NCLEX RN Adaptive Questions

A nurse is caring for a client with heart failure. The healthcare provider prescribes a 2-gram sodium diet. What should the nurse include when explaining how a low-salt diet helps achieve a therapeutic outcome?

Allows excess tissue fluid to be excreted A decreased concentration of extracellular sodium causes a decrease in the release of antidiuretic hormone (ADH); this leads to increased excretion of urine. Sodium restriction does not control the volume of food intake; weight is controlled by a low-calorie diet and exercise (if permitted). The resulting elimination of excess fluid reduces the workload of the heart but does not improve contractility. Potassium is retained inefficiently by the body; an adequate intake of potassium is needed.

What is the optimal nursing intervention to minimize perineal edema after an episiotomy?

Applying ice packs. Cold causes vasoconstriction and reduces edema by lessening the accumulation of blood and lymph at the episiotomy site; cold also deadens nerve endings and lessens the pain. Heat therapy alone does not resolve perineal edema. Aspirin is contraindicated in the early postpartum period because of the risk for hemorrhage. Elevating the hips provides minimal perineal relief.

A pathology report states that a client's urinary calculus is composed of uric acid. Which food item should the nurse instruct the client to avoid? Milk Liver Cheese Vegetables

Liver. Uric acid stones are controlled by a low-purine diet. Foods high in purine, such as organ meats and extracts, should be avoided. Milk should be avoided with calcium, not uric acid, stones. Cheese or animal protein should be avoided with cystine, not uric acid, stones. Vegetables do not have to be avoided.

What change is seen when a child enters from a stage of toddlerhood to the stage of preschooler?

Preschoolers get into the habit of extending bedtimes. Preschoolers desire to extend their bedtimes. They show hyperactivity during sleeping hours. Preschoolers have sleep disturbances instead of sleeping soundly. Daytime naps are infrequent in preschoolers. Preschoolers sleep around 12 hours each night.

A teenager is being discharged with a cast. What should the nurse recommend if the client experiences pruritus around the cast edges?

"Put an ice pack on the affected area." An ice pack numbs the area and may temporarily diminish the discomfort. Scratching stimulates the release of histamine, which worsens the pruritus; also, scratching may break the skin and open an avenue for infection. Powder may become caked and slip under the cast, causing additional discomfort. Also, powder should be avoided because it is toxic if inhaled. Antihistamines are not prescribed unless all other measures have failed.

A 1-day-old infant with an imperforate anus undergoes a pull-through procedure with an anoplasty. What should postoperative nursing care include?

Encouraging continuation of breastfeeding. TO AVOID DIARRHEA.

After an amputation of a limb, a client begins to experience extreme discomfort in the area where the limb once was. What is the nurse's greatest concern at this time?

Addressing the pain. Phantom limb sensation is a real experience with no known cause or cure. The pain must be acknowledged and interventions to relieve the discomfort explored. There are no data indicating that the client is hopeless. Although promoting mobility in the residual limb may be effective for some people, it may not be effective for others; all possible interventions should be explored. There are no data indicating that the client is grieving.

After the removal of a cast from a fractured arm, an 82-year-old client is to receive physical therapy. In an older adult, how is mild exercise expected to affect respirations? Increase to 24 breaths per minute Become progressively more difficult Decrease in rate as their depth increases Become irregular but remain within normal rates

Increase to 24 breaths per minute In an older client, respirations are expected to increase to 24 breaths per minute and are a response to the need for oxygen at the cellular level because of the increased metabolic rate associated with exercise. Becoming progressively more difficult should not occur with mild exercise unless the client has cardiac disease. The rate of respirations will increase with mild exercise; because of inflexibility of the chest in the older adult, the depth will increase only minimally. Irregular respirations are not an expected response to exercise; this indicates a problem.

A nurse is working in a health care organization that has Magnet status. What specific responsibility does the nurse have in this organization? The nurse must follow best-practices for quality improvement. The nurse must use research-based practice to provide client care. The nurse must collect data for comparison against a national level. The nurse must refrain from taking independent actions during client care.

The nurse must collect data for comparison against a national level. The nurse in a Magnet health care organization must collect data on specific nursing-sensitive quality indicators or outcomes. This data must be compared with the national, state, or regional database to demonstrate quality care. The nurse must always follow evidence-based practice while providing client care. Best practice may not always be beneficial for the client. The nurse must use a problem-solving approach and combine research-based practice with client preferences and values. Nurses in Magnet health care organizations are encouraged to practice with a sense of empowerment and autonomy to deliver quality care.

A nurse is preparing a 10-year-old child for a tonsillectomy and adenoidectomy to be performed later in the day. What information should the nurse share with the child?

