Saunder Nclex-PN 1

A clinic nurse is reinforcing instructions to a client with a diagnosis of pharyngitis. Which intervention should the client be encouraged to perform? 1. Avoid foods that are highly seasoned. 2.Restrict fluid intake to 1000 mL daily. 3.Drink warm herbal tea throughout the day. 4.Substitute hot chocolate in place of coffee.

1. Avoid foods that are highly seasoned.

The nurse must ambulate a client who has a nephrostomy tube attached to a drainage bag. The nurse plans to do this most safely by performing which action? 1.Changing the drainage bag to a leg collection bag 2.Hanging the drainage bag from a walker while ambulating 3.Tying the drainage bag to the client's waist while ambulating 4.Asking the client to hold the drainage bag lower than the level of the bladder

1.Changing the drainage bag to a leg collection bag

Which diagnostic tests indicate active tuberculosis? Select all that apply. 1.Chest x-ray 2.Tuberculin skin test 3.Gastric analysis washings 4.Sputum smear and culture 5.Interferon gamma release assays (IGRA)

1.Chest x-ray 3.Gastric analysis washings 4.Sputum smear and culture

A client with chronic obstructive pulmonary disease (COPD) on bed rest is weaned from the ventilator before transferring to a medical unit. To adequately restore client strength before getting the client out of bed, which is the priority client activity for the nurse to incorporate in the plan of care? 1.Instruct the client to reposition himself. 2.Elevate the head of the bed to 15 degrees. 3.Transfer the client to the chair three times daily. 4.Perform passive flexion and extension of the ankles.

1.Instruct the client to reposition himself.

A client who underwent kidney transplant 6 months earlier is seen in the clinic for a routine monthly appointment. The nurse reviews how the client has been doing and observes for signs/symptoms of acute rejection. Which signs/symptoms suggest acute rejection of the transplanted kidney? Select all that apply. 1.Oliguria 2.Swelling of the lips 3.Tachypnea with wheezing 4.Elevation of blood pressure over baseline 5.Abdominal tenderness on the side of the kidney transplant 6.Elevation of serum blood urea nitrogen (BUN) and creatinine

1.Oliguria 4.Elevation of blood pressure over baseline 5.Abdominal tenderness on the side of the kidney transplant 6.Elevation of serum blood urea nitrogen (BUN) and creatinine

A client is diagnosed with polycystic kidney disease, and the nurse provides information to the client about the treatment plan. The nurse determines that the client needs further teaching if the client states that which component is part of the treatment plan? 1.Sodium restriction 2.Genetic counseling 3.Increased water intake 4.Antihypertensive medications

1.Sodium restriction

The nurse is caring for a client with emphysema receiving oxygen. The nurse should consult with the registered nurse if the oxygen flow rate exceeded how many L/min of oxygen? 1.1 L/min 2.2 L/min 3.6 L/min 4.10 L/min

2.2 L/min

A client with benign prostatic hypertrophy (BPH) undergoes a transurethral resection of the prostate (TURP) and is receiving continuous bladder irrigations postoperatively. Which are the signs/symptoms of transurethral resection (TUR) syndrome? 1.Tachycardia and diarrhea 2.Bradycardia and confusion 3.Increased urinary output and anemia 4.Decreased urinary output and bladder spasms

2.Bradycardia and confusion

The nurse is instructing a client with diabetes mellitus about peritoneal dialysis. The nurse tells the client that it is important to maintain the prescribed dwell time for the dialysis because of the risk of which complication? 1.Peritonitis 2.Hyperglycemia 3.Hyperphosphatemia 4.Disequilibrium syndrome

2.Hyperglycemia

A client who has been taking isoniazid for 1½ months complains to the nurse about numbness, paresthesia, and tingling in the extremities. The nurse interprets that the client is experiencing which adverse effect? 1.Hypercalcemia 2.Peripheral neuritis 3.Small blood vessel spasm 4.Impaired peripheral circulation

2.Peripheral neuritis

The nurse is suctioning a client through a tracheal tube. During the suctioning procedure, the nurse notes on the cardiac monitor that the heart rate has dropped 10 beats. Which should be the nurse's next action? 1.Notify the registered nurse immediately. 2.Stop the procedure and oxygenate the client. 3.Continue to suction the client at a quicker pace. 4.Ensure that the suction is limited to 15 seconds.

2.Stop the procedure and oxygenate the client.

The nurse is assisting a client who underwent radical neck surgery to get out of bed. How does the nurse provide support to this client who is afraid to move the head? 1.The nurse applies a soft cervical collar. 2.The nurse places a hand behind the client's head. 3.The nurse raises the head of the bed 90 degrees. 4.The nurse assists the client to roll to the side of the bed and sit up slowly.

2.The nurse places a hand behind the client's head.

A client who is performing peritoneal dialysis at home calls the clinic and reports that the outflow from the dialysis catheter seems to be decreasing in amount. The nurse appropriately asks which question first? 1."Have you had any abdominal discomfort?" 2."Have you had any recurring bouts of diarrhea?" 3."Have you experienced any constipation recently?" 4."Have you had an increased amount of flatulence?"

