NCLEX RN #03

2

A nurse in the pediatric unit is preparing a 16 year old for a surgical procedure and observes that the client has signed the informed consent for surgery. What should be the "first " action by the nurse? #76123989 (59) 1. Cancel the procedure until a valid consent form is signed. 2. Determine if the client meets legal requirements to sign the consent form. 3. Locate the client's parent or guardian to sign the consent form 4. Verify that the consent is properly witnessed and send the client to surgery.

2, 4

A client in the postoperative period after an open reduction and internal fixation of a left wrist fracture reports constant, severe arm pain that is unrelieved by prescribed morphine administered 30 minutes ago. The client's nail beds appear dusky. What are the nurse's appropriate actions? "SELECT ALL THAT APPLY " #76123989 (58) 1. Apply a heating pad and encourage range-of-motion exercises 2. Assess the temperature and movement of the fingers. 3. Elevate the arm on pillows above the heart level. 4. Notify the health care provider. 5. Reassure client , document findings, and reassess in 1 hour.

1,3,4

A client was suspected foot osteomyelitis is scheduled for magnetic resonance imaging (MRI). which assessment findings should the nurse notify the health care provider (HCP) about before the test? "Select all that apply" #76123989 (60) 1. Cardiac pacemaker 2. Colostomy 3. Retained metal foreign body in eye 4. Total hip replacement 5. Transdermal testosterone patch.

1,4,5,6

A client with generalized anxiety disorder is referred to outpatient mental health department for cognitive behavioral therapy (CBT). The CBT includes which interventions and strategies? *SELECT ALL THAT APPLY.*#76123989 (48) 1. Desensitization for a specific stimulus or situation. 2. Discussing the interpersonal difficulties that have led to the client's psychological problems. 3. Helping the client develop insight into the psychological causes of the disorder. 4. Relaxation techniques 5. Self-observation and monitoring 6. Teaching new coping skills and techniques to reframe thinking.

1

A client's wife is panic stricken at the thought of withdrawing all life support from her husband, who is dying from end stage chronic obstructive pulmonary disease and sepsis. She ask the nurse what he will experience when mechanical ventilation is stopped. Which statement made by the nurse is *most appropriate* at this time? #76123989 (46) 1. "The healthcare provider will prescribe a continuous intravenous infusion of morphine to make him more comfortable" 2. "To maintain blood flow to his heart and lungs, we will continue norepinephrine, the vasopressor, but discontinue all other medications." 3. "To prevent aspiration, we will discontinue his feeding tube and begin total parenteral nutrition to meet his nutritional needs." 4. "We will continue basic care, such as monitoring his vital signs, giving nutrition, and monitoring laboratory test."

4

A nurse receives the following changes of shift morning report for the assigned clients. Which client should the nurse assess "first"? 1. Client 1 day postoperative with fine respiratory crackles in the lung bases on auscultation who is to ambulate for the first time this morning. #76123989 (50) 2. Client 1 day postoperative with serosanguineous drainage on the abdominal surgical dressing and temperature of 100.4 F 3. Client 2 days postoperative receiving intermittent epidural bolus analgesia who now reports incisional pain as a 4 on a 0-10 scale. 4. Client 2 days postoperative receiving fluids infusing at 125 mL/hr, with a Foley catheter and urine output of 100 mL during the last 8 hours.

1,4

A nurse teaches a client who is being discharged on warfarin for atrial fibrillation. Which client statements indicate that teaching has been effective? *SELECT ALL THAT APPLY" #76123989 (49) 1. "Antibiotics can affect my INR value." 2. "I am going to eat more leafy greens" 3. "I will shoot for my INR value to be between 4 and 5" 4. "I will take warfarin at the same time daily" 5. "If I miss a dose, I can double it on the following day."

3.5-5.0 g/dL

Normal albumin level #76123989(56)

patent IV line

Clients with acute pyelonephritis require aggressive IV fluids and IV antibiotics to stop progression of the infection and kidney scarring. A ________________ is the priority #76123989 (52)

serum albumin

plays an important role in maintaining intravascular oncotic pressure. Very low levels of albumin result in fluid leak from the vessels into the interstitial tissue and can lead to pitting edema of the lower extremities, periorbital edema and ascites. #76123989 (56)

atropine and transcutaneous pacing

Initial expected treatment for symptomatic clients include #76123989 (57)

Urine output

Low urine output in the first 24 hours after surgery is expected due to fluid restriction before surgery, hormonal responses to the physiological stress of surgery and fluid losses during surgery. ________ should increase by the second postoperative day.#76123989 (50)

Cognitive behavioral therapy (CBT)

Teaches clients to reframe their thought processes and develop new adaptive approaches for coping with anxiety, stress and conflict.