What the child will experience before and after the procedure. The explanation should be based on the sensations the child will experience. Discussing how the procedure is performed, the type of equipment that is used, or the changes in the child's anatomy during the procedure shortly before surgery may increase the child's anxiety.

A client at 10 weeks' gestation calls the clinic and tells a nurse that she has morning sickness and cannot control it. What should the nurse suggest to promote relief?

"Eat dry crackers before you get out of bed." Nausea and vomiting in the morning occur in almost 50% of all pregnancies. Eating dry crackers before getting out of bed in the morning is a simple remedy that may provide relief. Increasing fat intake does not relieve the nausea. Drinking high-carbohydrate fluids with meals is not helpful; separating fluids from solids at mealtime is more advisable. Eating two small meals a day and a snack at noon does not meet the nutritional needs of a pregnant woman, nor will it relieve nausea. Some women find that eating five or six small meals daily instead of three large ones is helpful.

A nurse receives an order to prepare the solution for administering a cleansing enema to a 3-year-old child. What is the volume of solution the nurse should prepare?

250 to 350 mL The nurse should prepare 250 to 350 mL of warmed solution for administering a cleansing enema in a toddler. The nurse should prepare 150 to 250 mL of warmed solution for infants. In school-aged children, the volume of warmed solution is 300 to 500 mL. In adolescents, the volume required is 500 to 750 mL.

A nurse is planning care for a client with substance-induced persisting dementia resulting from long-term alcohol use. Which nutritional problem, in addition to the effect of alcohol on brain tissue, has contributed to substance-induced persisting dementia?

Deficiency of thiamine. Substance-induced persistent dementia is caused by a prolonged deficiency of vitamin B1 (thiamine) and the direct toxic effect of alcohol on brain tissue. Increase in serotonin, reduction in iron intake, and malabsorption of riboflavin are problems that are unrelated to substance-induced persisting dementia caused by alcoholism.

The neonate has a protruding tongue and a crease that transverses the entire width of each palm. The nurse recognizes that these findings are characteristic of what congenital condition?

Down syndrome Dysmorphic features that are characteristic of Down syndrome include a protruding tongue and simian creases across the palms. A protruding tongue but not the transverse palmar creases may also occur with hypothyroidism. Turner syndrome is characterized by a webbed neck and peripheral edema. Children with fetal alcohol syndrome have dysmorphic features, but these are different from the ones that occur with Down syndrome.

Which are extrinsic factors responsible for falls in older adults? Select all that apply. Impaired vision Cognitive impairment Environmental hazards Inappropriate footwear Improper use of assistive devices

Environmental hazards, inappropriate foot wear, and improper use of assistive devices are extrinsic factors that are responsible for falls in older adults. Impaired vision and cognitive impairment are intrinsic factors that are responsible for falls in older adults.

During discharge planning the parents of an infant with spina bifida express concern about skin care and ask the nurse what can be done to avoid problems. What is the best response by the nurse?

Frequent diaper changes with cleansing are needed. Infants with spina bifida often exhibit dribbling of urine; they need meticulous skin care and frequent diaper changes to prevent skin breakdown. Changing diapers every 4 hours is insufficient and may result in skin breakdown. Medicated ointments are unnecessary; if a skin irritation develops and an ointment becomes necessary, it should be prescribed by the healthcare provider. Powder will not keep the skin dry; when powder mixes with urine, it forms a pastelike substance that promotes skin breakdown. Also, powder is toxic if inhaled and should be avoided.

An infant is admitted to the pediatric unit with the diagnosis of heart failure. What should the nurse include in the infant's plan of care? Increase the infant's fluid intake. Position the infant flat on the back. Offer the infant small, frequent feedings. Measure the infant's head circumference.

Offer the infant small, frequent feedings. Because infants with heart failure become extremely fatigued while suckling, small, frequent feedings with adequate rest periods between can improve their total intake. Infants with heart failure usually have fluids restricted to reduce the cardiac workload. Lying flat restricts lung expansion and should be avoided; positioning with the upper body elevated facilitates respirations. Infants with heart failure are not prone to hydrocephalus and do not need to have head circumference measured again if the initial newborn assessment findings are within expected limits.

An obese adult develops an abscess after abdominal surgery. The wound is healing by secondary intention and requires repacking and redressing every 4 hours. Which diet should the nurse expect the healthcare provider to prescribe to best meet this client's immediate nutritional needs?

Protein and vitamin C promote wound healing; this is a postoperative priority. Although a low-fat diet is preferred for an obese client, vitamin D, as well as other vitamins, should not be limited. A high-calorie diet can increase obesity, and there is no indication that this client is at risk for constipation requiring a high-fiber diet. A low-residue bland diet can cause constipation; the priority is for nutrients to promote healing.

