NCLEX review 6

The nurse has instructed a client with type 1 diabetes mellitus about proper exercise. Which of the following client statements indicates a correct understanding of the teaching?

"I can initially expect my glucose level to rise with vigorous exercise" Explain: For the client with type 1 diabetes mellitus, glucose levels will initially rise with exercise. The epinephrine released from the adrenal gland will cause the liver to discharge more glucose into the body. Prolonged exercise is likely to cause hypoglycemia because of the uptake of glucose from the muscles.

You are reinforcing counseling for two parents that are preparing for the birth of their first child. The mother has sickle cell anemia. So the father has decided to undergo genetic testing to determine if he is a carrier or not. He finds out that he is not a carrier. You tell them that their bay has what chance of having sickle cell anemia?

0% Explain: he baby has no chance, a 0% chance of having sickle cell anemia. Instead, the baby will be a carrier. Since the baby's mother has the disease, she is ss, and because the father has tested that he is not a carrier nor does he have the disease, he is SS. This means that the only combination possible for the baby is Ss (carrier).

The nurse notes that her patient arriving from the emergency department has increased intracranial pressure and is planning to adjust the bed to accommodate them. At what angle should the nurse elevate the head of the bed?

30-40 degrees Explain: A patient with increased intracranial pressure should have the head of the bed elevated at 30 or 40 degrees. Nurses should also be sure to avoid Trendelenburg and prevent the patient's neck from flexing. A standard ICP is about 5 to 15 mmHg.

Which of the following meals would you offer your client who practices Orthodox Judaism?

A cottage cheese salad with fresh fruit Explain: As outlined in the Torah, clients who practice Orthodox Judaism typically consume a kosher diet. Although a few dietary laws are associated with Orthodox Judaism (and discussed below), one of the key aspects required when following a kosher diet is avoiding consuming meat and dairy products in the same meal. Here, offering your client a cottage cheese salad with fresh fruit is acceptable, as the meal does not violate any kosher dietary laws.

Tourette's syndrome

A neurological disorder characterized by involuntary tics and vocalizations. It is often best known for the compulsive utterance of obscenities that sometimes occurs. Tourette's syndrome is not characterized by trouble reading and interpreting words, letters, or symbols

When the nurse notes an irregular radial pulse in a client, further evaluation should include assessing for which of the following?

A pulse deficit Explain: Assessing for a pulse deficit provides an indirect evaluation of the heart's ability to eject enough blood to produce a peripheral pulse. When a pulse deficit is present, the radial pulse is less than the apical pulse.

The nurse caring for a client with lung cancer who is scheduled for a wedge resection the following day. What part of the lung will be removed?

A small, localized slice near the superficial surface of the lung Explain: A small, localized portion of the lung will be removed during a wedge resection. This section is generally near the surface of the lung. Wedge resection is usually performed to remove a suspicious pulmonary module or a cancerous lung lesion. In addition to the suspected area, a small portion of healthy tissue is removed to ensure the lesion is completely removed with negative margins.

When caring for a client new to the general practice clinic, the nurse notes that the woman is "nulliparous." The nurse knows that the term "nullipara" describes:

A woman who has never given birth to a child

The charge nurse is planning patient care assignments for a licensed practical/vocational nurse (LPN/VN). Which of the following would be an appropriate patient assignment for the LPN?

A. A 75-year-old inpatient client with colon cancer needling colostomy care B. A 50-year-old client being treated for herpes zoster with prescribed oral antivirals 1. Administer oral and parenteral medications. The LPN may not administer IV medications in some states. In the NCLEX exam, a student is better off not choosing that option. 2. LPNs may reinforce patient teaching/education that was initially addressed by an RN. 3. LPNs may perform focused assessments but only after the RN's initial estimate. The performance of the first assessment is outside the scope of the LPN. 4. LPNs may attend routine procedures like bladder-catheterization, address tube feeding, and ostomy care.