4

The cardiac care unit has standing instructions that the health care provider (HCP) should be notified of an abnormal mean arterial pressure (MAP). The nurse will need to notify the HCP about which client? #76123989(55) 1. A client from the cardiac catheterization lab with a blood pressure (BP) of 102/58 mm Hg. 2. A client just admitted from the emergency department with a BP of 150/72 mm Hg. 3. A client with a BP of 92/60 mm Hg who just received a dose of nitroglycerin. 4. A client with heart failure on metoprolol with a BP of 106/42 mm Hg.

mean arterial pressure (MAP)

refers to the average pressure within the arterial system felt by the vital organs. A normal _________________ is between 70-105 mm Hg. #76123989 (55)

dizziness, syncope, chest pain and hypotension

what are the manifestation for sinus bradycardia? #76123989(57)

1

The nurse has received report on 4 clients. Which client should the nurse see "First" #76123989(52) 1. Client admitted this morning with acute pyelonephritis whose IV line is infiltrated. 2. Client scheduled for surgery in 2 hours who has questions about the procedure. 3. Client who had a colostomy yesterday and now has a leaking colostomy bag 4. Client with a total hip replacement 3 days ago who reports no bowel movement in 2 days.

3

The nurse is caring for a client who has been receiving mechanical ventilation (MV) for 4 days. During multidisciplinary morning rounds. the health care provider questions the development of a ventilator associated pneumonia (VAP). Which of the following manifestations does the nurse assess as the *best* indicator of VAP? #76123989 (45) 1. Blood tinged sputum 2. Positive blood cultures 3. Positive purulent sputum culture 4. Rhonchi and crackers

3

The nurse is reviewing a client's postoperative questionaire, which indicates a religious preference with spiritual needs concerning surgery scheduled later today. Which action is *most* appropriate at this time? #76123989 (44) 1. Ask the client when a spiritual leader or clergy member is coming to visit. 2. Document the response and notify the health care provider and perioperative team. 3. Follow up with the client regarding the nature of the spiritual needs or religious practices 4. Notify the hospital chaplain and tell the client that the chaplain will come by to assist.

4

The nurse is working with a client admitted with delirium and reduced level of consciousness due to pneumonia and respiratory failure. The nurse anticipates that the client may need to be intubated soon. The client is not able to make decisions. Who will make* decisions* for the clients? #76123989 (47) 1. The client's sibling 2. The client's spouse 3. The health care provider 4. The health care proxy

4

The nurse prepares to administer intravenous albumin to a client with severe liver disease who has a low serum albumin level of 1.5 g/dL. Which characteristic finding associated with hypoalbuminemia should the nurse anticipate ASSESSING? #76123989 (56) 1. Altered mental status 2. Easy bruising 3. Loss of body hair 4. Pitting edema

1

The parent of a 2 year old tells the nurse at the well-child clinic, " I am concerned because my child does not like to be cuddled, does not respond when called by name, and does not make eye contact when being fed" What is the "priority" question for the nurse to ask when completing the health history? #76123989 (51) 1. "How many words can your child say" 2. "Is your child potty trained?" 3. "What are your child's favorite foods?" 4. "What kind of toys does your child like to play with ?"

health care proxy

The role of the _______________ is to make decisions for a client who is unable to do so. They have a good understanding of the client's wishes and will be emotionally capable of fulfilling this important role. #76123989 (47)

2

When admitting a client who had an anterior wall ST elevation myocardial infarction to the cardiac stepdown unit, which intervention should the nurse perform "first?"#76123989 (54) 1. Assess for jugular venous distension 2. Attach the cardiac monitor to the client 3. Auscultate heart and heart sounds 4. Obtain the client's vital signs.

Dysrhythmias

are the most common complication following "Myocardial Infarction. " . The nurse should immediately attach the cardiac monitor when the client is admitted before taking vital signs and performing other assessment #76123989 (54)

Ist degree AV block

every impulse is conducted to the ventricles, but the time of AV conduction is prolonged. This is evidenced by a prolong PR interval of >0.20 second. #76123989 (57)

sinus rhythm

has a rate of 60-100 /min #76123989 (57)

sinus bradycardia (SB)

has the same conduction pathway as sinus rhythm, but the sinoatrial node fires at a rate <60/min. ##76123989 (57)

Acute pyelonephritis

is a severe bacterial infection of the kidney that causes it to swell. It can lead to permanent scarring of the kidney and can be life-threatening. #76123989(52)

colostomy

is a surgical opening (stoma) in the abdominal wall through which a section of large intestine is brought outside the body, either temporarily or permanently. #76123989(52)

compartment syndrome

is caused by decreased blood flow to the tissue distal to the injury and can cause ischemic necrosis. #76123989 (58)

Ventilator associated Pneumonia (VAP)

is the second most common health care associated infection in the united states and is associated with increased mortality , hospital cost and length of stay

Warfarin

must be taken at the same time daily to reach a therapeutic INR of 2-3 #76123989 (49)

mitral valve stenosis

often produces a diastolic murmur heard best at the APEX of the heart (5th intercostal space, midclavicular line) with a stethoscope. #76123989 (53)

Complete heart block

or 3rd degree atrioventricular (AV ) block, is a form of AV dissociation in which no impulses from the atria are conducted to the ventricles. #76123989(57)