NCLEX Unknowns
A pediatrician's prescription reads "ampicillin sodium 125 mL." The nurse prepares to draw up how many milliliters to administer 1 dose?
0.925 mL
Quinupristin-dalfopristin is prescribed as an intermittent intravenous (IV) infusion. The nurse should adjust the drip rate so that the dose is administered over what period of time?
1 hour
A client begins to experience extrapyramidal side effects from an antipsychotic medication. The nurse anticipates that the primary health care provider will prescribe which medication to treat this condition?
Benztropine
A 4-year-old child is admitted to the hospital for abdominal pain. The mother reports that the child has been pale and excessively tired and is bruising easily. On physical examination, lymphadenopathy and hepatosplenomegaly are noted. Diagnostic studies are being performed because acute lymphocytic leukemia is suspected. The nurse determines that which laboratory result confirms the diagnosis?
Bone marrow biopsy showing blast cells
The nurse caring for a child who has sustained a head injury in an automobile crash is monitoring the child for signs of increased intracranial pressure (ICP). For which early sign of increased ICP should the nurse monitor?
Changes in LOC
The nurse is caring for a 4-year-old child with human immunodeficiency virus (HIV) infection. The nurse should expect which statement that is aligned with the psychosocial expectations of this age?
I know it hurts to die
A client is participating in a therapy group and focuses on viewing all team members as equally important in helping the clients to meet their goals. The nurse is implementing which therapeutic approach?
Mileu therapy
A client has been placed in Buck's extension traction. The nurse can provide for countertraction to reduce shear and friction by performing which action?
Slightly elevating the foot of the bed
The nurse is monitoring a client who is in the active stage of labor. The nurse documents that the client is experiencing labor dystocia. The nurse determines that which risk factors in the client's history placed her at risk for this complication? Select all that apply.
-Age 54 -BMI 28 -Previous difficulty with fertility
The nurse is updating the client's plan of care based on the new onset of hypokalemia. Which priorities of care should the nurse include? Select all that apply.
-Ensure adequate oxygenation -Provide assistance to prevent falls -Monitor administration of diuretics -Prevent complications during administration of potassium
The nurse is preparing to teach a new mother how to sponge bathe a 1-day-old newborn. Which actions should the nurse take? Select all that apply.
-Gently pat baby dry -Support body during bath -Make sure room temp is 75 degrees -Clean one area at a time while keeping others covered
Which home care instructions should the nurse provide to the parent of a child with acquired immunodeficiency syndrome (AIDS)? Select all that apply.
-Monitor weight -Frequent hand washing is important -Avoid exposure to other illnesses -Clean up body fluid spills with bleach solution (10:1 ratio)
The nurse should monitor the client with a history of heroin addiction for which signs/symptoms of heroin withdrawal?
-Nausea -Vomiting -Diarrhea -Muscle aches -Diaphoresis
The nurse is completing an assessment on a client who is being admitted for a diagnostic workup for primary hyperparathyroidism. Which client complaint would be characteristic of this disorder? Select all that apply.
-Polyuria -Bone pain
Before providing care for a client in the late stages of chronic kidney disease (CKD), the nurse should review the results of which most relevant laboratory studies?
-Serum potassium -Serum calcium
A 67-year-old man is receiving outpatient radiation treatments for carcinoma of the oropharynx and has developed dysphagia. The nurse develops a teaching plan regarding dysphagia and includes which interventions in the plan? Select all that apply.
-Teach to examine oral mucosa daily -Encourage to use artificial saliva to manage dryness
A client with status epilepticus has been prescribed phenytoin to be given by the intravenous (IV) route. The nurse administering the medication is careful not to exceed which recommended infusion rate?
50 mg/min
The client with a crush injury to the leg has a highly positive urine myoglobin level. The nurse should assess this client carefully for signs and symptoms of which problem?
Acute tubular necrosis
The nurse is monitoring a child with burns during treatment for burn shock. Which assessment provides the most accurate guide to determine the adequacy of fluid resuscitation?
Adequacy of cap refill
The nurse in the labor room is caring for a client in the active stage of the first phase of labor. The nurse is assessing the fetal patterns and notes a late deceleration on the monitor strip. What is the most appropriate nursing action?
Administer oxygen via facemask
The nurse is caring for a client with a radius fractured across the shaft and bone splintered into fragments. Information about which type of fracture should be included by the nurse in the client's education?
Comminuted fracture
The nurse is caring for a client with a diagnosis of severe dehydration. The client has been receiving intravenous (IV) fluids and nasogastric (NG) tube feedings. The nurse monitors fluid balance using which as the best indicator?
Daily weight
The mother of an 8-year-old child being treated for right lower lobe pneumonia at home calls the clinic nurse. The mother tells the nurse that the child complains of discomfort on the right side and that ibuprofen is not effective. Which instruction should the nurse provide to the mother?
Encourage the child to lie on the right side
The nursing instructor is evaluating a nursing student for knowledge of antibody classes. Which statement by the nursing student indicates that teaching has been effective?
IgM is the first antibody produced in response to an antigen
A client has frequent bursts of ventricular tachycardia on the cardiac monitor. What should the nurse be most concerned about with this dysrhythmia?
It can develop into Vfib at any time
When teaching a client with glaucoma about the effects of a miotic medication, the nurse should tell the client that the medication will produce which effect?
Lower intraocular pressure and improve blood flow to the retina
The nurse is assessing the reflexes of a newborn infant. In eliciting the Moro reflex, the nurse should perform which action?
Make a loud, abrupt noise to startle the newborn
The nurse caring for a client with a diagnosis of acute schizophrenia should use which approach when planning care?
Provide assistance with grooming and nutrition until the client's thinking has cleared
The emergency department nurse is preparing to administer fomepizole to a client suspected of having ethylene glycol (antifreeze) intoxication. The nurse obtains the vial of medication and notes that the medication has solidified. Which action should the nurse take?
Run the vial under warm water
The nurse is caring for a client admitted for a fractured hip status post fall at home. On assessment of the client's affected lower extremity, which signs/symptoms would most likely be noted?
Shortening and external rotation
The nurse is reviewing the laboratory and diagnostic test results of a 5-year-old child scheduled to be seen in the clinic. The nurse notes that the primary health care provider documented that diagnostic studies revealed the presence of Reed-Sternberg cells. The nurse prepares to assist the primary health care provider to discuss which initial procedure with the parents?
Surgical biopsy
The nurse is assessing a client suspected of having meningitis for meningeal irritation and elicits a positive Brudzinski's sign. Which finding did the nurse observe?
The client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column.
A client being treated for heart failure is administered intravenous bumetanide. Which outcome indicates that the medication has achieved the expected effect?
Urine output increases from 10 mL/hour to greater than 50 mL hourly.
