NCLEX Question of the Day

"There are poison crystals hidden in the shower head, they'll kill me if I take a shower.

Accepting these fears and allowing patient to take a sponge bath

A client with Rh isoimmunization gives birth to a neonate with an enlarged heart and severe, generalized edema. The neonate is immediately transferred to the neonatal intensive care unit. Which nursing diagnosis is most appropriate for the client?

Impaired parenting related to the neonate;s transfer to the ICU

A client with type 1 diabetes must undergo bowel resection in the morning. How should the nurse proceed while caring for him on the morning of surgery?

administer half the client's typical morning insulin dose as ordered/

When performing a physical assessment on an 18-month-old child, which of the following would be best?

have a parent hold the toddler

third degree laceration extends through..

into the anal sphincter

The comatose victim of the car accident is to have a gastric lavage. Which of the following positions would be most appropriate for the client during this procedure?

lateral

The neonate of a client with type 1 diabetes is at high risk for hypoglycemia. An initial sign the nurse should recognize as indicating hypoglycemia in a neonate is

lethargy

The nurse is assessing the development of a 7-month-old. The child should be able to:

sit without support

A nurse is caring for a client with lower back pain who is scheduled for myelography using metrizamide (a water-soluble contrast dye). After the test, the nurse should place the client in which position?

HOB 45 degrees

On initial assessment of a 7-year-old child with rheumatic fever, which of the following would require contacting the primary care provider immediately?

HR of 150/min

The nurse is assessing a client at her postpartum checkup 6 weeks after a vaginal delivery. The mother is bottle feeding her baby. Which client finding indicates a problem at this time?

a firm fundus at the symphysis

A nurse, a licensed practical nurse (LPN), and a nursing assistant are caring for a group of clients. The nurse asks the nursing assistant to check the pulse oximetry level of a client who underwent laminectomy. The nursing assistant reports that the pulse oximetry reading is 89%. The client Kardex contains an order for oxygen application at 2 L/min should the pulse oximetry level fall below 92%. The nurse is currently assessing a postoperative client who just returned from the postanesthesia care unit. How should the nurse proceed?

c) Ask the LPN to obtain vital signs and administer oxygen at 2 L/min to the client who underwent laminectomy.

Family members of a client with bipolar disorder tell a nurse that they are concerned that the client is becoming manic. The nurse knows that the manic phase is marked by:

flight of ideas and inflated self-esteem

A client with pneumonia has a temperature of 102.6° F (39.2° C), is diaphoretic, and has a productive cough. The nurse should include which of the following measures in the plan of care?

frequent linen changes

Total parenteral nutrition (TPN) is prescribed for a client who has recently had a significant small and large bowel resection and is currently not taking anything by mouth. The nurse should

handle TPN using aseptic technique