3."Have you experienced any constipation recently?"

The nurse is performing nasotracheal suctioning of a client. The nurse determines that the client is adequately tolerating the procedure if which observation is made? 1. Skin color becomes cyanotic. 2.Secretions are becoming bloody. 3.Coughing occurs with suctioning. 4.Heart rate decreases from 78 to 54 beats per minute.

3.Coughing occurs with suctioning.

A client is scheduled for intravenous pyelography (IVP). Which priority nursing action should the nurse take? 1. Restrict fluids. 2.Administer a sedative. 3.Determine if there is a history of allergies. 4.Administer an oral preparation of radiopaque dye.

3.Determine if there is a history of allergies.

The nurse is caring for a client undergoing peritoneal dialysis. The nurse checks the client and notes that the drainage from the outflow catheter is cloudy. The nurse notifies the registered nurse and plans to take which action? 1.Stop the peritoneal dialysis. 2.Institute hemodialysis temporarily. 3.Obtain a culture and sensitivity of the drainage. 4.Add antibiotics to the next several dialysis bags.

3.Obtain a culture and sensitivity of the drainage.

A client arrives in the emergency department with an episode of status asthmaticus. What is the nurse's priority action? 1.Obtain a set of vital signs. 2.Administer oxygen at 21%. 3.Place the client in high-Fowler's position. 4.Obtain equipment for starting an intravenous line.

3.Place the client in high-Fowler's position.

A client had thoracic surgery 2 days ago and has a chest tube in place connected to a closed chest tube system. The nurse notes continuous bubbling in the water seal chamber. The nurse determines which? 1.This is normal on the second postoperative day. 2.The client has a large amount of fluid that is being evacuated by the system. 3.There is a leak in the system that requires immediate investigation and correction. 4.This is due to the suction applied to the system, which is set at 20 cm of suction pressure.

3.There is a leak in the system that requires immediate investigation and correction.

Which is an appropriate question to ask to determine the specific type of incontinence? 1."Do you feel pain when you urinate?" 2."Do you have any difficulty in starting your stream of urine?" 3."Have you needed to empty your bladder more frequently than usual?" 4."Have you been experiencing any urgency accompanied by dribbling or leaking urine?"

4."Have you been experiencing any urgency accompanied by dribbling or leaking urine?"

A client who suffered a crush injury to the leg has a highly positive urine myoglobin level. The nurse plans to monitor this particular client carefully for signs of which complication? 1.Respiratory failure 2.Brain attack (stroke) 3.Myocardial infarction 4.Acute tubular necrosis

4.Acute tubular necrosis

The nurse is checking the chest tube drainage system of a postoperative client who had a right upper lobectomy. The closed drainage system has 300 mL of bloody drainage, and the nurse notes intermittent bubbling in the water-seal chamber. One hour following the initial data collection, the nurse notes that the bubbling in the water-seal chamber is now constant, and the client appears dyspneic. Based on these findings, which action should the nurse do first? 1.Check the client's vital signs. 2.Note the amount of drainage. 3.Check the client's lung sounds. 4.Inspect chest tube connections.

4.Inspect chest tube connections.

The nurse is urging a client to cough and deep breathe after a nephrectomy. The client tells the nurse, "That's easy for you to say! You don't have to do this." The nurse interprets that the client's statement is likely a result of which contributing factor? 1.A stress response to the ordeal of surgery 2.A latent fear of needing dialysis if the surgery is unsuccessful 3.Effects of circulating metabolites that have not been excreted by the remaining kidney 4.Pain that is intensified because the location of the incision is near the diaphragm

4.Pain that is intensified because the location of the incision is near the diaphragm

The nurse is assigned to care for a client who has a chest tube. The nurse is told to monitor the client for crepitus (subcutaneous emphysema). Which method should be used to monitor the client for crepitus? 1.Auscultating the posterior breath sounds 2.Asking the client about pain upon inspiration 3.Placing the hands over the rib area and observing expansion 4.Palpating the skin around the chest and neck for a crackling sensation

4.Palpating the skin around the chest and neck for a crackling sensation

The nurse is assessing a client with suspected acute kidney injury. Which finding would support a diagnosis of acute intrarenal failure? 1.Urine output of 30 mL/hr for the past 24 hours 2.Urine analysis positive for casts and cellular debris 3.Renal ultrasound indicating the presence of ureteral calculi 4.Blood urea nitrogen (BUN) level of 48 mg/dL and creatinine level of 1.2 mg/dL

2.Urine analysis positive for casts and cellular debris

The nurse is caring for a 58-year-old client with chronic kidney disease who is receiving peritoneal dialysis. Which finding is considered most important by the nurse, requiring primary health care provider notification? 1. BUN: 40 mg/dL 2.WBC 15,000 mm3 3.ECG: First-degree heart block 4.Heart rate: 96 beats per minute

2.WBC 15,000 mm3