Exam 1 Saunders NCLEX Questions

A client with Parkinson's disease has begun therapy with levodopa/carbidopa. The nurse determines that the client understands the action of the medication if he or she verbalized that results may not be apparent for how long?

2 to 3 weeks

The parents of a child recently diagnosed with cerebral palsy ask the nurse about her limitations of the disorder. The nurse responds by explaining that the limitations occur as a result of which pathophysiological process?

A chronic disability characterized by impaired muscle movement and posture

A client with a. History of gastrointestinal upset has been diagnosed with acute diverticulitis, the nurse should anticipate a prescription from the primary health care provider for which type of diet for this client?

A low fiber diet

The nurse is assisting a primary health care provider during the examination of an infant with hip dysplasia. The PCP performs the Ortolani maneuver. The nurse determines that the infant exhibits a positive response to this maneuver if which findings is noted?

A palpable click during abduction of the affected hip

The nurse is caring for a client after abdominal surgery and creation of a colostomy. The nurse is assessing the client for a prolapsed stoma and should expect to note which observations if this is present?

A stoma that is elongated with a swollen appearance

A child with developmental dysplasia of the hip is placed in the PAvlik harness. The nurse should demonstrate to the parents who to place the child in this harness by placing her child's legs in which position?

Abduction

A client with acute ulcerative colitis requests a snack. Which is the most appropriate snack for this client?

Applesauce and a graham cracker

The nurse is caring for a postoperative client who is receiving demand dose hydro morphine via a PCA pump for pain control. The nurse enters the clients room and finds the client drowsiest and records the following vital signs: T 97.2 oral, P52, BP 101/48, RR 18, SpO2 93% on 3 liters of O2. Which action should the nurse take next?

Attempt to arouse the patient

The ambulatory care nurse is providing instructions to a client who is scheduled fo ra colonoscopy and possible removal of a polyp. Which instructions are appropriate for a client preparation for this procedure?

Bowel preparation will be needed in preparation for the procedure

The nurse is caring for a client with a resolved intestinal obstruction who has a nasogastric tube in place. The PCP has now prescribed that the nasogastric tube be removed. What is the priority nursing assessment prior to removing the tube?

Checking for the presence of bowel sounds in all 4 quadrants

A client with crohns disease is scheduled to receive an infusion of infiximab. What intervention by the nurse will determine the effectiveness of treatment?

Checking the frequency and consistency of bowel movements

The nursing instructor is discussing the topic of pain with a student nurse who is assessing the status of pain in a cognitively impaired older adult. What comment by the student implies that further education is needed?

Clients in this age group are less sensitive to pain and have a greater pain tolerance.

Diphenoxylate hydrochloride with atropine sulfate is prescribed for a client with ulcerative colitis. The nurse should monitor the client for which therapeutic effect of this medication?

Decreased diarrhea

The nurse is caring for a client with ulcerative colitis. Which finding does the nurse determine is consistent with this diagnosis

Decreased hemoglobin

the nurse is caring for a client experiencing acute lower gastrointestinal bleeding. In developing the plan of care, which priority problem should the nurse assign to this client?

Deficient fluid volume related to acute blood loss

The nurse is caring for a client who has just returned from the operating room after the creation of a colostomy. The nurse is assessing the drainage in the pouch attached to the site where the colostomy was formed and notes serosanguineous drainage. Which nursing action is appropriated based on this assessment?

Document the amount and characteristics of the drainage

The nurse is providing instructions to a client diagnosed with IBS. Who is experiencing abdominal distinction, flatulence, and diarrhea. What interventions should the nurse include in the instructions?

Eat yogurt Take loperamide to treat diarrhea Use stress management techniques

The nurse is caring for a client receiving morphine sulfate for pain. because this medication has been prescribed for the client, which nursing action should be included in the plan of care?

Encourage the client to cough and deep breathe

A client has just had surgery to create an ileostomy. The nurse assess the client in the immediate postoperative period for high most frequent complication of this type of surgery?

Fluid and electrolyte imbalance

A client with a history of duodenal ulcer is taking calcium chewable tablets. Which finding indicated that the client is experiencing optimal effects of the medication?

Heartburn is relieved

transcutaneous electrical nerve stimulation (TENS) is prescribed for a client with pain, and the nurse instructs the client about the purpose of the TENS unit. Which statement by the client indicates the need for further teaching?

Hospitalization is required because the unit is not portable Rationale: the unit is portable, client controls the system for relieving pain and reducing the need for analgesics, is attached to the skin of the body.

The nurse is instructing a client with Parkinson's disease about preventing falls. Which client statement reflects a need for further teaching?

I don't need to use my walker to get to the bathroom

The nurse has given instructions for taking codeine sulfate to a client with a severe headaches. Which statement by the client indicates the teaching has been effective?

