NCLEX Review Questions
The nurse is reviewing the laboratory test results for a client seen in the health care clinic. The nurse determines that the client's fasting serum glucose level is normal if which value is noted? 99 mg/dL (5.5 mmol/L) 120 mg/dL (6.9 mmol/L) 130 mg/dL (7.4 mmol/L) 140 mg/dL (8 mmol/L)
99 mg/dL (5.5 mmol/L) Rationale: The normal fasting blood glucose is 70 to 99 mg/dL (4 to 5.65 mmol/L) in the adult client. The results in the remaining options indicate elevated fasting serum glucose levels.
A client is at risk for pulmonary embolism and is on anticoagulant therapy with warfarin sodium. The client's prothrombin time is 20 seconds, with a control of 11 seconds. How should the nurse interpret these results? The client needs to have the test repeated. Client results are within the therapeutic range. Client results are higher than the therapeutic range. Client results are lower than the needed therapeutic level.
Client results are within the therapeutic range. Rationale: The therapeutic range for prothrombin time is 1.5 to 2 times the control for clients at high risk for thrombus. Based on the client's control value, the therapeutic range for this individual would be 16.5 to 22 seconds; therefore, the result is within the therapeutic range.
A client who has undergone preadmission testing has had blood drawn for serum laboratory studies, including a complete blood count, coagulation studies, and electrolyte and creatinine levels. Which laboratory result should be reported to the surgeon's office by the nurse, knowing that it could cause surgery to be postponed? Hemoglobin, 8.0 g/dL (80 mmol/L) Sodium, 145 mEq/L (145 mmol/L) Platelets, 210,000 mm3 (210 × 109/L) Serum creatinine, 0.8 mg/dL (70.6 mmol/L)
Hemoglobin, 8.0 g/dL (80 mmol/L) Rationale: Routine screening tests include a complete blood count, serum electrolyte analysis, coagulation studies, and a serum creatinine test. The complete blood count includes the hemoglobin analysis. All of these values are within normal range except for hemoglobin. If a client has a low hemoglobin level, the surgery likely could be postponed by the surgeon.
The client tells the nurse that he ingests large amounts of oral antacids on a daily basis. The nurse plans care knowing that the excessive use of oral antacids containing bicarbonate can result in which acid-base disturbance? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis
Metabolic alkalosis Rationale: Increases in base components occur as a result of oral or parenteral intake of bicarbonates, carbonates, acetates, citrates, or lactates. Excessive use of oral antacids containing bicarbonate can cause a metabolic alkalosis. The remaining acid-base disturbances are incorrect.
The nurse is teaching a client who had a stroke how to use a walker for ambulation. Which level of prevention is the nurse implementing? Basic level Primary level Secondary level Tertiary level
Tertiary level Rationale: The tertiary level is focused on rehabilitation skills. Therefore, teaching a client who had a stroke how to use a walker is a tertiary level of prevention. The primary level is focused on prevention. The secondary level is a screening level that entails such procedures as vision screening, mammography, or similar screening tests. There is no basic level of prevention.
A client is being discharged to home after application of a plaster leg cast. Which statement indicates to the nurse that the teaching has been effective? "I will avoid getting the cast wet." "I will use my fingertips to lift and move the leg." "I can use a padded coat hanger end to scratch under the cast." "I need to cover the casted leg with warm blankets for the next few days."
"I will avoid getting the cast wet." Rationale: A plaster cast must remain dry to keep its strength. The cast should be handled using the palms of the hands, not the fingertips, until fully dry. The client should never scratch under the cast. A hair dryer set at a cool setting may be used to relieve an itch. Air should circulate freely around the cast to help it dry. Also, the cast gives off heat as it dries.
The nurse provides discharge instructions to a client following myelography. Which instructions should the nurse provide? Select all that apply. Restrict fluid intake. Avoid bending over. Avoid strenuous exercise. Rest with the head elevated. Expect some clear drainage from the dressing site.
2,3,4 Rationale: A myelogram uses x-rays and contrast material to view the bones and the fluid-filled space (subarachnoid space) between the bones in the spine. Following the procedure, the client needs to increase fluid intake to flush the contrast material. Since dye is injected and spinal fluid leakage is a concern, the client should avoid bending over, avoid strenuous exercise, and rest with the head elevated. Clear drainage from the dressing site indicates cerebrospinal fluid leakage, which requires primary health care provider notification.
