NCLEX RN #33

1

A client has been on lithium carbonate therapy for 7 days. Which of the following findings would be MOST important to report to the health care provider? #70769904 (65) 1. Diarrhea, vomiting, and mild tremor 2. Dry mouth and mild thirst 3. Hyperactivity and auditory hallucinations 4. Lithium level of 1.3 mEq/L

1

A client involved in a motor vehicle collsion reports severe pelvic and right heel pain. While waiting for imaging, the nurse assesses the client. Which finding should the nurse report to the health care provider IMMEDIATELY? #70769904 (55) 1. Distended abdomen and absent bowel sounds 2. Ecchymosis over the pelvic bones 3. Hemoglobin of 11.5 g/dL and hematocrit of 34% 4. Tenderness over the right heel

2

A client is scheduled for coronary artery bypass surgery in the morning. In the middle of the night, the nurse find the client wide awake. The client demonstrates symptoms of EXTREME ANXIETY and tells the nurse about wanting to refuse the surgery. Which statement by the nurse would be MOST APPROPRIATE? #70769904 (60) 1. "Please try not to worry, you have an excellent surgeon." 2. "Tell me about how you feel about your surgery." 3. "Why are you considering refusing the surgery." 4. "You have the right to make your own deci-sion and can refuse the surgery."

4

A client is taking MORPHINE SULFATE for acute pain. Which statement will BEST assist the client worried about nausea and vomiting while taking this medication? #70769904 (43) 1. "Nausea and vomiting rarely occur with this medication." 2. "Nausea and vomiting rarely occur when you are up and walking." 3. "Take the medication on an empty stomach." 4. "Tolerance develops quickly and persistent nausea is rare."

3

A client who is diagnosed with BREAST CANCER asks the nurse. "Am I going to die?" Which state-ment by the nurse promotes a therapeutic relationship? #70769904 (63) 1. "Cancer is no longer a death sentence, you may live for many years" 2. "I will ask the chaplain to talk to you sometime today." 3. "People with cancer experience fear of dying, tell me about your concerns." 4. "Tell me about your life and hopes for the future."

3,,4,5

A client with type 1 diabetes mellitus is brought to the emergency department by his wife. The client has fruity breath with rapid, deep respirations at 35 breathes per minute, reports abdominal pain, and appears weak. The nurse should anticipate imple-mentation of which prescription? SELECT ALL THAT APPLY. #70769904 (66) 1. Administer dextrose 50 mg intravenous IV push 2. Instruct client to breathe into a paper bag to treat hyperventilation 3. Perform a fingerstick and serum blood glucose level 4. Prepare to administer an IV infusion of regular insulin. 5. Start an IV line and administer a bolus of normal saline.

3

A nurse has received report from the off-going shift that a client is confused and has been identified as a high risk for falls. The nurse shares this information with the unlicensed assistive per-sonnel (UAP), Which finding by the nurse requires intervention? #70769904 (59) 1. UAP has attached a bed alarm to the client's gown and bed 2. UAP has been making hourly rounds on the client 3. UAP has lowered the bed and raised all 4 side rails 4. UAP has placed a fall risk ID bracelet on the client's wrist.

2

A nurse is caring for a client 1 day after a LEFT-SIDED MASTECTOMY with lymph node dissection. Which nursing INTERVENTION is the PRIORITY in caring for this client? #70769904 (64) 1. Apply an ice pack to the left shoulder 2. Elevate the affected arm on a pillow 3. Help the client ambulate frequently 4. Obtain pneumatic compression sleeve

4

A parent calls the nursing triage line during the evening. The parent says that a 7 year old was found playing in an an area with POISON IVY and ask what to do? Which is the MOST important instruction to give the parent? #70769904 (50) 1. Apply cool, wet compresses for itching 2. Apply topical cortisone ointment to the area 3. Discourage the child from scratching the area 4. Wash the skin where the contact occurred.

4

A young client is diagnosed with MAJOR DEPRESSIVE DISORDER.. Three weeks prior, the client's fiance' broke off their engagement, claiming the client was "too fat and ugly." During a one on one interaction with the nurse , the client says. "My fiance' is really wonderful and is not to blame for calling off the engagement. I look awful and I'm not much good for anything" What is the BEST response by the nurse? #70769904 (53) 1. "How could your fiance' be wonderful after saying those things to you.." 2. "I think you are better off without your fiance" 3. "Maybe the breakup was for the best" 4. "Tell me how you felt when your fiance broke up with you."