Fear and anxiety are quite similar. However, there are differences. Select the statements below that are accurate in terms of differentiating fear from anxiety.

A. Anxiety is secondary to a psychological stressor, whereas fear is secondary to a physical or psychological stressor B. Fear is secondary to an identifiable source, whereas anxiety is secondary to an unidentifiable source C. Anxiety is diffuse and vague, whereas fear is more specific and definable

The nurse is caring for a client who presents with a blood glucose level of 45 mg/dL. Which of the following findings are expected?

A. Blurred vision B. Cool and clammy skin C. Palpitations D. Paresthesias

The nurse is conducting a health screening at a local health fair. Which of the following should the nurse recognize as a risk factor for developing testicular cancer? Select all that apply.

A. Cryptorchidism B. Human immunodeficiency virus (HIV) C. Family history

The nurse is caring for a client with newly prescribed amphotericin b for a systemic fungal infection. The nurse should anticipate a prescription for which medication before the infusion? Select all that apply.

A. Diphenhydramine B. Acetaminophen C. 0.9% saline bolus Explain: Amphotericin B is a potent antifungal medication. The infusion can make the client feel quite ill, and preventative treatments such as acetaminophen, 0.9% saline bolus, and diphenhydramine are often used. Symptoms the client experiences during the infusion include nausea, rigors, fever, and chills. Thus, premedication is necessary. Amphotericin B is nephrotoxic, and the client should increase their fluid intake.

The nurse is caring for a client receiving lorazepam. Which of the following reported herbal supplements would require follow-up?

A. Kava B. Valerian Explain: Lorazepam is a CNS depressant, and the client should avoid potentiating the effects of this medication. Herbal products such as kava and valerian are CNS depressant medications that should not be given concurrently while a client is receiving lorazepam. Lorazepam and one of these medications may cause profound sedation.

You are taking care of a 5-year old that presents with impetigo. Which of the following symptoms would be expected for this disease?

A. Lesions B. Burning C. Pruritus

The nurse is caring for a client who is receiving prescribed fentanyl. Which of the following findings would indicate the client is having a side effect? Select all that apply.

A. Nausea and vomiting B. Constipation C. Pruritus D. Urinary retention

The nurse is teaching a group of students on incident reports. Which of the following situations would require an incident report? Select all that apply. A visitor

A. Refusing to wear PPE B. Activating a client's patient-controlled analgesia (PCA) device C. Stating that they fell while using the bathroom

The nurse discusses the signs and symptoms of child abuse at an interprofessional conference. It would be correct for the nurse to identify which manifestations are associated with physical abuse? Select all that apply

A. Spiral fractures without any sports injury B. Scalded burns on legs C. Bruises without plausible explanation Explain: These manifestations are consistent with physical abuse. Physical abuse is when an individual deliberately causes a child pain and/or injury. The degree of physical abuse can be minor to severe. Scalded burn injuries, bruising without a plausible explanation, and spiral fractures without sports injuries are consistent with physical abuse.

The nurse is planning care for a client with a borderline personality disorder. The nurse recognizes that the client will likely demonstrate which defense mechanism? Select all that apply.

A. Splitting B. Projection

The nurse is caring for a client who is recovering from surgery. Which assessment data would suggest that the client's pain is not well controlled? Select all that apply.

A. Tachypnea B. Nausea C. Mydriasis D. Increased blood glucose

When caring for an Amish patient, what does the nurse know to be true?

A. They use traditional and alternative health care B. Funerals are conducted in the home C. Many choose to live without health insurance D. Health is believed to be a gift from God

The NICU nurse is caring for an infant with heart failure and watching for interventions that necessitate administering oxygen. Of the following procedures, which will the nurse most likely need oxygen to be available?

Administering vaccinations Explain: The nurse would be most accurate if they applied oxygen to the infant receiving vaccinations. Since injections are often painful, most babies cry while receiving them. Crying uses much of an infant's energy, increasing its demand for oxygen.