The nurse is reviewing the laboratory results from a lumbar puncture performed in a client with a diagnosis of meningitis. Which laboratory findings are expected to be noted with bacterial meningitis? Select all that apply Increased glucose level Elevated protein level Increased white blood cells (WBCs) Clear appearance of the cerebrospinal fluid (CSF) Elevated CSF pressure
2,3,5 Rationale: If a bacterial infection of CSF is present, findings include reduced glucose level, an elevated protein level, increased WBCs, a cloudy appearance of CSF, and an elevated CSF pressure
A client is at risk for developing disseminated intravascular coagulopathy (DIC). The nurse determines that which fibrinogen level is normal? 170 mg/dL (1.7 g/L) 400 mg/dL (4.0 g/L) 480 mg/dL (4.8 g/L) 500 mg/dL (5.0 g/L)
400 mg/dL (4.0 g/L) Rationale: The normal fibrinogen level is 200 to 400 mg/dL (2 to 4 g/L). With DIC, the fibrinogen level drops because fibrinogen is used up in the clotting process. The correct option is the only one that identifies a normal level.
The nurse is assessing the skin of a client with a history of malabsorption deficiency and discovers brittle nails. What type of nutritional deficiency should the nurse suspect based on this observation? Iron deficiency Protein deficiency Fatty acid deficiency Vitamin K deficiency
Iron deficiency Rationale: Brittle nails result from an iron deficiency. Protein deficiency leads to hair thinning and loss. Fatty acid deficiency can result in dermatitis, and vitamin K deficiency results in bruising.
The nurse assists a primary health care provider in performing a liver biopsy. After the biopsy, the nurse should place the client in which position? Prone Supine A left side-lying position with a small pillow or folded towel under the puncture site A right side-lying position with a small pillow or folded towel under the puncture site
A right side-lying position with a small pillow or folded towel under the puncture site Rationale: After a liver biopsy, the client is assisted to assume a right side-lying position with a small pillow or folded towel under the puncture site for 3 hours. This position compresses the liver against the chest wall at the biopsy site. Therefore, all other options are incorrect
The nurse is caring for a client with a diagnosis of dehydration, and the client is receiving intravenous (IV) fluids. Which assessment finding would indicate to the nurse that the dehydration remains unresolved? An oral temperature of 98.8º F (37.1º C) A urine specific gravity of 1.043 A urine output that is pale yellow A blood pressure of 120/80 mm Hg
A urine specific gravity of 1.043 Rationale: The client who is dehydrated will have a urine specific gravity greater than 1.030. Normal values for urine specific gravity are 1.005 to 1.030. A temperature of 98.8º F (37.1º C) is only 0.2 points above the normal temperature and would not be as specific an indicator of hydration status as the urine specific gravity. Pale yellow urine is a normal finding. A blood pressure of 120/80 mm Hg is within normal range.
The nurse is assessing a client who had abdominal surgery earlier in the day. Which preexisting medical condition would place the client at most risk for postoperative complications? Pacemaker Osteoporosis Alcohol abuse Peptic ulcer disease
Alcohol abuse Rationale: A client with a history of alcohol abuse is at risk for liver disease, including altered metabolism and elimination of medications, impaired wound healing, and clotting and bleeding abnormalities. A client with this risk factor also would be at risk for experiencing alcohol withdrawal during the postoperative period. Clients with a pacemaker, osteoporosis, and peptic ulcer disease need to be monitored closely but are not at risk for major complications, as is the client with alcohol abuse and liver disease.
The nurse is planning to obtain blood for arterial blood gas analysis from a client with chronic obstructive pulmonary disease. The nurse should plan time for which activity after the arterial blood specimen is drawn? Holding a warm compress over the puncture site for 5 minutes Encouraging the client to open and close the hand rapidly for 2 minutes Applying pressure to the puncture site by applying a 2 × 2 gauze for 5 minutes Having the client keep the radial pulse puncture site in a dependent position for 5 minutes
Applying pressure to the puncture site by applying a 2 × 2 gauze for 5 minutes Rationale: Applying pressure over the puncture site reduces the risk of hematoma formation and damage to the artery. A cold (not warm) compress would aid in limiting blood flow. Keeping the extremity still and out of a dependent position will aid in the formation of a clot at the puncture site
The nurse is providing directions to a client about how to test a stool for occult blood. The nurse cautions the client that which could cause a false-negative result? Iodine Colchicine Ascorbic acid Acetylsalicylic acid
Ascorbic Acid Rationale: Ascorbic acid can interfere with results of occult blood testing, yielding a false-negative result. Colchicine and iodine can cause false-positive results. Acetylsalicylic acid would have no effect or could cause a positive result by inducing bleeding from the gastrointestinal tract.
