NCLEX REVIEW

The nurse is preparing to irrigate a client's sigmoid colostomy. The nurse would plan for which intervention to perform this procedure?

Instilling 500 to 1000 mL of lukewarm tap water through the stoma

The nurse is reinforcing teaching to a pregnant woman about the physiological effects and hormonal changes that occur during pregnancy. The woman asks the nurse about the purpose of estrogen. The nurse bases the response on which purpose of estrogen?

It stimulates uterine development to provide an environment for the fetus and stimulates the breasts to prepare for lactation.

The nurse is assisting in caring for a client who has sustained a nasal fracture. The nurse monitors for which priority finding specifically related to this injury?

Leakage of clear fluid from the nose

The nurse is assisting in caring for a client who suffered blows to the face with a baseball bat and a gunshot wound to the abdomen. The nurse is reviewing the prescriptions in the client's medical record and determines there is a need for follow-up with the primary health care provider if which prescription is noted?

Nasogastric tube insertion

An older client with ischemic heart disease has experienced an episode of dizziness and shortness of breath. The nurse reviews the plan of care and notices documentation of decreased cardiac output, dyspnea, and syncopal episodes. The nurse plans to take which important action?

Place the client on a cardiac monitor.

The nurse reviews the client's serum calcium level and notes that the level is 8.0 mg/dL (2.0 mmol/L). The nurse understands that which condition would cause this serum calcium level?

Prolonged bed rest

The nurse is caring for a hospitalized child with a history of seizures who is receiving oral phenytoin sodium. Which would be included in the plan of care for this child?

Providing oral hygiene, especially care of the gums

The nurse arrives at work and is told to report (float) to the pediatric unit for the day because the unit is understaffed and needs additional nurses to care for the clients. The nurse has never worked in the pediatric unit. Which is the appropriate nursing action?

Report to the pediatric unit and identify tasks that can be safely performed.

The nurse reinforces instructions to a client regarding the use of tretinoin. Which statement by the client indicates the need for further teaching?

"I should apply a very thin layer to my skin."

The nurse is collecting data on a client suspected of having Alzheimer's disease. The priority data would focus on which characteristics of this disease? Select all that apply.

1) Difficulty learning 2)Recent memory loss

The nurse is caring for a client following an abdominal surgery performed 1 day ago. An intravenous (IV) line is infusing, and a nasogastric (NG) tube is in place and attached to low intermittent suction. The nurse monitors the client and notes that the bowel sounds are absent. The nurse would perform which actions? Select all that apply.

1)Ask the client whether he has passed any flatus. 2) Document the finding and continue to check for bowel sounds.

An acutely ill-looking client arrives at the emergency department. The client complains of "the worst pain I ever felt in my belly. I can't get comfortable." The client is quiet but with each movement the client cries out in pain. The nurse suspects the client has peritonitis. Which data would the nurse collect to assist in validating this suspicion? Select all that apply.

1)Inspect the abdomen for rigidity. 2)Check for the presence of hiccups. 3)Inspect the client's mucous membranes.

The nurse is reinforcing instructions about psoriasis to a client with a high risk of the disorder. The nurse explains to the client the plaques of psoriasis most often appear in which areas? Select all that apply.

1)Knees 2)Elbows 3)Base of the spine

The nurse is assigned to care for a client experiencing episodes of postural hypotension who will be discharged home soon. Which actions would the nurse take to ensure safety while transferring the client from the bed to the chair? Select all that apply.

1)Put the client's shoes on to help the client avoid slipping on the floor during the transfer. 2)Allow the client to dangle the legs in a sitting position on the bed before transfer to a chair. 3)Question the client about feelings of dizziness.

The nurse is reading the primary health care provider's (PHCP) documentation regarding a pregnant client and notes that the PHCP has documented that the client has a platypelloid pelvic shape. The nurse recognizes which characteristics to be present in the platypelloid pelvis? Select all that apply.

1)Shallow depth 2)Wide suprapubic arch 3)Compatible with vaginal delivery 4)Flattened anteroposteriorly and wide transversely

The nurse in the newborn nursery is assisting in monitoring a preterm newborn for respiratory distress syndrome (RDS). Which findings, if noted in the newborn, would alert the nurse to the possibility of this syndrome? Select all that apply.

1)Tachypnea 2)Retractions 3)Nasal flaring

peritoneal dialysis for the treatment of chronic kidney disease would be contraindicated for which client?

The client with chronic obstructive pulmonary disease (COPD)

An 84-year-old client in an acute state of disorientation was brought to the emergency department by the client's daughter. The daughter states that this is the first time that the client experienced confusion. The nurse determines from this piece of information that which is unlikely to be the cause of the client's disorientation?

Alzheimer's disease

The nurse instructs a pregnant client diagnosed with human immunodeficiency virus (HIV) to report immediately to the primary health care provider any early signs of vaginal discharge or perineal tenderness. Which is the primary expected outcome for this intervention?

Assists in identifying infections that may need to be treated