When epinephrine is administered to a client, the nurse should expect this agent to rapidly affect:

Adrenergic receptors

The nurse is caring for a client receiving a continuous infusion of norepinephrine. The nurse should plan to monitor which of the following for the client?

Advocate for pain management even if the life-threatening side effects hasten death

The patient recovering from cardiac surgery is wondering when he can resume sexual activity. The nurse would be most correct in stating that sexual intercourse may be returned at which point in time?

After exercise tolerance is assessed Explain: Patients who have undergone cardiac surgery should have their exercise tolerance evaluated by a physician before resuming sexual activity. Many physicians agree that a patient may return to sexual activity if they can climb two flights of stairs without symptoms.

A woman was admitted to the obstetric unit in active labor and has had a frank rupture of membranes. A fetal scalp electrode and intrauterine pressure catheter were inserted promptly. The woman had progressed to 8-cm dilation when the nurse noticed abrupt decreases in the fetal heart rate of 15-20 bpm that quickly returned to baseline. The changes in fetal heart rate occurred with and without contractions. At this point, the nurse should prepare to initiate a client teaching about the possibility of which procedure?

Amnioinfusion Explain: The fetus is experiencing variable decelerations of heart rate in the setting of ruptured membranes. Amnioinfusion refers to the infusion of a warmed isotonic solution into the uterine cavity through the IUPC. It is mostly used as a treatment to correct fetal heart rate changes caused by umbilical cord compression, indicated by variable decelerations seen on cardiotocography. It can help cushion the cord and relieve pressure when the membranes have ruptured.

The occupational health nurse administers a Mantoux intradermal skin test. Which teaching is correct regarding the results of this test?

A 3mm induration after 48 hours indicates a negative result Explain: A 3mm induration after 48 hours would be recorded as a negative result. In clients with no risk factors for tuberculosis (TB), an induration of 15mm or more is considered positive. In healthcare workers, an induration measuring ≥10 mm after 48-72 hours is a positive reaction. In immunocompromised clients (HIV patients and organ transplant patients) and the recent contacts of confirmed TB patients, an induration of 5 mm or more is considered positive.

The nurse reviews a client's laboratory results and notes that their potassium level is 5.6 mEq/L. Which change to the cardiac rhythm would be expected?

A narrow and peaked T waves Explain: A potassium level over 5.0 mEq/L indicates hyperkalemia and is known for causing alterations to the cardiac rhythm. Tall peaked T waves with a shortened QT interval are usually the first findings. ECG changes do not always correlate with the severity of the potassium alterations.

The emergency department (ED) triage nurse is assigned to see the following clients. Which of the following clients requires the most rapid action in the ED?

A pregnant woman with a blister-like rash on the face who possibly has varicella Explain: Chickenpox (Varicella) is transmitted airborne and can be easily transferred to other clients in the emergency unit. The pregnant woman with suspected Varicella rash (Choice C) should be isolated right away from other clients through placement in a negative-pressure room.

The nurse is caring for a client receiving a continuous infusion of norepinephrine. The nurse should plan to monitor which of the following for the client?

A. Blood pressure B. Intravenous site C. Urine output D. Blood glucose

The definition of a "nonverbal" client in the context of pain assessment can include the clients:

Absence of consciousness

A client is scheduled to undergo electroconvulsive therapy (ECT). The nurse understands, which action needs to be performed prior to the ECT?

Apply a blood pressure cuff to the client's arm

The nurse is discussing the risk of wound disruption following surgery with another healthcare team member. It would be correct for the nurse to identify which condition is a potential cause of this complication?

Cushing's syndrome Explain: Excessive corticosteroids characterize Cushing's syndrome. Exposure to the corticosteroid suppresses the production of white blood cells, which inhibits them from migrating to the wound bed. Cushing's also is characterized by high blood glucose levels, which delay healing. An example of a wound disruption would be dehiscence.