The nurse is reviewing the surgeon's prescription sheet for a preoperative client, which states that the client must be NPO (nothing by mouth) after midnight. Which medication should the nurse clarify to be given and not withheld? Atenolol Atorvastatin Cyclobenzaprine Conjugated estrogen
Atenolol Rationale: Atenolol is a beta blocker. Beta blockers should not be stopped abruptly, and the health care provider should be contacted about the administration of this medication before surgery. If a beta blocker is stopped abruptly, the myocardial need for oxygen is increased. Atorvastatin is a cholesterol-lowering medication used to treat high cholesterol. Cyclobenzaprine is a skeletal muscle relaxant. Conjugated estrogen is an estrogen used for hormone replacement therapy in postmenopausal women. The other 3 medications may be withheld before surgery without undue effects on the client.
A gastrectomy is performed on a client with gastric cancer. In the immediate postoperative period, the nurse notes bloody drainage from the nasogastric tube. The nurse should take which most appropriate action? Notify the surgeon. Measure abdominal girth. Irrigate the nasogastric tube. Continue to monitor the drainage.
Continue to monitor the drainage. Rationale: Following gastrectomy, drainage from the nasogastric tube is normally bloody for 24 hours postoperatively, changes to brown-tinged, and is then yellow or clear. Because bloody drainage is expected in the immediate postoperative period, the nurse should continue to monitor the drainage. The nurse does not need to notify the surgeon at this time. Measuring abdominal girth is performed to detect the development of distention. Following gastrectomy, a nasogastric tube should not be irrigated unless there are specific surgeon prescriptions to do so.
During an assessment of a newly admitted client, the nurse notes that the client's heart rate is 110 beats/min, his blood pressure shows orthostatic changes when he stands up, and his tongue has a sticky, paste-like coating. The client's spouse tells the nurse that he seems a little confused and unsteady on his feet. Based on these assessment findings, the nurse suspects that the client has which condition? Dehydration Hypokalemia Fluid overload Hypernatremia
Dehydration Rationale: When a client is dehydrated, the heart rate increases in an attempt to maintain blood pressure. Blood pressure reflects orthostatic changes caused by the reduced blood volume, and when the client stands, he may experience dizziness because of insufficient blood flow to the brain. Alterations in mental status also may occur. The oral mucous membranes, usually moist, are dry and may be covered with a thick, pasty coating. These findings are not manifestations of the conditions noted in the other options.
The long-term care nurse about to give a daily dose of digoxin is told that a serum digoxin level drawn earlier in the day measured 2.4 ng/mL (2.7 nmol/L). Which action should the nurse take first? Report the finding to the cardiologist. Administer the daily dose of the medication. Record the normal value on the intershift report sheet. Gather data from the client related to signs of toxicity.
Gather data from the client related to signs of toxicity. Rationale: The normal therapeutic range for digoxin is 0.5 to 2.0 ng/mL (0.6 to 2.4 nmol/L). A value of 2.4 ng/mL (2.88 nmol/L) exceeds the therapeutic range and could be toxic to the client. The nurse should gather data about signs of digoxin toxicity first and then notify the cardiologist. Option 2 is incorrect because the next dose should not be administered automatically. Recording the value on the intershift report sheet is incorrect because the value is high, not normal, and dismisses the subject at hand.
A female client seen in the ambulatory care clinic has a history of syphilis infection. The nurse assessing the client for reinfection would expect to observe a lesion on the labia that has which characteristic? Is painless and indurated Has a cauliflowerlike appearance Is erythematous and papular in appearance Appears as 1 or more vesicles that then rupture
Is painless and indurated Rationale: The characteristic lesion of syphilis is painless and indurated. The lesion is referred to as a chancre. Genital warts are characterized by cauliflowerlike growths or growths that are soft and fleshy. Scabies is characterized by erythematous, papular eruptions. Genital herpes is accompanied by the presence of 1 or more vesicles that then rupture and heal.