A nurse is caring for a client with pain due to muscle spasm. Which nursing action is beneficial for the client? Providing heat compresses at the site Providing a massage to the affected area Encouraging the client to perform isometric exercises Encouraging the client to do active-passive range-of-motion (ROM) exercises

Providing heat compresses at the site The nurse provides thermotherapy (heat) to a client with muscle spasm. Heat compresses at the site of pain comforts the client by relaxing the muscle. A massage may stimulate muscle tissue contraction that increases spasm and pain. The client with muscle spasm may not be able to perform isometric muscle-strengthening exercises. The client may be encouraged to perform active-passive range-of-motion (ROM) exercises when the pain subsides.

Which dietary modifications can help improve the nutritional status of a client with acquired immunodeficiency syndrome (AIDS)? Refraining from consuming fatty foods Refraining from consuming frequent meals Refraining from consuming high-calorie foods Refraining from consuming high-protein foods

Refraining from consuming fatty foods Many clients with AIDS become intolerant to fat due to the disease and the antiretroviral medications. Therefore the client should be instructed to refrain from consuming fatty foods. The client should be encouraged to eat small and frequent meals to improve nutritional status. High-calorie and high-protein foods are beneficial to clients with AIDS because they provide energy and build immunity.

A client has a diskectomy and fusion for a herniated nucleus pulposus. When getting out of the bed for the first time since surgery, the client reports feeling faint and lightheaded. What should the nurses assisting with the ambulation have the client do?

Sit on the edge of the bed so they can hold the client upright. Sitting maintains alignment of the back and allows the nurses to support the client until orthostatic hypotension subsides. Sliding to the floor and bending forward will induce flexion of the vertebrae, which can traumatize the spinal cord. Rapid movement can flex the vertebrae, which will traumatize the spinal cord; taking the blood pressure at this time is not necessary.

A recently hospitalized client with multiple sclerosis is concerned about generalized weakness and fluctuating physical status. What is the priority nursing intervention for this client?

Space activities throughout the day. Spacing activities will encourage maximum functioning within the limits of strength and fatigue. Bed rest and limited activity may lead to muscle atrophy and calcium depletion. Strengths, rather than limitations, should be stressed. Having one of the client's relatives stay at the bedside is unnecessary. It is the nurse's responsibility to maintain client safety and meet client needs.

A 13-year-old adolescent is found to have idiopathic scoliosis. Because exercise and avoidance of fatigue are essential components of care, which sport should the nurse suggest as the most therapeutic for this preadolescent?

The hyperextension required in swimming helps strengthen back muscles and necessitates deeper respirations, both of which are necessary before surgery and before wearing a brace or cast. The other options involve twisting the back muscles, which is not therapeutic for a child with this condition.

Which statement is applicable to Watson's theory of transpersonal caring?

Watson's theory defines the outcome of nursing activity in relation to the humanistic aspects of life. Watson's theory of transpersonal caring defines the outcome of nursing activity in relation to the humanistic aspects of life. The Roy adaptation model views the client as an adaptive system. The Neuman systems model is based on stress and the client's reaction to the stressor. Leininger's theory focuses on cultural diversity; the goal of nursing care should be to provide the client with culturally specific nursing care.

A nurse is conducting cholesterol screening for a manufacturing corporation during a health fair. A 50-year-old man who is 6 feet (183 cm) tall and weighs 293 pounds (133 kg) puts out his cigarette and asks the nurse how to modify his risk factors for coronary artery disease. On which risk factors should the nurse help the client focus? Select all that apply. Age Height Weight Smoking Family history

Weight, Smoking

The goal of a particular nursing theory is to use communication to help a client re-establish positive adaptation to environment, and the framework for the nursing practice is based on treating nursing as a dynamic interpersonal process among the nurse, the client, and the healthcare system. Which nursing theory are these points related to?

King's theory

A mother who is visiting the pediatric clinic with her 10-month-old son tells the nurse how pleased she is with her chubby infant. She exclaims, "Look how much weight he's gained even though he drinks only orange juice! He won't drink any milk!" What is best response by the nurse?

"Let's talk about his nutrition." The nurse must determine whether the infant is eating solid foods and receiving vitamin and mineral supplements. Although orange juice contains vitamin C, it is too high in simple sugars and contains insufficient amounts of iron, calcium, and other essential vitamins and minerals. It is inappropriate to comment on the infant's weight; it is also insufficient to comment on just one aspect of the infant's dietary history. Asking why the infant is only drinking orange juice is a judgmental and accusatory question; again, it is insufficient to comment on just one aspect of the infant's diet history.