The nurse is working the night shift in the ER when a patient is suddenly rushed in with burns on his legs and torso. The nurse notices that the wounds appear moist and pale white with a sluggish capillary refill. The nurse can classify the injury as which of the following?

Deep partial Explain: wounds that appear moist and pale white with sluggish capillary refill are classified as deep-partial

A patient in the prenatal clinic has stated her intention to choose formula feeding for her infant. Identify which action by the nurse is most appropriate in being a patient advocate.

Determine the patient's knowledge base related to infant feeding options Explain: A central concept of patient advocacy is ensuring that the patient's decisions are based on sufficient information and understanding while supporting the patient's right to exercise autonomy.

The nurse is working with a child who has a learning disability. The child is ten years old and has trouble reading and interpreting words, letters, and symbols. What is the most likely diagnosis?

Dyslexia Explain: Dyslexia is defined as a disorder that involves trouble reading and interpreting words, letters, and symbols. It does not affect general intelligence, but children may need special assistance at school when learning to read. They may not understand at their appropriate grade level, depending on the severity of the disorder.

Crisis helplines are highly important due to which of the following?

Often saves lives when a person is in a severe crisis

Which of the following best describes an appropriate outcome for a 75-yr-old patient with a history of Huntington's disease, which has developed contractures?

The patient will participate in range of motion exercises to reduce the effects of contractures

The nurse is triaging clients in the emergency department (ED). Which client should the nurse triage as emergent? A client

With sudden onset of ataxia and dysarthria Explain: Sudden onset of dysarthria and ataxia concerns for stroke. These manifestations require emergent prioritization because treatment is necessary to prevent further tissue damage.

While reviewing medication-related hematological side effects, the nurse recognizes which of the following as the most severe form of bone marrow toxicity:

Aplastic anemia Explain: Aplastic anemia leads to pancytopenia, a severe decrease in all hematological cell types: red blood cells, white blood cells, and platelets. Aplastic anemia may be caused by primary bone marrow failure or from secondary causes such as medications. Some medications that cause aplastic anemia include chloramphenicol, phenylbutazone, sulfonamides, anticonvulsants, cimetidine, and NSAIDs. Drug-induced aplastic anemia is the result of an idiosyncratic hypersensitivity reaction and is often reversible. In such drug-related aplastic anemias, the nurse must notify the physician and withdraw the offending agent.

The nurse is taking care of a client with a chest tube due to a flail chest. After 3 days, the water seal compartment is no longer tidaling. What is the most appropriate action of the nurse?

Auscultate the client's back for breath sounds Explain: The nurse should check the client's lungs for re-expansion once the water-seal drainage has stopped tidaling. Tidaling refers to fluctuations in the water-seal chamber with respiration. With the chest tube in pleural space, the water level in the chamber fluctuates - water level rises during spontaneous inspiration and falls during expiration. Absence of tidaling indicates: A potential kink or occlusion in the tubing Re-expansion of the client's lung.

A 24-year old woman presents to the emergency department and appears as shown in the exhibit. What type of injury does this assessment finding suggest? See the exhibit.

Basilar skull fracture Explain: Assessment symptom called Raccoon's eyes (retroorbital ecchymosis). Pooling of blood surrounding the eyes is most often associated with fractures of the anterior cranial fossa or basilar skull fracture. This assessment finding may be delayed by 1 to 3 days following the initial injury. If bilateral, this sign is highly suggestive of a basilar skull fracture. Other signs of basilar skull fractures include hemotympanum (pooling of blood behind the tympanic membrane) and Battle sign (retro auricular or mastoid ecchymosis)

The nurse is developing a care plan for a toddler who has autism. What information regarding the child is most important to obtain from the parents?

Bedtime routine

The nurse is assessing a client with Paget's disease. Which of the following would be an expected finding?

Bone deformities Explain: Paget's disease is caused by a bone becoming weakened and remodeled, which may result in deformities. The most common area affected by this inappropriate bone remodeling is the skull, pelvis, and spine.