1

An 81 year old client is admitted to a rahabilitation facility 3 days after total hip replacement. The next morning , the unlicensed assistive personnel (UAP) take the client's vital signs, but when the UAP goes back to assist the client with a shower, the client curses at and tries to hit the UAP. Which of the following is the MOST APPROPRIATE response by the registered nurse? CLICK ON THE EXHIBIT BUTTON FOR ADDITIONAL INFORMATION #70769904 (62) Vital signs Temperature 98.7 Blood pressure 110/64 mm Hg Pulse 92/min Respirations 22/min Oxygen saturation 90% on room air 1. "I need to assess the client." 2. "It sounds like the client is not satisfied with the care provided. I'll see if we can make the client more comfortable." 3. "Just leave the client alone now and try again later." 4. "The patient probably has dementia and is under a lot of stress with the change of environ-ment."

1

An adolescent client with a sore throat is diagno-sed with infectious. mononuclosis. Which comment by the caregiver would alert the nurse that ADDITIONAL INSTRUCTION IS NECESSARY? #70769904 (42) 1. "I need to go to the pharmacy to pick up an antibiotic prescription" 2. "It is acceptable for my child to have ibuprofen for discomfort or fever." 3. "My child will be on bed rest with few activi-ties for the next 2 weeks." 4. "Participation in soccer practice will not be allowed for the next month."

30

An infusion of norepinephrine at 8 mcg/min is prescribed for a client in shock. The concen-tration of norepinephrine is 4 mg in 250 mL D5W For how many mL per hour should the nurse program the IV pump? #70769904 (45) 1. Convert the prescribed dose to milligrams 1,000 mcg = 1mg 8 mcg/min x 1 mg/1000 mcg = 0.008 mg/min 2, Convert the prescribed dose from milligrams to milliliters Norepinephrine concentration is 4 mg per 250 mL 0.008 mg/min x 250 mL/4 mg = 0.5 mL/min 3, Convert the time from minutes to hours 60 min = 1 hour 0.5 mL/min x 60 min/hr = 30 mL/hr

3

Four clients come to the emergency department simultaneously . Which client should the nurse see FIRST for definitive care? #70769904 (47) 1. 6 month old with a temperature of 101 F (38 C) who is rubbing the ears and being fussy. 2. 10 day old client with a red mark (stork bite) on the neck, the mother is concerned. 3. A client who took a handful of amitriptyline pills, a tricyclic antidepressant drug. 4. A client who tripped and hit the head but is alert with no loss of consciousness, currently takes warfarin.

bowel rest

Management of acute diverticulitis focuses on ________________(NPO status, NG suction, bed rest) and drug therapy (IV antibiotics, analgesics). . Any procedure or treatment that increases intra-abdominal pressure or may cause rupture of the inflamed diverticula should be avoided. #70769904 (61)

1.3.5.6

The clinic nurse educator is developing a teaching plan for the following 6 clients. The nurse should instruct the client to avoid the VALSALVA MANEUVER when defecating? SELECT ALL THAT APPLY #70769904 (40) 1. 22 year old man with a head injury sustained during a college football game. 2. 30 year old woman recently hospitalized for reconstructive augmentation mammoplasty. 3. 56 year old man 2 weeks post myocardial infarction. 4. 68 year old woman recently diagnosed with pancreatic cancer. 5. 74 year old man with portal hypertension related to alcohol induced cirrhosis 6. 82 year old woman 1 week post cataract surgery.

1,2,5

The clinic nurse prepares to teach the parent of a child who has been diagnosed with SCABIES. Which instructions should the nurse include in the teaching plan? SELECT ALL THAT APPLY #70769904 (51) 1. All persons in contact with the child need treatment. 2. Apply permethrin to all body areas below the head. 3. Discard the stuffed animals 4. Fumigate all the living areas 5. Wash the child's bedding in hot water.

4

The daughter of an 80 year old client recently diagnosed with ALZHEIMER DISEASE says to the nurse. "I can anticipate getting this disease myself at some point." What is the BEST RESPONSE by the nurse? #70769904 (67) 1. "Have you suffered any recent head trauma." 2. "If you modify your lifestyle, you can reduce your risk of familial Alzheimer disease." 3. "It is good that you recognize this now so you can plan to our future care." 4. "Not necessarily, The strongest known risk factor for Alzheimer disease is age."

3

The nurse admits a client who fell off a 20 ft ladder. On arrival in the emergency department, the client is arousable but lethargic,. What is the nurse's PRIORITY action? #70769904 (41) 1. Ask about client's chronic medical conditions 2. Assess for level and duration of pain 3. Obtain a Glasgow Coma Scale score. 4. Perform a head to toe assessment.

