RN NCLEX study quiz

A client presenting at the clinic has a history of systemic lupus erythematosus (SLE). Which finding would indicate to the nurse that the client is having a flare-up of the disease?

- Abdominal discomfort - Butterfly rash on face - Fever

Anosia

Inability to recognize object by sight.

What food should the nurse include when teaching an older adult about increasing vitamin B12 intake?

- Calf liver - Feta cheese - Shrimp - Tuna

Biot's respirations

Respiratory pattern characterized by periods of rapid respirations, then apnea periods

A client with a history of intolerance to fatty foods is admitted to the hospital with a sudden onset of severe right upper quadrant pain radiating to the right shoulder. What should be included in the nurse's initial focused assessment of this client?

"Please describe your bowel habits and stool."

The charge nurse is making assignments for the evening shift. Which client would be an appropriate assignment for a new LPN/VN graduate?

An elderly adult diagnosed with diverticulitis

Dysgraphia

Difficulty communicating via writing

In what position should the nurse place a client post intracranial surgery?

Head of bed elevated 30 degrees.

After completing the initial morning assessment of a client, the nurse notes that a dose of intranasal desmopressin is to be administered. What action is most important for the nurse to take?

Hold desmopressin dose: clients in fluid volume excess cannot have desmopressin:

A client has just had a bone marrow biopsy. What is the nurse's priority intervention post procedure?

Hold pressure on needle site for at least 5 minutes.

The nurse is caring for a burn victim with a skin graft to the hand. The area is pale and mottled but has good capillary refill. What is the nurse's best action at this time?

Warm the room.

Diabetic Ketoacidosis (metabolic acidosis)

will have signs of dehydration due to polyuria fruity breath odor is from the acetone that occurs with breakdown of fats and formation of ketones client will spill glucose into the urine vomiting with abdominal pain are frequent Will have Kussmaul respirations

Which clients would the nurse monitor for the development of hypovolemic shock?

- Addisonian crisis - Partial thickness burns over 50% total body surface area - Type 2 diabetic with hyperglycemic hyperosmolar nonketotic coma

A client with renal failure has returned to the unit post kidney transplant. Which postoperative interventions should the nurse provide?

- Administer furosemide - weigh daily - Measure urine output every 30-60 minutes

What signs or symptoms should the nurse assess for when monitoring a client who has a brain injury?

- Rhinorrhea - BP 150/60 - Papilledema - Projectile vomiting

What signs/symptoms would the nurse expect to find in a client diagnosed with pernicious anemia?

- Smooth, red tongue - Burning feeling in feet - lightheadedness - dyspnea on exertion - neurological problems such as a burning feeling in the feet, slow reflexes, and disorientation. light headedness, dyspnea on exertion, fatigue, and breathlessness are anemia symptoms that clients often report.

A nurse is in the mall when a shopper who suddenly becomes non-responsive. Obtaining an available AED, the nurse would initiate what emergency interventions?

- Clear everyone before shock - Turn on the machine - Place pads on client's chest.

The nurse is teaching a group of clients how to decrease the risk of developing osteoarthritis. What should the nurse include?

- Control high blood sugar - Use largest, strongest joints for lifting - Maintain a healthy weight - Wear joint padding with playing sports.

A nurse suspects that a client admitted to the emergency department is in diabetic ketoacidosis. What data would lead the nurse to this conclusion?

- Dry mucous membranes - Fruity-smelling breath - Glycosuria - Client report of abdominal pain

A community health nurse is planning to teach a group of caregivers about early warning signs of Alzheimer's disease (AD). What signs should the nurse include?

- Mild disorientation - Difficulty with words and numbers.

A client returns to the unit after a liver biopsy. Which nursing interventions would the nurse implement?

- Put a pillow under the costal margin - Place in the right side lying position - Take vital signs every 10-15 minutes for first hour. - Place pillow under costal margin to place additional pressure on the rib cage which will assist with applying pressure to the liver capsule, place on right side so the liver capsule at the site of the biopsy is compressed against the chest wall. - If the puncture site is not compressed, there is the possibility that blood or bile will leak from the puncture site

Which food items, if chosen by a new unlicensed assistive personnel (UAP), would indicate to the nurse that the UAP understands a clear liquid diet?

- White grape juice - Gelatin - Lemon popsicle - Fat free broth - Tea with honey

A client receiving chemotherapy for lung cancer reports increased fatigue. The family confirms client is sleeping most of the day and night. What priority action would the nurse take?

Check current lab values of hematocrit and hemoglobin.

A client has been admitted to the med-surg floor with lower abdominal pain and bloating, fever, chills, and vomiting. Following a Cat scan, a diagnosis of diverticulitis is made. What action by the nurse is most appropriate after the initial assessment?

Notify dietary the client will need a clear liquid diet.

A client diagnosed with hypothyroidism has received dietary education from the nurse. Which snack selection chosen by the client would indicate that education has been successful?

Popcorn. - Hypothyroidism clients tend to have constipation due to decreased motility of the GI tract and need increased fiber and fluid intake. popcorn is high in fiber.

After applying oxygen using bi-nasal prongs to a client who is having chest pain, the nurse should implement which intervention?

Post signs on the client's door and in the client's room indicating that oxygen is in use.

A post-operative client becomes anxious and reports acute onset of chest pain when taking a deep breath and shortness of breath. Initial vital signs obtained by the nurse reveals tachycardia, hemoptysis, and a pulse oximeter reading of 90%. What intervention should the nurse initiate first?

Raise head of bed to 90 degrees.

The nurse is making an initial home visit to a client newly diagnosed with diverticulitis. The client had been on a liquid diet but is now to begin solid foods appropriate for the disease process. The nurse knows dietary teaching has been successful when the client selects which meal?

Spaghetti with meatballs, fruit cocktail, garlic bread

A community health nurse prepares a presentation about decreasing the risk of the spread of influenza in the community. Which information should the nurse include in the presentation?

Use a shirtsleeve when coughing or sneezing

Desmopressin

Used for diabetes insipidus - DI occurs when client does not produce enough antidiuretic hormone - causing the client to lose too much water. - Desmopressin is a synthetic ADH to make the client retain water. - Monitor for fluid volume excess: drowsiness, mild headache, dry mucous membranes, pitting edema, increased pulse pressure, vital signs and weight increase progressively, decreased urinary output. - if fluid volume excess is noted, reduce or hold desmopressin, administer furosemide