Percuss the client's abdomen. Perform light palpation.

A client is admitted to the hospital after sustaining a closed head injury in a skiing accident. The physician ordered neurologic assessments to be performed every 2 hours. The client's neurologic assessments have been unchanged since admission, and the client is complaining of a headache. Which intervention by the nurse is best?

Assess the client's neurologic status for subtle changes, administer acetaminophen, and then reassess the client in 30 minutes.

After cataract removal surgery, the nurse teaches the client about activities that can be done at home. Which activity would be contraindicated?

Bending over the sink to wash the face is contraindicated after cataract surgery because it increases intraocular pressure.

A client in the postoperative setting asks the nurse if he or she will have compression stockings like after the last surgery. What is the next action by the nurse?

Check the medical record for a provider's prescription for compression stockings. -The application of compression stockings for a client in the postoperative period requires a healthcare provider's prescription. The nurse should check the medical record for the given prescription before proceeding with the placement of the compression stockings. Placement of compression stockings may be delegated to unlicensed assistive personnel (NAP) after properly measuring the client for the appropriate size. It is important to measure the client for the appropriate size stocking before retrieving the compression stockings from the supply room.

The nurse who cared for a client in the home environment for several months learns that the client has died. What should the nurse do to support the family at this time?

It is appropriate for the nurse who took care of a client for a prolonged period to attend the funeral. It also is appropriate for the nurse to make a follow-up personal or phone call to the client's family after the funeral or memorial service to offer both concern and care for the family's well-being. Follow-up visits are important to give support to the family. Flowers may not be desired by the family. The nurse needs to do more than just remove the client's name from the care list.

To reduce the risk of dumping syndrome, what should the nurse teach the client to do?

Decrease the carbohydrate content of meals. -Carbohydrates are restricted, but protein, including meat and dairy products, is recommended because it is digested more slowly. Lying down for 30 minutes after a meal is encouraged to slow movement of the food bolus. Fluids are restricted to reduce the bulk of food. There is no need to avoid caffeine.

During a visit to the clinic, a pregnant 25-year-old woman who began prenatal care at 10 weeks' gestation and is now in her third trimester reports frequent constipation. Which suggestion by the nurse would be most helpful?

Eat at least four pieces of fruit daily. -Dietary measures such as increasing dietary intake of bulk and roughage (e.g., eating at least four pieces of fruit each day) help to relieve constipation and should be suggested initially. Other nonpharmacologic measures include drinking a glass of hot fluid in the morning, increasing fluid intake, and exercising regularly.

A client is brought to the emergency department with a painful swollen ankle. What is the nurse's most appropriate action?

Elevate the ankle. -Soft tissue injuries should be treated with rest, ice, compression, and elevation (RICE). Elevation of the ankle will decrease tissue swelling. Moving the ankle through the ROM will increase the risk of further injury. Morphine is not the drug of choice for pain due to inflammation.

A nurse is reviewing a client's fluid intake and output record. Fluid intake and urine output should relate in which way?

Fluid intake should be about equal to the urine output -Normally, fluid intake is about equal to the urine output. Any other relationship signals an abnormality. For example, fluid intake that is double the urine output indicates fluid retention; fluid intake that is half the urine output indicates dehydration. Normally, fluid intake isn't inversely proportional to the urine output.

The nurse is teaching a client with multiple sclerosis about prevention of urinary tract infection (UTI) and renal calculi. Which nutrition recommendations by the nurse would be the most likely to reduce the risk of these conditions?

Increase fluids (2500 mL/day) and maintain urine acidity by drinking cranberry juice.

A client in the second stage of labor who planned an unmedicated birth is in severe pain because the fetus is in the ROP position. The nurse should place the client in which position for pain relief?

Placing the client in the hands and knees position pulls the fetal head away from the sacral promontory (relieving pain) and facilitates rotation of the fetus to the anterior position. Lithotomy is the position preferred by some health care providers (HCP) for delivery but does not facilitate rotation. The right lateral position will perpetuate the ROP position. Tailor sitting facilitates descent in OA positions.

A week ago, a tornado destroyed the client's home and seriously injured her husband. The client has been walking around the hospital in a daze without any outward display of emotions. She tells the nurse that she feels like she is going crazy. Which intervention should the nurse use first?

Reassure the client that her feelings are typical reactions to serious trauma. -The nurse initially reassures the client that her feelings and behaviors are typical reactions to serious trauma to help decrease anxiety and maintain self-esteem. Explaining the effects of stress on the body may be helpful later. Telling the client that her symptoms are temporary is less helpful. Acknowledging the unfairness of the client's situation does not address the client's needs at this time.