The nurse is preparing medications when a pill pops out of the medication container and falls onto the countertop. What action should the nurse take? Promptly pick up the pill and put it into the medicine cup. Promptly pick up the pill, blow off the dust, and then put it into the medicine cup. Promptly pick up the pill, dispose of it properly, and obtain a new one from the pharmacy. Promptly pick up the pill, use an alcohol swab to clean it off, and put it into the medicine cup.
Promptly pick up the pill, dispose of it properly, and obtain a new one from the pharmacy. Rationale: Medication that is dropped on any surface is considered contaminated and should not be administered; therefore, the remaining options are incorrect.
A client is scheduled for a fiberoptic gastrointestinal procedure. The nurse instructs the client to remain on clear liquids the day before the test because a clear liquid diet supports which action? Stimulating peristalsis Promoting a laxative action Providing little or no residue Providing minimal calories and nutrients
Providing little or no residue Rationale: Before a gastrointestinal (GI) procedure, the primary health care provider (PHCP) generally desires that the GI tract be cleansed of substances. Because clear liquid diets have little or no residue, the GI tract will have an opportunity to empty itself of solid contents. This will enable the PHCP to view the GI tract clearly. Clearing the GI tract via diet is safer than having enemas until clear because this process can disrupt fluid and electrolyte balance. All other options are inaccurate regarding a clear liquid diet.
A client who is found unresponsive has arterial blood gases drawn and the results indicate the following: pH is 7.12, Paco2 is 90 mm Hg (90 mmol/L), and HCO3- is 22 mEq/L (22 mmol/L). The nurse interprets the results as indicating which condition? Metabolic acidosis with compensation Respiratory acidosis with compensation Metabolic acidosis without compensation Respiratory acidosis without compensation
Respiratory acidosis without compensation Rationale: The acid-base disturbance is respiratory acidosis without compensation. The normal pH is 7.35 to 7.45. The normal Paco2 is 35 to 45 mm Hg. In respiratory acidosis the pH is decreased and the Pco2 is elevated. The normal bicarbonate HCO3-level is 21 to 28 mEq/L (21 to 28 mmol/L). Because the bicarbonate is still within normal limits, the kidneys have not had time to adjust for this acid-base disturbance. In addition, the pH is not within normal limits. Therefore, the condition is without compensation. The remaining options are incorrect interpretations.
The nurse is caring for a client who is experiencing metabolic alkalosis. Knowing the risks of this imbalance, the nurse plans to protect the client's safety by carefully implementing which prescribed precaution? Contact isolation Seizure precautions Bleeding precautions Neutropenic precautions
Seizure precautions Rationale: The client with metabolic alkalosis is at risk for tetany and seizures. The nurse would maintain client safety by using seizure precautions with this client. The remaining options are unnecessary in the care of the client experiencing metabolic alkalosis.
Which action by the parent of an infant with respiratory syncytial virus infection who is receiving ribavirin would indicate a need for further instruction regarding the management of the disease process? Wearing protective garb when visiting the infant Washing the hands before leaving the infant's room Telling a family member who has asthma that he should not visit the infant Telling the infant's aunt, who is pregnant, that it is acceptable to visit the infant
Telling the infant's aunt, who is pregnant, that it is acceptable to visit the infant Rationale: When an infant is receiving ribavirin, exposure precautions need to be observed. Anyone entering the infant's room should wear a gown, mask, gloves, and hair covering. Anyone who is pregnant or considering pregnancy and anyone with a history of respiratory problems or airway disease should not care for or visit the infant who is receiving ribavirin. Hand washing is absolutely necessary before leaving the room to prevent the spread of germs.
The nurse is reviewing an adult male's serum creatinine level of 4.0 mg/dL (353 mcmol/L). What does this level indicate? Low Normal Slightly elevated and needs referral Very high, indicating severe renal failure
Very high, indicating severe renal failure Rationale: The normal serum creatinine level for an adult male is 0.6 to 1.2 mg/dL (53 to 106 mcmol/L) and female 0.5 to 1.1 mg/dL (44 to 97 mcmol/L). A creatinine level of 4.0 mg/dL (353 mcmol/L) is a critical value and indicates serious impairment in renal function. This value is not low, normal, or slightly elevated.