An elderly client has just finished a total knee replacement surgery. The nurse suspects fluid overload in the client. Which of the following signs and symptoms would confirm the nurse's suspicion?

Cool, clammy skin; bounding pulse; cough Explain: Cool and clammy skin, bounding pulses, productive cough, distended neck veins, edema, and polyuria are signs of fluid overload.

The nurse is preparing a client for a bronchoscopy the following day. All of the following are appropriate interventions, except:

Educate the client that he will be able to eat immediately after the procedure is completed Explain: Following the procedure, the client will be kept NPO (nothing by mouth) until the client's cough and gag reflex return. Upon the return of those protective reflexes, the client will be provided ice chips and small sips of water before slowly progressing into a regular diet to minimize the risk of aspiration.

The RN is caring for a patient with suspected meningitis. Which action would the nurse recognize as the highest priority immediately following a lumbar puncture procedure?

Encourage oral fluid intake Explain: A lumbar puncture (or spinal tap) procedure is used to obtain cerebrospinal fluid (CSF) to diagnose meningitis and identify the cause. The nurse would encourage oral fluid intake following this procedure to replace CSF volume and reduce the risk of spinal headaches.

The nurse is caring for a patient who has just returned from an intravenous urography procedure. Which of the following nursing interventions is most important at this time?

Encourage the patient to drink at least 1L of fluid Explain: The dye used during intravenous urography is sometimes nephrotoxic. Thus patients should be encouraged to increase fluids unless contraindicated.

Which action taken by the school nurse will have the most impact on the incidence of infectious disease in the school?

Ensure that students are immunized according to national guidelines

The nurse is triaging phone calls at a local obstetrics clinic. Which client situation requires immediate follow-up? A client reporting

Epigastric pain and a frontal headache not relieved with acetaminophen Explain: These symptoms are strongly suggestive of severe pre-eclampsia. Severe pre-eclampsia manifests as epigastric to right-upper quadrant pain suggestive of a liver injury. This, combined with a frontal headache, is highly concerning for severe pre-eclampsia. The client needs to be immediately evaluated as these symptoms may worsen to an eclamptic seizure.

The nurse in the ICU is using the Critical-Care Pain Observation Tool (CPOT) to evaluate the patient's pain. The patient was in a motor vehicle accident two days ago; he sustained a flail chest and fractured femur. He is intubated and on a mechanical ventilator. When using the CPOT, the nurse understands that the best indicator of the patient's pain is:

Facial expression

What statement about contractures secondary to immobility is accurate?

Flexion contractures are the most commonly occurring contracture

The nurse is assessing a client with ulcerative colitis. Which of the following would be an expected finding?

Frequent blood stools Explain: Ulcerative colitis has clinical features such as frequent bloody stools, iron deficiency anemia, colicky abdominal pain, fever, fatigue, and weight loss.

The emergency department (ED) nurse cares for a client receiving prescribed warfarin and reports dizziness, black tarry stools, and bloody gums. The international normalized ratio (INR) returns at 5. The nurse anticipates the primary healthcare provider (PHCP) will prescribe which blood product?

Fresh frozen plasma (FFP) Explain: FFP would be prescribed because this client is experiencing bleeding related to the prescribed warfarin. The client's INR is grossly elevated (therapeutic for VTE prophylaxis is 2-3), and FFP includes the Vitamin K-dependent clotting factors (factors II, VII, IX, X, proteins C, and S) that need to be replaced to stop the bleeding. Vitamin K may be prescribed, but the efficacy takes six to eight hours. FFP can treat the bleeding almost immediately.

The nurse is assessing a client with carbon monoxide (CO) poisoning. Which of the following would be an expected finding?

Headache Explain: CO poisoning is odorless, colorless, and tasteless. This potentially lethal poison initially causes clients to develop symptoms such as headache, reduced visual acuity, and slight breathlessness. As the CO level increases, it causes hypotension, confusion, and vertigo and then progresses to death.