The nurse is caring for a client during a prolonged hospital stay for congestive heart failure. The client has a prescription for thigh high antiembolism stockings. In regard to the antiembolism stockings, what is the priority action by the nurse?

Remeasure the client's legs routinely. Using the correct size of antiembolism stockings is critical to their effectiveness. If a stocking is not tight enough, it will not improve venous return effectively. If the stocking is too tight, it may impair circulation. In a client who has had a prolonged hospitalization for congestive heart failure, the potential for changes in leg circumference related to increases or decreases in the amount of lower extremity edema requires the legs be remeasured routinely to ensure the appropriate sized stocking.

The nurse is caring for a client with a nasogastric tube who is receiving intermittent tube feedings by gravity every 4 hours. The nurse aspirates 75 mL of residual prior to the next feeding. What action should the nurse take next?

Return the residual and begin the feeding -The amount of residual is within normal limits, and the client should have the feeding started. The residual should be returned to help prevent electrolyte imbalances. The other options do not ensure adequate nutritional management for the client.

A client develops chronic pancreatitis. What would be the appropriate home diet for a client with chronic pancreatitis?

a low-fat, bland diet distributed over five to six small meals daily -A low-fat, bland diet prevents stimulation of the pancreas while providing adequate nutrition.Dietary protein and fiber are not directly related to pancreatitis.Although calcium is important, the low-fat content is more significant.The hyperglycemia of acute pancreatitis is usually transient and does not require long-term dietary modification.

A client with Addison's disease has fluid and electrolyte loss due to inadequate fluid intake and to fluid loss secondary to inadequate adrenal hormone secretion. As the client's oral intake increases, which fluids would be most appropriate?

chicken broth and juice - Electrolyte imbalances associated with Addison's disease include hypoglycemia, hyponatremia, and hyperkalemia. Regular salted (not low salt) chicken or beef broth and fruit juices provide glucose and sodium to replenish these deficits. Diet soda does not contain sugar. Water could cause further sodium dilution. Coffee's diuretic effect would aggravate the fluid deficit. Milk contains potassium and sodium.

The nurse is preparing the client newly diagnosed with peripheral arterial disease for discharge with the medication atorvastatin. What laboratory work should the nurse obtain to establish a baseline before starting the medication?

creatinine level and liver function tests -Atorvastatin has serious adverse reactions of hepatotoxicity and acute renal failure, so it is recommended that creatinine level and liver function tests be performed at baseline as a monitoring parameter. Diabetes, upper respiratory infections, urinary tract infections, anemia, and thrombocytopenia can also be adverse reactions, but these are not included in recommendations for baseline safety monitoring.

The client attends two sessions with the dietitian to learn about diet modifications to minimize gastroesophageal reflux. The teaching would be considered successful if the client decreases the intake of which foods?

fats - Fats are associated with decreased esophageal sphincter tone, which increases reflux. Obesity contributes to the development of hiatal hernia, and a low-fat diet might also aid in weight loss

A depressed client in the psychiatric unit hasn't been getting adequate rest and sleep. To encourage restful sleep at night, the nurse should:

gently but firmly set limits on how much time the client spends in bed during the day -Setting limits on how much time the client may spend in bed and what time the client must get up in the morning lets the cleint know what is expected while conveying genuine concern. Talking with the client for a long time at night would interfere with sleep and give the client attention for not sleeping. Encouraging environmental stimulation in the evening would discourage rest and sleep at night. While most antianxiety agents have sedating adverse effects, they aren't intended for use as sleep-inducing agents.

A child with cystic fibrosis has been admitted to the pediatric unit. What type of diet should the nurse request for the client?

high-calorie, high-protein -A high-calorie, high-protein diet is necessary to ensure adequate growth. Some children require up to two times the recommended daily allowance of calories (increased calorie diet includes foods high in fat and balanced carbohydrates). Pancreatic enzyme activity is lost and malabsorption of fats, proteins, and carbohydrates occurs.

A client who has skeletal traction to stabilize a fractured femur has not had a bowel movement for 2 days. The nurse should:

increase the client's fluid intake to 3,000 mL/day.

After giving birth to an 8-lb (3.6-kg) girl, a client asks the nurse what her daughter should receive for the first feeding. For a bottle-fed neonate, the first feeding usually consists of

iron-fortified infant formula. -For a bottle-fed neonate, the first feeding usually consists of iron-fortified formula. It isn't necessary to start with sterile water or glucose water.

A client is in the eighth month of pregnancy. To enhance cardiac output and renal function, the nurse should advise the client to use which body position?

left lateral -The left lateral position shifts the enlarged uterus away from the vena cava and aorta, enhancing cardiac output, kidney perfusion, and kidney function. The right lateral and semi-Fowler positions don't alleviate pressure of the enlarged uterus on the vena cava. The supine position reduces sodium and water excretion because the enlarged uterus compresses the vena cava and aorta; this decreases cardiac output, leading to decreased renal blood flow, which in turn impairs kidney function.