The nurse explains to a client why telemonitoring is needed. What response by the client indicates a need for further instruction? "Telemonitoring ignores artifact." "These systems are not fail-proof." "Monitoring helps to diagnose dysrhythmias, ischemia, or infarction." "Electrodes have to be replaced when the conductive gel has dried out."
"Telemonitoring ignores artifact." Rationale: Telemonitoring does not ignore artifact. In fact, accurate interpretation of heart rhythm is difficult when artifact is present. All of the other options are correct
A client is about to have arterial blood gases drawn, and the nurse explains what an Allen's test is. What comment shows that the client understands the nurse's explanation? "Blood is drawn from the ulnar artery." "I know I have to lie down while blood is drawn." "This test is done to ensure adequate collateral circulation." "Direct pressure has to be placed over the site for 15 minutes after blood is drawn."
"This test is done to ensure adequate collateral circulation." Rationale: The Allen's test is important because it ensures collateral circulation to the hand if thrombosis of the radial artery occurs after the puncture. Failure to determine the presence of adequate collateral circulation could result in severe ischemic injury to the hand if damage to the radial artery occurs with arterial puncture. Options 1, 2, and 4 are incorrect.
The nurse is caring for a client with a diagnosis of celiac disease. The nurse recognizes that client teaching has been effective when the client makes which statement? "I can eat whatever I want." "I will eat rice cereal for breakfast." "I will eat beef barley soup for lunch." "I will eat only wheat bread for a snack."
"I will eat rice cereal for breakfast." Rationale: A client with celiac disease should be instructed to avoid gluten-containing products such as wheat, barley, oats, and rye.
The nurse is giving postprocedure instructions to a client returning home after arthroscopy of the shoulder. What is the priority instruction for this client? "Do not eat or drink anything until tomorrow morning." "Keep the shoulder completely immobilized for the rest of the day." "You need to refrain from strenuous activity for the next few weeks." "Report any fever or redness and heat at the site to your primary health care provider."
"Report any fever or redness and heat at the site to your primary health care provider." Rationale: After arthroscopy, signs and symptoms of infection such as fever or redness and heat at the site should be reported to the primary health care provider. The client may resume the usual diet immediately. The arm does not have to be completely immobilized once sensation has returned, but the client usually is encouraged to refrain from strenuous activity for at least a few days.
The nurse is preparing to test a client's blood glucose level with a glucometer. Which steps would facilitate obtaining an accurate result? Select all that apply. Hold the finger in a dependent position during the test. Use gentle pressure to obtain an adequate amount of blood. Obtain the blood specimen by puncturing the central tip of the finger. Obtain the blood specimen by puncturing the lateral side of the finger. Allow the drop of blood to form without squeezing near the puncture site. Clean the site with an antiseptic swab, and then puncture the site immediately.
1,2,4 Rationale: When obtaining a droplet of blood for a blood glucose monitor, the site needs to be cleaned with an antiseptic swab and then allowed to dry completely. The puncture site should be the lateral side of the finger because the central tip contains more nerves and may be more painful. Holding the finger in a dependent position improves blood flow to the puncture site. Gentle pressure may be needed to obtain an adequate amount of blood for the test strip.
The nurse notes that a client's arterial blood gas (ABG) results reveal a pH of 7.50 and a Paco2 of 30 mm Hg (30 mm Hg). The nurse monitors the client for which clinical manifestations associated with these ABG results? Select all that apply. Nausea Confusion Bradypnea Tachycardia Hyperkalemia Lightheadedness
1,2,4,6 Rationale: Respiratory alkalosis is defined as a deficit of carbonic acid or a decrease in hydrogen ion concentration that results from the accumulation of base or from a loss of acid without a comparable loss of base in the body fluids. This occurs in conditions that cause overstimulation of the respiratory system. Clinical manifestations of respiratory alkalosis include lethargy, lightheadedness, confusion, tachycardia, dysrhythmias related to hypokalemia, nausea, vomiting, epigastric pain, and numbness and tingling of the extremities. Hyperventilation (tachypnea) occurs. Bradypnea describes respirations that are regular but abnormally slow. Hyperkalemia is associated with acidosis.