3,4,5

The nurse is caring for a client admitted with SEROTONIN SYNDROME after taking citalopram and tramadol. Which assessement findings does the nurse expect to find? SELECT ALL THAT APPLY #70769904 (56) 1. Absent deep tendon reflexes 2. Cold, clammy skin 3. Muscle rigidity 4. Restlessness and agitation 5. Sinus tachycardia

3

The nurse is giving report at the end of a shift to the incoming nurse at 1900. A client was admitted with PNEUMONIA that morning . Which informa-tion is MOST IMPORTANT for the nurse to commu-nicate about the client during the change of shift report (hand-off)? #70769904 (58) 1. Chest x-ray showed left lobe infiltrate and white blood cell of 14,000 2. Client spouse was rude to the nurse earlier. 3. Current respirations are 24/min, pulse oximetry is 93% 4. Intravenous (IV) line has been infusing without complications.

2

The nurse is reviewing prescriptions for the assigned clients. Which prescription should the nurse QUESTION? #70769904 (68) 1. Allopurinol for a client who developed tumor lysis syndrome from chemotherapy for acute leukemia 2. Dicyclomine for a client with a history of irri-table bowel syndrome who develops a postope-ratively paralytic ileus. 3. IV morphine for a client after percutaneous nephrolithotripsy who reports the last bowel movement was 2 days ago. 4. Levofloxacin for a client with a urinary tract infection who has a history of anaphylaxis to penicillin drugs.

3

The nurse receives report on 4 clients. Which client conditions require PRIORITY assessment? #70769904 (57) 1. 34 year old with acute pericarditis reporting left sided chest pain that is worse with inspirations 2. 54 year old post right femoropopliteal bypass surgery reporting sudden onset severe right foot pain. 3. 64 year old post hip replacement reporting sudden onset right sided chest pain and dyspnea 4. 70 year old with pneumonia, rapid, irregular pulse of 140/min and blood pressure of 130/86 mm Hg.

4

The nurse reviews laboratory data for a client admitted to the emergency department with chest pain. Which serum value requires the most IMMEDIATE action by the nurse? #70769904 (48) 1. Glucose 200 mg/dL 2. Hematocrit 38% 3. Potassium 3.4 mEq/L 4. Troponin 0.7 ng/mL

4

The public health nurse conducts a teaching prog-ram for parents of infants. Which statement by a participant indicates that teaching has been successful? #70769904 (44) 1. "I can offer my 7 month old an egg while omelet with soft, mushy vegetables. 2. "I will switch my 1 year old to low fat milk instead of commercial formula." 3. "It is safe to sweeten my 4 month old infant's formula with honey." 4. "My infant should be able to pick up small finger foods by age 10 months. "

1

The unit implemented a quality improvement program to address client pain relief. Which set of criteria is the BEST determinant that the goal has been met. ? #70769904 (46) 1. Chart audits found clients' self reported pain scores improved by 10% 2. Number of narcotics used on the unit increased by 20% 3. Positive comments on returned client satisfac-tion surveys increased by 30%. 4. Survey found that 90% of the nurses believed clients had pain control

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? #70769904 (54) 1. Assess for jugular venous distension 2. Attach the cardiac monitor to the client 3. Auscultate heart and breath sounds 4. Obtain the client's vital signs

2,4

Which ACTIONS are appropriate for the registered nurse to delegate to an experienced licensed practical nurse? SELECT ALL THAT APPLY #70769904 (49) 1. Administer heparin continuous infusion to a client with a venous thromboembolism 2. Auscultate bowel sounds 2 days after repair of an inguinal hernia 3. Discuss concerns about last shift's care with an irate family member 4. Monitor flow rate and drainage in a client receiving bladder irrigation. 5. Teach kegel exercises after a child has a catheter removed.

2

Which nursing instruction is the HIGHEST PRIORITY when teaching a 38 year old female client newly diagnosed with stress incontinence? #70769904 (52) 1. Coaching related to kegel exercise 2. Importance of voiding every 2 hours 3. Minimizing caffeine and alcohol 4. Use of incontinence pads and pessary

4

Which prescription should the nurse QUESTION when caring for a hospitalized client diagnosed with ACUTE DIVERTICULITIS? #70769904 (61) 1. Metronidazole 500 mg IV every 8 hours 2. Nasogastric tube to suction. 3. Nothing by mouth (NPO) 4. Prepare for barium enema in AM

Pincer grasp

a thumb to forefinger movement, develop at age 8-10 months. This is the time to start offering small finger foods such as cheerios or cut up pieces of nutritious foods. #70769904 (44)

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 assessments. #70769904 (55)

Pulmonary embolism

is a life threatening emergency. Clients who have had major surgery, prolonged immo-bilization or are taking estrogen containing contraceptive pills are at high risk. #70769904 (57)

Scabies

is a skin infestation caused by the Sarcoptes scabiei mite. It spread easily via direct PERSON TO PERSON contact (eg. nursing homes, day cares , prisons) #70769904 (51)

valsalva maneuver

is contraindicated in the client diagnosed with increased intracranial pressure, stroke, head, injury, heart disease, glaucoma , eye surgery , abdominal surgery, and liver cirrhosis. #70769904 (40)