The nurse plans to provide a back massage to a client. What should the nurse do first in this situation? Assist the client into an appropriate position. Start massaging the client as soon as possible. Assess the client's preference for touch and massage. Provide information regarding the massage procedure.

Assess the client's preference for touch and massage. The nurse should first assess the client's preference for touch and massage when planning to give a back massage. The nurse can assist the client into an appropriate position, but only after assessing the client's preference for touch and massage. The nurse can start the massage, but only after knowing the client's perspective on touch. The nurse can provide information regarding the massage, but only after assessing the client's preferences.

A nurse is trying to soothe a 2-month-old infant who is crying. What is the best way to soothe a young infant? Offering the infant a bottle of diluted juice Holding and rocking the infant in a quiet room Changing the diaper before returning the infant to the crib Wrapping a blanket around the infant and placing him in a supine position

Holding and rocking the infant in a quiet room The comfort measures of close physical contact, the gentle rhythm of rocking, and the reduction of stimuli in a quiet room are conducive to a young infant's rest and sleep. Although offering a bottle will satisfy the sucking reflex, if the infant is not hungry this is a temporary measure that will not ease the discomfort felt by the infant. Although the diaper should be inspected and changed if needed, emotional comfort should be offered before the infant is returned to the crib. Wrapping the infant snugly in a blanket is not a substitute for close physical contact when trying to soothe a crying infant.

The nurse is taking care of a client with cirrhosis of the liver and ascites. Which lunch is the best choice for a client with this disorder?

Penne pasta, spinach, banana, and decaffeinated iced tea. A client with cirrhosis and ascites will require moderate to low fat and low sodium (penne pasta, spinach, banana, and decaffeinated iced tea). Caffeine can stimulate and cause distention. Ham, cheese, whole milk, potato chips, baked lasagna with sausage, milkshake, hamburger, french fries, and cola all have more fat and sodium than a client with cirrhosis should consume.

The nurse is caring for a client who had a hip replacement 2 days prior. After removing a bedpan from under the client, what is a priority nursing intervention?

Provide perineal care. Providing perineal care helps to preserve skin integrity for the client who is incapable of providing self-care. Turning and positioning the client who has decreased physical mobility after hip surgery is important in preventing skin breakdown, but it is not an immediate client need. Giving a complete bed bath is not necessary after each bowel movement because only the perineal area is typically soiled. Documenting the bowel movement should be done only after meeting immediate needs of the client.

A nurse needs to perform a postural drainage of both lung apices in a 4-year old child. In what position should the nurse place the child?

Sitting on nurse's lap, leaning forward In order to perform a postural drainage in a 4-year-old child, the nurse should place the child sitting on the nurse's lap, leaning forward against a pillow. In order to perform a postural drainage of the apical segments of adults, the client should sit on the side of the bed. In order to perform a right upper lobe drainage in an adult, the client should be the supine position with the head elevated. In order to perform a drainage of both lower lobes in an adult, the client should lie supine in Trendelenburg position.

A client is receiving hypertonic tube feedings. What should the nurse consider to be the main reason this client may experience diarrhea?

The increased osmolarity (concentration) of many formulas draws fluid into the intestinal tract, which can cause diarrhea; such feedings may need to be diluted initially until the client develops tolerance or is changed to a more iso-osmolar strength formula. Formulas frequently have reduced fiber content. Bacterial contamination is not a factor if the manufacturer's recommendations are followed. Inappropriate positioning may increase the risk for aspiration, but it does not cause diarrhea.

While caring for a client with a second-degree left ankle sprain, a nurse raises the injured part above heart level. What is the reason behind this nursing intervention?

To prevent further edema. A client with a second-degree sprain may have a deeply torn ankle ligament with swelling and tenderness. Elevation of the injured lower limb above heart level helps mobilization of the excess fluid from the area and prevents further edema. Strengthening exercises help to build bone density and muscle strength and significantly reduce the risk of sprains and strains. Cryotherapy and adequate rest help to reduce pain by reducing the transmission and perception of pain impulses.

Each year, a client takes many trips to other countries. The client reports leg swelling during the long flights. How should the nurse best advise this client when traveling? Relax in a reclining position Sit upright with legs extended Walk around at least every hour Sit in any position that relieves pressure on the legs

Walk around at least every hour Muscle contraction associated with walking prevents pooling of blood in the extremities and dependent edema. Movement is required, not inactivity (reclining or sitting). Sitting in any position that relieves pressure on the legs does not include movement, which is essential to prevent thrombus formation.