The nurse is caring for a client with suspected hepatitis. What diagnostic test results will assist in confirming this client's diagnosis? Select all that apply. Leukopenia Elevated hemoglobin Elevated liver enzymes Elevated serum bilirubin level Elevated blood urea nitrogen (BUN) Elevated serum erythrocyte sedimentation rate (ESR)
1,3,4,6 Rationale: Laboratory indicators of hepatitis include leukopenia, elevated liver enzyme levels, elevated serum bilirubin levels, and elevated ESRs. An elevated BUN level may indicate renal dysfunction. A hemoglobin level is unrelated to this diagnosis.
A client in the later stages of chronic kidney disease (CKD) has hyperkalemia. With CKD, what other factors besides tissue breakdown can cause high potassium levels? Select all that apply. Blood transfusions Metabolic alkalosis Bleeding or hemorrhage Decreased sodium excretion Ingestion of potassium in medications Failure to restrict dietary potassium
1,3,5,6 Rationale: With CKD, factors other than tissue breakdown that can cause hyperkalemia include blood transfusions, bleeding or hemorrhage, ingestion of potassium in medications, and failure to restrict dietary potassium. Metabolic alkalosis and decreased sodium excretion are not contributing factors.
When communicating with a client who speaks a different language, which best practice should the nurse implement? Speak loudly and slowly. Arrange for an interpreter to translate. Speak to the client and family together. Stand close to the client and speak loudly.
Arrange for an interpreter to translate
A client is to undergo weekly intravesical chemotherapy for bladder cancer for the next 8 weeks. What instruction should the nurse provide to the client regarding management of the urine as a biohazard? Void into a bedpan and then empty the urine into the toilet. Disinfect the toilet with bleach after voiding for 6 hours after a treatment. Purchase extra bottles of scented disinfectant for daily bathroom cleansing. Have 1 bathroom strictly set aside for the client's use for the next 2 months
Disinfect the toilet with bleach after voiding for 6 hours after a treatment. Rationale: After intravesical chemotherapy, the client treats the urine as a biohazard. This involves disinfecting the urine and the toilet with household bleach for 6 hours after the treatment. Using a bedpan for voiding is of no value in this situation. Scented disinfectants are of no particular use. The client does not need to have a separate bathroom for personal use.
To prevent postoperative atelectasis in a client recovering from an open cholecystectomy, what should the nurse do first? Request a cardiopulmonary consult. Teach the client to splint the incision. Teach the proper technique for huff coughing. Ensure that the client is experiencing adequate pain control.
Ensure that the client is experiencing adequate pain control. Rationale: Coughing is 1 of the protective reflexes. Its purpose is to move mucus that is in the airways upward toward the mouth and nose. Coughing is needed in the postoperative client to mobilize secretions and expel them from the airways and prevent atelectasis. The client with an abdominal incision is hesitant to cough unless pain control is adequate. The incision in an open cholecystectomy is just under the diaphragm in the right upper quadrant of the abdomen, making coughing and deep breathing painful. The nurse should first ensure that pain control is adequate so that pulmonary hygiene measures are maximally effective. A cardiopulmonary consult is requested for clients with preexisting risk caused by lung pathology or for clients already experiencing postoperative respiratory complications. Splinting the incision is an effective postoperative strategy for assisting with effective coughing and deep breathing, but it should follow pain control. Huff coughing, although it can be used in the postoperative client, is an effective coughing strategy that is most often recommended for clients with chronic obstructive airway disorders.
The nurse in a surgical unit receives a postoperative client from the postanesthesia care unit. After the initial assessment of the client, the nurse should plan to continue with postoperative assessment activities how often? Every hour for 2 hours and then every 4 hours as needed Every 30 minutes for the first hour, every hour for 2 hours, and then every 4 hours as needed Every 15 minutes for the first hour, every 30 minutes for 2 hours, every hour for 4 hours, and then every 4 hours as needed Every 5 minutes for the first half-hour, every 15 minutes for 2 hours, every 30 minutes for 4 hours, and then every hour as needed
Every 15 minutes for the first hour, every 30 minutes for 2 hours, every hour for 4 hours, and then every 4 hours as needed Rationale: When the postoperative client arrives from the postanesthesia care unit, the nurse performs an initial assessment. Common time frames for continuing postoperative assessment activities are every 15 minutes the first hour, every 30 minutes for 2 hours, every hour for 4 hours, and then every 4 hours as needed. However, agency policies should always be followed. Options 1 and 2 identify time frames that are too infrequent and that will not provide adequate assessment of the postoperative client. Option 4 identifies close time frames that are unnecessary.
