NCLEX RN #06

1,4,5

A nurse cares for a frail, elderly client with osteoporosis in a nursing home. Which interventions are APPROPRIATE to include in the client's care plan to help prevent a hip fracture? "SELECT ALL THAT APPLY" #72116868 (20) 1. Calcium supplement 2. Encourage bed rest 3. Use of full bed rails during the night 4. Vitamin D supplements 5. Weight-bearing exercises.

3

A child with attention-deficit hyperactivity disorder (ADHD) has been taking methylphenidate for a year. What are the "PRIORITY" nursing assessments when the client comes to the clinic for a well-child visit? #72116868 (27) 1. Attention span and activity level 2. Dental health and mouth dryness 3. Height/weight and blood pressure 4. Progress with schoolwork and in making friends.

1,4,5

A client is admitted with SICKLE CELL CRISIS has a hemoglobin level of 9 g/dL. The client reports severe pain in the back and leg joints. The nurse would anticipate which of the following ?"SELECT ALL THAT APPLY " #72116868 (15) 1. Folic acid supplements 2. Folic high in Iron 3. Ice packs to painful joints 4. Intravenous hydration 5. Intravenous morphine

4

A client presents to the emergency department with alcohol intoxication. Assessment shows nystagmus, ataxia and confusion. the client's breath sounds smells of alcohol. Which prescription from the health care provider should the nurse implement "FIRST"? #72116868 (31) 1. Blood draw for liver function tests 2. D5 1/2 normal saline 3. Folic acid IV 4. Thiamine, IV

2

A nurse auscultates a loud cardiac murmur on a newborn with suspected trisomy 21 (Down syndrome). A genetic screen and an echocardiogram are scheduled that day. The neonate's vital signs are shown in the exhibit. What would be an APPROPRIATE action for the nurse to complete "NEXT"? #72116868 (21) Vital sign: Temperature--- 98.6, Heart rate--- 146/min, Respirations ---42/min , O2 saturation --- 98% 1. Call the health care provider (HCP) immediately 2. Document the assessment finding 3. Place the neonate in a knee-chest position 4. Provide oxygen to the neonate.

fall and hip

Intervention to reduce the risk of ___and ____ fracture include bisphosphonate medication, calcium and vitamin D supplements, mobility and weight bearing exercise, smoking cessation and avoiding excessive use of alcohol #72116868 (20)

pleural effusion

Absent breath sounds in the lung base in this client with _____________________is an expected finding as the collection of fluid in the pleural space prevents the lungs from expanding. #72116868 (32)

3

After the nurse receives the change of shift report, which client should the nurse assess "FIRST"? #72116868 (32) 1. Client with asthma who has shortness of breath and high pitched expiratory wheezing 2. Client with diabetes and a stasis leg ulcer dressing saturated with serosanguinenous drainage. 3. Client with heart failure who is short of breath coughing up pink frothy sputum. 4. Client with left pleural effusion and absent breath sounds in the left base.

1,2,4

An elderly client with staphylococcal pneumonia treated with intravenous antibiotic therapy for 3 days becomes extremely short of breath and restless and is difficult to arouse. Which additional assessments findings indicate to the nurse that the client can be developing SEPSIS? "SELECT ALL THAT APPLY" #72116868 (30) 1. Absent bowel sounds 2. Capillary refill 5 seconds 3. Diminished breath sounds in bases 4. Serum glucose level 180- mg/dL 5. Urine output 1 mL /kg/hr.

thiamine deficiency

Clients with alcoholism often have #72116868 (31)

1,2,4,5

The nurse cares for a client following a percutaneous coronary intervention via the right groin. The client received an IV infusion of abciximab during the procedure. Which ACTIONS should the nurse implement? "SELECT ALL THAT APPLY" #72116868 (22) 1. Assess invasive procedure sites for bleeding 2. Check hemoglobin and platelet count 3. Initiate a second large-bore IV line 4. Place the client on continuous cardiac monitoring 5. Report black tarry stools to the health care provider

4

The client screams at the nurse, "you are all incompetent here , I have been waiting for 2 hours"How should the nurse respond "INITIALLY"? 1. "I know you are upset, but I will have to call security if you continue to scream." #72116868 (17) 2. "I see that you are upset. Let's focus on how I can help you." 3. "I want you to know that the health care providers (HCP) are all well-qualified professionals." 4. "It is frustrating to wait so long, and I am sorry for the delay."

1

The following 4 clients are brought to the emergency department triage nurse. The client with which of these signs should be a "PRIORITY" to be seen for immediate care? #72116868 (24) 1. A 2 year old has sclera visible above the iris (sunset eyes) 2. A 3 year old has a single transverse crease across the entire palm of the hand. 3. A 6 month old breastfed client had 8 wet diapers in the last 24 hours. 4. A 9 month old client's toes fan out and the big toe dorsiflexes when the foot sole is stroked.

4

The labor and delivery (L&D) nurse is floated to a medical-surgical floor for a shift. Which client is MOST APPROPRIATE for the charge nurse to assign to the L&D nurse? #72116868 (14) 1. Child with an occluded arteriovenous fistula receiving IV heparin infusion. 2. Client with cirrhosis and ascites who requires bedside paracentesis. 3. Client with diabetes who is one day postoperative below-the-knee amputation. 4. Client with pyelonephritis who is febrile and receiving IV antibiotics

3

The mother of a 6 year old child with CYSTIC FIBROSIS (CF) has received instruction on the use of pancreatic enzymes. Which statement made by the mother indicates a "NEED FOR FURTHER TEACHING" #72116868 (19) 1. "I need to monitor the total amount of this medication that I give to my child everyday." 2. "I should give this medication with or just before my child has a meal or snack." 3. "It is okay for my child to chew this medication." 4. "It is okay to open the capsule and sprinkle the medicine on a tablespoon of applesauce."