The nurse is caring for a client who recently had a dosage increase of prescribed levothyroxine. Which of the following is a priority?

Heart rate Explain: For a client who has a dosage increase of levothyroxine, the nurse should assess the client for hyperthyroidism. Signs and symptoms of hyperthyroidism would include tachycardia, weight loss, increased temperature, and increased motor activity. It is a priority to assess the client's heart rate because tachydysrhythmias may occur.

The nurse is assessing a client's cardiac rhythm strip and notices U-waves. Which laboratory value alteration may cause this finding?

Hypokalemia Explain: U waves on the ECG are associated with hypokalemia. Other ECG manifestations include large, flat T waves, ST depression, or prolonged QT intervals.

The right brake on your client's wheelchair is not holding as strong as the left brake. What is your priority action?

Immediately remove the wheelchair from use

The nurse is caring for a client with a tracheostomy. Which of the following items is essential to have at the bedside?

Inner cannula Explain: An inner cannula of the tracheostomy size and one smaller must be kept at the bedside. This is essential in case the inner cannula becomes dislodged.

Phonologic processing deficit

It is a specific deficit where the child has difficulty discriminating and processing different speech sounds

The nurse is teaching a client about peptic ulcer disease. Which of the following statements should the nurse include?

It will be important to reduce the stress in your life

A client who is 28 weeks pregnant is admitted to the gynecology ward for labor induction due to fetal demise. Which of the following substances will be used for the effacement of the client's cervix?

Laminaria Explain: Laminaria is a cone-shaped substance made from sterile, dried seaweed. For second-trimester abortions, cervical dilation with the removal of the fetus and placenta is generally performed. To begin this process, dilation is initiated with the insertion of laminaria into the cervix 12 to 24 hours before the procedure into the cervical canal to absorb the cervical secretion. Additionally, laminaria expands and aids in the effacement and dilatation of the cervix.

The nurse is caring for a patient with post-gastrectomy dumping syndrome. What teaching should the nurse provide for this patient?

Meals should consist of dry foods with low carbohydrates, moderate fat, and protein content Explain: The patient should be instructed to eat small portions of dry foods to aid digestion. A low carbohydrate, moderate fat, and moderate protein content will promote tissue healing and help to meet the body's increased energy demands.

The nurse is performing a health assessment on a newborn. Which assessment finding would lead the nurse to suspect cystic fibrosis?

Meconium ileus Explain: Meconium Ileus is frequently the first sign of cystic fibrosis in a newborn. Meconium ileus is a small bowel obstruction that occurs when the infant's first stool is thicker and stickier than usual, causing a blockage in the ileum. Often, it presents within a few hours of birth with bilious vomiting as soon as feedings are initiated. Abdominal distension may be present. Some infants may manifest with just delayed passage of meconium rather than acute symptoms of obstruction. Meconium peritonitis may occur if there is perforation and may manifest with abdominal tenderness, fever, and shock.

The nurse educator is talking to a group of RNs regarding the chemical mediators involved in allergic reactions. The nurse tells the RNs that in an allergic reaction, the chemical mediator, histamine, is responsible for the following manifestations, except:

Mucus plugging Explain: Mucus plugging is caused by slowed smooth muscle contraction brought about by bradykinin, not histamine.

The nurse is caring for a client with a potassium of 3.1 mEq/L. The primary healthcare provider (PHCP) prescribed 40 mEq of intravenous (IV) potassium over four hours. Which assessment finding would indicate a therapeutic effect?

Normoactive bowel sounds Explain: Hypokalemia (potassium less than 3.5 mEq/l) produces manifestations such as hypoactive bowel sounds, muscle cramping, weakness, and electrocardiogram changes such as flattened T-waves. Bowel sounds that are normoactive indicate a therapeutic finding because of the restoration peristalsis.