The nurse is creating a plan of care for a client scheduled for surgery. The nurse should include which activity in the nursing care plan for the client on the day of surgery? Avoid oral hygiene and rinsing with mouthwash. Verify that the client has not eaten for the last 24 hours. Have the client void immediately before going into surgery. Report immediately any slight increase in blood pressure or pulse.
Have the client void immediately before going into surgery. Rationale: The nurse would assist the client to void immediately before surgery so that the bladder will be empty. Oral hygiene is allowed, but the client should not swallow any water. The client usually has a restriction of food and fluids for 6 to 8 hours (or longer as prescribed) before surgery instead of 24 hours. A slight increase in blood pressure and pulse is common during the preoperative period and is usually the result of anxiety.
The nurse checks for residual before administering a bolus tube feeding to a client with a nasogastric tube and obtains a residual amount of 150 mL. What is the most appropriate action for the nurse to take? Hold the feeding and reinstill the residual amount. Reinstill the amount and continue with administering the feeding. Elevate the client's head at least 45 degrees and administer the feeding. Discard the residual amount and proceed with administering the feeding.
Hold the feeding and reinstill the residual amount. Rationale: Unless specifically indicated, residual amounts greater than 100 mL require holding the feeding, but this is individualized and each agency's policy should be checked. The residual amount should be reinstilled unless it is greater than 250 mL or per agency policy. In addition, the feeding is not discarded unless its contents are abnormal in color or characteristics.
The nurse is monitoring the status of a postoperative client in the immediate postoperative period. The nurse would become most concerned with which sign that could indicate an evolving complication? Increasing restlessness A pulse of 86 beats per minute Blood pressure of 110/70 mm Hg Hypoactive bowel sounds in all 4 quadrants
Increasing restlessness Rationale: Increasing restlessness is a sign that requires continuous and close monitoring because it could indicate a potential complication such as hemorrhage, shock, or pulmonary embolism. A blood pressure of 110/70 mm Hg with a pulse of 86 beats per minute is within normal limits. Hypoactive bowel sounds heard in all 4 quadrants are a normal occurrence in the immediate postoperative period.
The registered nurse is observing a newly hired nurse perform a dressing change on a client with a leg ulcer. An enzymatic agent is being used to treat the ulcer. Which observation, if made by the registered nurse, would indicate a need for further teaching with the newly hired nurse? Cleans the wound with a sterile normal saline solution Tapes gauze dressing in place over ulcer Applies the enzymatic agent to the area of necrosis Leaves the ulcer open to the air after the enzymatic agent is applied
Leaves the ulcer open to the air after the enzymatic agent is applied Rationale: The wound should be cleansed with a sterile solution, such as normal saline, before applying the enzymatic agent. The nurse then applies a thin film of the enzymatic agent on the necrotic areas only and applies a loose, thin dressing taped securely in place.
A client with diabetes mellitus has a blood glucose level of 644 mg/dL (35.7 mmol/L). The nurse plans care knowing that the client is at risk for the development of which type of acid-base imbalance? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis
Metabolic acidosis Rationale: Diabetes mellitus can lead to metabolic acidosis. When the body does not have sufficient circulating insulin, the blood glucose level rises. At the same time, the cells of the body use all available glucose. The body then breaks down glycogen and fat for fuel. The by-products of fat metabolism are acidotic, potentially leading to the condition known as diabetic ketoacidosis. The remaining options are incorrect.
The nurse assesses a client with an admitting diagnosis of bipolar affective disorder, mania. Which symptom presented by the client would require the nurse's immediate intervention? Outlandish behaviors and inappropriate dress Nonstop physical activity and poor nutritional intake Grandiose delusions of being a royal descendent of King Arthur Constant, incessant talking that includes sexual innuendoes and teasing the staff
Nonstop physical activity and poor nutritional intake Rationale: Mania is a mood characterized by excitement, euphoria, hyperactivity, excessive energy, decreased need for sleep, and impaired ability to concentrate or complete a single train of thought. It is a period during which the mood is predominantly elevated, expansive, or irritable. All options reflect the client's possible symptomatology. Option 2, however, clearly presents a problem that compromises physiological integrity and needs to be addressed immediately.