2

The nurse is caring for a client who is participating in a research study (randomized controlled trial) of a new medication. Which statement indicates that the client has an APPROPRIATE understanding of the study and reason for participation? #72116868 (26) 1. "I changed my mind, but once in you're stuck." 2. "I hope others will be helped through my involvement." 3. " I know I will get new medication by being in this study." 4. "If I don't participate, my health care provider (HCP) will be upset."

3,5

The nurse is caring for an agitated client with dementia who is pulling at the oxygen and IV tubing. Wrist restraints are applied after less-restrictive safety measures have been ineffective. Which actions are APPROPRIATE to protect the client from injury? "SELECT ALL THAT APPLY" #72116868 (28) 1. Attach wrist restraint straps to the upper side rails 2. Position the client supine to keep restraint straps taut 3. Release restraints at regular intervals and assess behavior. 4. Use a square knot to tie restraint straps to the bed 5. Use gauze to pad bony prominences under restraints.

2,3,5

The nurse is performing a physical examination on a 10 year old client with abdominal discomfort. Which actions would be APPROPRIATE during the examination? "SELECT ALL THAT APPLY" #72116868 ( 16) 1. Ask the accompany parent to rate and describe the client's pain. 2. Ask the client to describe the the chief symptom. 3. Conduct a head-to-toe assessment in the same manner as an adult assessment 4. Explain the outcome of the examination to the parent without the child present 5. Honor the client's request to be examined without a parent consent.

4

The nurse is preparing to administer 160 mg of furosemide via IV piggyback to a client with chronic kidney disease and fluid overload. The nurse plans to give the dose slowly over 40 minutes to PREVENT which adverse effect? #72116868 (29) 1. Bradycardia 2. Hypokalemia 3. Nephrotoxicity 4. Ototoxicity

1

The nurse is preparing to administer morning medications to a client with type 2 diabetes mellitus and end stage renal disease who is scheduled for dialysis today. Which medication should the nurse HOLD for clarification prior to administration? ##72116868 (23) 1. Atenolol 2. Calcium acetate 3. Insulin lispro 4. Vitamin E

3,1,4,2,5,6

The nurse prepares to insert a large-bore nasogastric tube for gastric decompression. After obtaining equipment, the nurse identifies the client, performs hand hygiene, applies clean gloves, assesses nares, and selects a naris.PLACE THE REMAINING STEPS IN THE CORRECT ORDER. ALL OPTIONS MUST BE USED. #72116868 (25) 1. Instruct client to extend neck back slightly 2. Ask client to flex head forward and swallow 3. Measure, mark, and lubricate tube 4. Gently insert tube just past nasopharynx 5. Advance tube to the marked point 6. Verify tube placement and anchor

sunset eyes

The presence of ______________________ (sclera above iris) is a late sign of increased intracranial pressure and a priority. #72116868 (24)

2,3,5

The school nurse creates a cafeteria menu for a newly enrolled child with CELIAC DISEASE. Which lunches would be APPROPRIATE for this child? "SELECT ALL THAT APPLY" #72116868 (18) 1. Beef barley soup with mixed vegetables and French bread. 2. Grilled chicken, baked potato, and strawberry yogurt. 3. Mexican corn tacos with ground beef and cheese 4. Peanut butter and jelly on rice cakes with an oatmeal cookie 5. Rice needles with chicken and broccoli

Pancreatic enzyme supplements

are used to aid the absorption of carbohydrates, fats and proteins in a child with CF. They are taken with or just before every meal ( not as needed) , should be swallowed whole or sprinkled on an acidic food and should not be crushed or chewed. They should not be taken with milk. Excessive intake could result in fibrosing colonopathy. #72116868 (19)

labor and delivery (L&D)

frequently care for pregnant woman with urinary tract infections and would be familiar with the management of a client with pyelonephritis. #72116868 (14)

Atrioventricular (AV) canal defect

is a cardiac anomaly often associated with trisomy 21 (Down syndrome). As an echocardiogram is already scheduled for that day, documenting the assessment finding would be the appropriate action for the nurse to complete at this time.#72116868 (21)

Celiac disease

is an autoimmne disorder in which an individual cannot tolerate gluten, a protein found in barley, rye, oats and wheat (BROW). Rice, corn and potatoes are allowed in the diet and can be used as grain substitutes. #72116868 (18)

IV thiamine

is given before or with IV glucose to a client with alcohol intoxication to prevent Wernicke encephalopathy. #72116868 (31)

Trisomy 21 (Down syndrome)

is often associated with the cardiac anomaly AV canal defect. Assessment typically includes a loud murmur that requires no immediate action when vital signs are stable. Surgery will correct the anomaly when the neonate grows in size and can tolerate the invasive procedure better .#72116868 (21)

IV furosemide

may cause OTOTOXICITY particularly when high doses are administered in clients with compromised renal function. The rate of administration should not exceed 4 mg/min in dose>120 mg. #72116868 (29)

Glycoprotein

receptor inhibitor ( eg. abciximab) inhibit platelet aggregation and increase bleeding risk. ##72116868 (22)

Hydration

reduces the viscosity of the blood and prevent sickling. Ice pack should not be applied to swollen joints. #72116868(15)

Veracity

refers to the duty to tell the truth. #72116868 (48)

osteoporosis

related fall is the most common cause of hip fracture in the elderly. #72116868 (20)

sickle cell crisis

treatment are narcotic analgesia, aggressive hydration, oxygenation and folic acid, not iron supplementation.