While auscultating a client's bowel sounds, the nurse notes a swooshing sound to the left of the umbilical area. What would be the nurse's priority action?

Notify the primary healthcare provided (PHCP) Explain: Upon auscultation, the nurse should suspect this client is presenting with an abdominal aortic aneurysm (AAA) due to the bruit or swooshing sound. The nurse should immediately notify the patient's healthcare provider of this urgent situation. An AAA Rupture can occur spontaneously or with trauma. If the aneurysm bursts, it may cause life-threatening bleeding. The aneurysm should be assessed immediately to determine the need for surgical intervention.

The nurse cares for a client receiving positive end-expiratory pressure (PEEP) while being mechanically ventilated. The nurse understands that this setting is used to

Prevent closure of the small airways during expiration Explain: Positive end-expiratory pressure (PEEP) is used in clients with acute respiratory distress syndrome (ARDS) because it improves lung compliance and oxygenation. This is accomplished by adding pressure at exhalation to keep the alveoli open. PEEP is a setting that may be added to a variety of ventilator modes.

Your pregnant client has been hospitalized with hyperemesis gravidarum. She is given ondansetron to treat this illness. What serious side effects should the hospital nurses be watching for?

Prolonged QT interval Explain: Prolonged QT intervals have been noted as a severe side effect of ondansetron. This medication is used to treat hyperemesis gravidarum when the patient is losing weight and or unable to cope with pregnancy-related nausea.

The intensive care nurse (ICU) cares for a group of assigned clients. The nurse should initially follow-up with the client who is

Receiving intravenous (IV) dopamine via a peripheral vascular access device and reports pain at the site Explain: Dopamine is a vasopressor and is indicated in the treatment of shock. Dopamine is a vesicant, and a major adverse effect of dopamine is that it can extravasate and cause serious tissue damage. Hence, this medication is recommended to be infused through a central line to prevent this adverse complication. The nurse should immediately attend to this client and stop the infusion. If extravasation is suspected, the nurse should stop the infusion and aspirate any remaining IV fluid from the catheter.

The nurse is preparing to teach a client who was recently diagnosed with Meniere's disease. To help the client reduce the incidence of attacks, the nurse should recommend that the client do which of the following?

Reduce dietary sodium intake Explain: Reducing dietary sodium intake is key to reducing attacks associated with Meniere's disease. By reducing sodium, the client will reduce endolymphatic fluid, reducing the incidence of attacks.

Which of the following labs for a client with acute renal failure should be reported immediately?

Serum potassium 6mEq/L

The nurse is caring for a client with a hyphema. The nurse should plan to take which action?

Shield the affected eye Explain: The initial nursing priorities for a hyphema are shielding the affected eye and raising the head-of-the bed to 30 degrees.

The nurse is caring for a client with angle-closure glaucoma. It would be correct to place the client in which position?

Supine Explain: Placing the client supine, who has angle-closure glaucoma, is effective as it will assist in the lens falling away from the iris, decreasing the pupillary block.

The nurse reviews the vital signs of a client admitted to the medical-surgical unit. The unlicensed assistive personnel (UAP) indicates that the client's blood pressure was obtained in the client's leg. The nurse should expect which change in the blood pressure when taken in the leg?

Systolic pressure in the legs is usually higher by 10 to 40 mm Hg Explain: When blood pressure is obtained in the leg, the systolic blood pressure is increased by up to 10 to 40 mm Hg compared to blood pressure obtained over the brachial artery. The higher SBP is due to the calcification in the distal arteries, which raises the SBP. DBP in the lower extremities is usually the same when compared to the upper extremities.

Cool and clammy skin, bounding pulses, productive cough, distended neck veins, edema, and polyuria are signs of fluid overload.

Talk to the child about the procedure Explain: The nurse must always explain the procedure to the child in words that he/she can understand.

The nurse is caring for a client interested in pre-exposure prophylaxis for human immunodeficiency virus (HIV). Which prescription would the nurse anticipate?