A client is in the manic phase of bipolar disorder. To help the client maintain adequate nutrition, the nurse should plan to:

offer finger foods and sandwiches. -Finger foods and sandwiches help maintain adequate nutrition and provide calories for this client's high energy level. During the manic phase, the client can't sit still for large meals. Providing a stimulating mealtime environment is incorrect because a quiet mealtime environment is more beneficial than a stimulating one. Letting the client choose some favorite foods is inappropriate because the client has a short attention span and has trouble making choices.

A high-carbohydrate, low-protein diet is prescribed for the client with acute renal failure. What should the nurse tell the client to expect when following this diet?

prevent the development of ketosis. High-carbohydrate foods meet the body's caloric needs during acute renal failure. Protein is limited because its breakdown may result in accumulation of toxic waste products. The main goal of nutritional therapy in acute renal failure is to decrease protein catabolism. Protein catabolism causes increased levels of urea, phosphate, and potassium. Carbohydrates provide energy and decrease the need for protein breakdown. They do not have a diuretic effect. Some specific carbohydrates influence urine pH, but this is not the reason for encouraging a high-carbohydrate, low-protein diet. There is no need to reduce demands on the liver through dietary manipulation in acute renal failure.

Upon repositioning an immobile client, the nurse notes redness with blanching over a bony prominence. What is the most probable cause?

reactive hyperemia is likely transient.

A 9-month-old is admitted because of dehydration. How should the nurse go about accurately monitoring fluid intake and output? Select all that apply.

weighing and recording all wet diapers obtaining an accurate daily weight obtaining an accurate stool count -Accurate intake and output recording includes noting all intake, including IV fluids; noting output, such as emesis and stool; weighing diapers; measuring weight daily; measuring urine specific gravity; monitoring serum electrolytes; and monitoring for signs of dehydration. Children who are dehydrated must receive sufficient fluid intake, but having a breast-feeding child switch to bottle-feeding will not promote intake. Restricting fluids just prior to weighing the child will not alter the accuracy of the weight, and the nurse should continue to encourage fluids for this dehydrated child.

A client with a leg incision has a prescription for graduated compression stockings. The client rates the incision pain at 8/10. What is the best action by the nurse prior to applying the graduated compression stockings?

Premedicate the client with prescribed morphine 1 mg I.V. 15 minutes prior to application. -The application of graduated compression stockings will increase the incisional pain for this client, therefore the client should be premedicated with prescribed morphine 1 mg I.V. 15 minutes prior to application. Oral acetaminophen 500 mg will not likely provide effective pain relief 15 minutes prior to application of the graduated compression stockings. Although an ice pack may reduce pain, the prescribed morphine will be more effective for relieving pain rated 8/10. Placing a gauze pad to the incision prior to applying the graduated compression stockings may be necessary to absorb drainage, but will not provide pain relief during application.

A client who is 14 weeks pregnant mentions that she has been having difficulty moving her bowels since she became pregnant. Which hormones are responsible for this common discomfort during pregnancy? Select all that apply

progesterone -Progesterone increases smooth muscle relaxation, thereby decreasing peristalsis. This slowed movement of contents through the gastrointestinal system can lead to firmer stools and constipation. Estrogen, testosterone, human chorionic gonadotropin, and human chorionic somatomammotropin do not cause constipation.

A nurse is caring for an unconscious client recovering from a closed-head injury following placement of a percutaneous endoscopic gastrostomy (PEG) tube. Which action has the highest priority?

Elevate the head of the bed during and after the PEG tube feedings.

The nurse is performing effleurage for a primigravid client in early labor. Which technique should the nurse use?

light stroking of the skin surface -Light stroking of the skin, or effleurage, is commonly used with the Lamaze method of childbirth preparation. Light abdominal massage with just enough pressure to avoid tickling is thought to displace the pain sensation during a contraction. Deep kneading and secure grasping are typically associated with relaxation massages to relieve stress. Prolonged pressure on specific sites is associated with acupressure.

The nurse is reviewing the intraoperative record of a client. Which information would alert the nurse to the greatest possibility of a potential for skin breakdown?

length of surgery -The client length of time in surgery is the most important factor here since the procedure lasted over 9 hours with the client in the dorsal recumbent position. This position is standard for surgery and the length of time would have given the client pressure on bony prominences since there was not a position change. Having general anesthesia is a factor in other potential surgery complications, and there is no evidence that the transfer to stretcher involved any shearing or friction.