A client with a gastric ulcer is scheduled for surgery. The client cannot sign the operative consent form because of sedation from opioid analgesics that have been administered. The nurse should take which most appropriateaction in the care of this client? Obtain a court order for the surgery. Have the charge nurse sign the informed consent immediately. Send the client to surgery without the consent form being signed. Obtain a telephone consent from a family member, following agency policy.
Obtain a telephone consent from a family member, following agency policy. Rationale: Every effort should be made to obtain permission from a responsible family member to perform surgery if the client is unable to sign the consent form. A telephone consent must be witnessed by 2 persons who hear the family member's oral consent. The 2 witnesses then sign the consent with the name of the family member, noting that an oral consent was obtained. Consent is not informed if it is obtained from a client who is confused, unconscious, mentally incompetent, or under the influence of sedatives. In an emergency, a client may be unable to sign and family members may not be available. In this situation, a primary health care provider is permitted legally to perform surgery without consent, but the data in the question do not indicate an emergency. Options 1, 2, and 3 are not appropriate in this situation. Also, agency policies regarding informed consent should always be followed.
When administering an intramuscular injection in the ventrogluteal muscle, how should the nurse position the client to best relax the muscle? Semi-Fowler's position Prone with a toe-in position On the side with the hip and knee of the uppermost leg flexed On the side with the hip and knee of the lowermost leg flexed
On the side with the hip and knee of the uppermost leg flexed Rationale: The client can be placed in the supine or lateral position. Side-lying (lateral) with the uppermost hip and knee flexed will help to relax the muscle to be injected. Options 1, 2, and 4 will not best relax the muscle and are improper positioning for this injection site.
A hospitalized client who has been placed on contact precautions has been prescribed to have a chest radiograph in the radiology department. The nurse should plan to take which action on receipt of this prescription? Transport the client through empty corridors only. Place a mask on the client in preparation for transport. Place a sterile gown on the client in preparation for transport. Question the primary health care provider about whether a portable chest radiograph may be obtained.
Question the primary health care provider about whether a portable chest radiograph may be obtained. Rationale: The client who is placed on contact precautions has a high microorganism count in some type of body secretion (e.g., feces or wound drainage). This client is placed in a private room whenever possible and is removed from the room only when absolutely necessary. Client transport should be done only for essential purposes. Notification of departmental personnel and disinfection of any environmental surfaces with which the client has contact are imperative.
The nurse is admitting to the hospital a client with a diagnosis of Guillain-Barré syndrome. The nurse knows that if the disease is severe, the client will be at risk for which acid-base imbalance? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis
Respiratory acidosis Rationale: Guillain-Barré is a neuromuscular disorder in which the client may experience weakening or paralysis of the muscles used for respiration. This could cause the client to retain carbon dioxide, leading to respiratory acidosis and ventilatory failure as the paralysis develops. Therefore, the remaining options are incorrect
The nurse reviews the arterial blood gas results of an assigned client and notes that the laboratory report indicates a pH of 7.30 (7.30), a Paco2 of 58 mm Hg (58 mm Hg), a Pao2 of 80 mm Hg (80 mm Hg), and an HCO3 of 26 mEq/L (26 mmol/L). The nurse should interpret this to mean that the client has which acid-base disturbance? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis
Respiratory acidosis Rationale: The normal pH is 7.35 to 7.45. The normal Paco2is 35 to 45 mm Hg. In respiratory acidosis, the pH is low and the Paco2 is elevated. In respiratory alkalosis, an opposite effect occurs; the pH is elevated and the Paco2 is low. In metabolic acidosis, the pH is low and the bicarbonate is low; in metabolic alkalosis, the opposite effect occurs.
A hospitalized client has a diagnosis of pelvic inflammatory disease (PID). The nurse should encourage the client to assume which therapeutic position when in bed? Left side-lying Right side-lying Prone with the head flat Supine in semi-Fowler's
Supine in semi-Fowler's Rationale: Placing the client in a semi-Fowler's position allows gravity to aid in drainage of the abdominal cavity. This helps to prevent the formation of abscesses high in the abdomen. Abscesses in this location could rupture, potentially causing peritonitis. The color, odor, and amount of vaginal secretions also are noted and recorded. Options 1, 2, and 3 will not aid in gravity drainage