Tenofovir- emtricitabine Explain: Tenofovir-emtricitabine is a medication used as pre-exposure prophylaxis (PrEP) for clients at high risk for HIV infection. This medication is taken daily and may provide up to 96% efficacy against HIV infections.

Which of the following statements should the nurse use to best describe a very low-calorie diet?

This diet can be used only when there is close medical supervision Explain: Very Low-Calorie Diets (VLCDs) are used in the clinical treatment of obesity under close medical supervision. The diet is low in calories, high in quality proteins, and has a minimum of carbohydrates to spare protein and prevent ketosis.

Beta transferrin

To confirm that the fluid is indeed CSF

Following a diagnosis of cystitis, a client was instructed to drink cranberry juice. Changes in which of the following assessment parameters would indicate to the nurse that this recommendation has been effective?

Urine pH Explain: the client is being instructed to consume cranberry juice to alter the pH of the urine as part of the acid-ash diet. The acid-ash diet is based on the concept that by altering the composition of one's diet, one can change the pH of their urine. Here, the goal is to make the client's urine more acidic, which may help reduce some symptoms of cystitis that the client is experiencing. Therefore, the nurse would utilize the client's urine pH as an assessment parameter to indicate whether this recommendation has been effective.

The nurse is caring for a client who has newly prescribed fondaparinux. The nurse understands that this medication is intended to treat which condition?

Venous thromboembolism Explain: Fondaparinux is a selective inhibitor of factor Xa, which is indicated for prophylaxis or treatment of DVT or PE.

The nurse has instructed a client newly diagnosed with the human immunodeficiency virus (HIV). Which of the following statements by the client would indicate effective understanding? This disease is caused by a retrovirus leading to

Viral integration into the CD4+ T-cells

The nurse is caring for a client who is receiving clozapine. Which of the following findings would warrant immediate follow-up?

WBC 3,000 mm3

The hospital's disaster plan is initiated due to a nearby factory fire. One of the victims is responsive but unable to walk, with a respiratory rate of 28 and capillary refill <2 seconds. What color tag would the ED triage nurse assign to this patient?

Yellow Explain: A yellow triage tag indicates the victim has injuries that are not immediately life-threatening and can wait up to an hour before receiving treatment. This patient is responsive, with adequate respiratory function (respirations below 30/minute) and perfusion intact (capillary refill under 2 seconds). This patient could wait until the most severe injuries are treated before receiving treatment.

The nurse is teaching a client who is scheduled for a percutaneous kidney biopsy. Which of the following information should the nurse include?

You will need to lay flat immediately after this procedure Explain: A percutaneous kidney biopsy will be required to lay supine immediately following the procedure to achieve and maintain hemostasis

Apraxia

defined as the inability to perform particular purposive actions, as a result of brain damage. It is not a learning disability and is not characterized by trouble reading and interpreting words, letters, or symbols

For the client with type 1 diabetes mellitus, glucose levels will initially rise with exercise. The epinephrine released from the adrenal gland will cause the liver to discharge more glucose into the body. Prolonged exercise is likely to cause hypoglycemia because of the uptake of glucose from the muscles.

question the resident physician's order Explain: Oxybutynin is cautioned/contraindicated in clients with glaucoma as it blocks the parasympathetic nervous system and increases the risk of increased intraocular pressure.

The nurse is preparing a client for a breast exam. The nurse should position the client

supine, with the arm on the side examined behind the head and a small pillow under the shoulder

The nurse has administered prescribed five units of regular insulin and ten units of NPH insulin. The nurse anticipates that the soonest this insulin will peak will be within

two to four hours Explain: This client was administered regular insulin that peaks within two to four hours. Additionally, this client received NPH insulin which peaks within four to twelve hours. It would be appropriate for the nurse to assess the client for hypoglycemia when the regular insulin peaks as it peaks sooner.