I should increase fluids intake

Dicyclomine hydrochloride has been prescribed for a client with IBS and the nurse provides instructions to the client about how to take this medication. Which statement made by client, indicated an understanding of how to take this medication?

I should take the pill 30 minutes before each meal.

A staff nurse is precepting a new graduate nurse and the new graduate is assigned to care for a client with chronic pain. Which statement, if made by the new graduate nurse, indicated the need for further teaching regarding pain management?

I will be sure to cue in to any indicators that the client may be exaggerating their pain

Carbidopa-levodopa is prescribed for a client with Parkinson's disease. The nurse monitors the client for side and adviser effects of the medication. Which fining I indicates that the client is experiencing an adverse effect?

Impaired voluntary movements

The nurse is assisting a client with crowns disease to ambulated to the bathroom. After the client has a bowel movement, the nurse should assess the stool for which characteristic that is expected with this disease?

Loose watery stool

The nurse is giving dietary instructions to a client who has a new colostomy. The nurse should encourage the client to eat foods representing which diet for the first 4-6 weeks postoperatively?

Low fiber

The nurse is administering a cleansing enema to a client with a fecal impact ion. Before administering the enema, the nurse should place the client in which position?

Modified left lateral recumbent position

the nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis who is scheduled for surgery in 2 hours. The client begins to complain of increased abdominal pain and begins to vomit. On assessment, the nurse notes that the abdomen is distended and bowel sounds are diminished. Which is the most appropriate nursing intervention?

Notify the health care provider (HCP).

The nurse is assisting a PCP examine a 3 week old infant with developmental dysplasia of the hip. What test or sign should the nurse expect the PCP to assess?

Ortolani's maneuver

The nurse is assessing the status of pain in an alert older client who was recently admitted to the hospital with a diagnosis of ruptured lumbar disc. What are some of the beliefs and concerns older adults have about pain?

Pain is something that must be lived with Nurses are too busy to listen to reports of pain. Pain signifies a serious illness or impending death. Reporting pain will result in being labeled as a bad client.

The nurse in a long term care facility is reviewing the primary health care providers prescription on an assigned patient. The nurse notes that the PCP prescribed ropinirole hydrochloride has been prescribed to treat which condition in the client?

Parkinson's disease

A child with cerebral palsy is in a management program to achieve maximum potential for locomotion, self care, and socialization in school. The nurse works with the child to meet these goals by performing which action?

Placing the child on a wheeled scooter board

The nurse is caring for a client who had a cholecystectomy 1 day ago. The nurse plans pain management techniques, knowing that the severity of the clients pain can be related to which factor?

Positioning of the client during surgery The duration of the operation, and the degree of tissue trauma also contribute to the presence and severity of postoperative pain.

The nurse caring for a client with crowns disease who has a calcium level of 8 mg/do . Which patterns would the nurse watch for on the electrocardiogram?

Prolonged QT interval Prolonged ST interval

The nurse is providing care for a client with a recent transverse colostomy. Which observation requires immediate notification of the primary health care provider?

Purple discoloration of the stoma

The nurse is caring for a hospitalized client with a diagnosis of ulcerative colitis. Which finding, if noted on assessment of the client, should the nurse report to the primary health care provider?

Rebound tenderness

A client with Crohn's disease is experiencing acute pain, and the nurse provides information about measures to alleviate the pain. Which statement by the client indicated the need for further teaching?

The best portion fo me is to lie supine with my legs straight

Sulfasalazine is prescribed for a client with a diagnosis of ulcerative colitis, and the nurse instructs the client about the medication. Which statement made by the client indicated a need for further teaching?

The medication will cause constipation

A client has a new colostomy created 2 days earlier and is beginning to pass malodorous flats from the stoma. What is the correct interpretation by the nurse?

This is a normal expected event

A client arrives at the emergency department complaining fo back spasm. The client states, "i. Have been taking 2-3 aspirin every 4 hours for the last week, it hasn't helped my back" since acetylsalicylic acid intoxication is suspected, the nurse should assess the client for which manifestation?

Tinnitus

Meperidine has been prescribed for a client to treat pain. Which side and adverse effects should the nurse monitor for? Select all that apply.

Tremors, drowsiness, hypotension

The nurse is preparing to teach a client with a new colostomy about how to preform a colostomy irrigation. Which information should the nurse include in the teaching plan?

Use 500-1000ml of warm tap water

The nurse is caring for a client who takes ibuprofen for pain. The nurse is gathering information on the clients medication history and determines it is necessary to contact the primary health care provider if the client is also taking which medications?

Warfarin, Glimepiride, amlodipine

A client with a new osteomyelitis is concerned about the odor from stool in the osteomyelitis drainage bag. The nurse should teach the client to include which food in the diet to reduce odor?

Yogurt