FON Learning system 3.0 NCLEX-PN
A hemoglobin level expected reference range
12 to 18 g/dL.
Sodium level reference range
136 to 145 mEq/L.
The nurse should instruct the client to hold the cane with the elbow
slightly flexed to provide support and stability.
What does a heart murmur sound like?
swishing or a whistling sound.
Low- and medium-frequency sounds are more easily heard with
the bell of the stethoscope
Preoperative care begins when
the client agrees to have surgery and ends when the client is transferred to the surgical suite table.
Postoperative care begins when
the client is admitted to the PACU and ends when healing is complete.
Intraoperative care begins when
the client is transferred to the surgical suite table and ends when the client is admitted to the PACU.
Jean Piaget's theory of cognitive development places children between the ages of 2 and 7 years in
the preoperational period.
Heart murmurs are caused by turbulent blood flow through valves or ventricular outflow tracts.
turbulent blood flow through valves or ventricular outflow tracts.
Rotation is
turning the head as far as possible in a circular movement to each side.
A murmur can be a manifestation of
valvular disease.
Bearing down before insertion of indwelling catheter helps the nurse
visualize the urinary meatus and also relaxes the external sphincter, which facilitates insertion of the catheter.
A client who has end-stage cirrhosis likely has a life expectancy of
≤6 months.
A nurse is preparing to insert an indwelling urinary catheter for a client. Which of the following actions should the nurse have the client perform just before inserting the catheter?
D. Bear down gently
The client should have a colonoscopy every________; testing should occur more often if the client has risk factors for colorectal cancer.
10 years
blood glucose expected reference range
70 to 110 mg/dL for fasting <200 mg/dL for a casual blood draw.
A nurse is caring for a client who has a prescription for the collection of a sputum specimen for culture and sensitivity. Which of the following actions should the nurse plan to take when obtaining the specimen?
A. Collect the specimen once the client rises in the morning
A nurse on a medical-surgical unit is admitting a client. Which of the following pieces of information should the nurse document in the client's record first?
A. Data collection for the client
A nurse is reinforcing teaching with a group of young adults. Which of the following should the nurse identify as an expected developmental task for this age group?
A. Independent moral development
A nurse is performing a breast examination for a female client. Which of the following techniques should the nurse use first?
A. Inspect both breasts simultaneously
A nurse is caring for a client who is exhibiting confusion. The nurse should identify that which of the following laboratory values can cause confusion?
A. Sodium 123 mEq/L
A nurse is planning a community presentation for young adults. Which of the following behaviors should the nurse suggest incorporating into the presentation as part of Erikson's expected developmental task for this age group?
B. Adjusting to living with a partner
A nurse on a pediatric unit is caring for a child who is 4 years old. To help with communication and play activities for this client, the nurse should consider which of the following characteristics of Piaget's preoperational period?
B. Animism
A nurse is caring for a client who is having difficulty breathing. The client is lying in bed with a nasal cannula delivering oxygen. Which of the following interventions is the nurse's priority?
B. Assist the client to an upright position
A nurse is assisting with planning a community campaign about seasonal influenza. Which of the following plans should be included as a secondary prevention strategy?
B. Screening groups of older adults in nursing care facilities for early influenza manifestations
A nurse is caring for a middle adult client. Which of the following statements indicates that the client has completed Erikson's developmental task for her age group?
B."I think I have done a good job with my children since they are all independent now."
A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the following actions should the nurse take?
C. Administer analgesics to the child on a routine schedule throughout the day and night
A nurse is caring for a client who has a methicillin-resistant Staphylococcus aureus (MRSA) infection. A dietary assistant asks the nurse what precautions are necessary for entering the client's room with the lunch tray. Which of the following instructions should the nurse give the dietary assistant?
C. Don gloves when entering the room and use hand sanitizer when exiting
A nurse is reinforcing teaching with a middle adult client about disease prevention and health maintenance. Which of the following diagnostic tests should the nurse recommend as part of routine health screening for women 50 to 64 years of age?
C. Eye examination every 2 years
A nurse is reinforcing teaching with a group of unit nurses about the experiences of clients who are having surgery. Which phase of care begins with transferring the client to the surgical suite table and ends with the transfer to PACU?
C. Intraoperative
A nurse is reinforcing teaching with a client regarding protein intake. Which of the following foods should the nurse include as an example of an incomplete protein?
C. Lentils
A nurse is removing a dressing over the surgical incision of a client who is postoperative following abdominal surgery. Today, the client reported that "something opened up." The nurse finds that the incision has separated and intestinal tissue is protruding. After calling for help, which of the following actions should the nurse take?
C. Position the client supine with the knees in flexion
A nurse in an oncology clinic is collecting data for a client who is undergoing treatment for ovarian cancer. Which of the following statements by the client indicates she is experiencing psychological distress?
C."I keep having nightmares about my upcoming surgery."
A nurse is caring for a client who is unstable and has vital signs measured every 15 min by an electronic blood pressure machine. The machine begins to measure the blood pressure at varied intervals, and the readings are inconsistent. Which of the following actions should the nurse take? A. Turn on the machine every 15 min to measure the client's blood pressure B. Record only blood pressure readings needed for the 15-min intervals C. Obtain manual and automatic readings and compare them
D. Disconnect the machine and measure the blood pressure manually every 15 min
A nurse is collecting data as part of a comprehensive physical examination of a client. The nurse should use inspection to evaluate which of the following?
D. Gait
A nurse in an urgent-care center is caring for a 15-year-old client whose symptoms suggest a sexually transmitted infection (STI). The client's parent is unavailable, but the client's grandmother accompanied the client to the clinic. Which of the following actions should the nurse take?
D. Have the adolescent sign the consent form
A nurse is planning to obtain the vital signs of a 2-year-old child who is experiencing diarrhea and may have a right ear infection. Which of the following routes should the nurse use to obtain the temperature?
D. Temporal
A nurse is evaluating a client's use of crutches. The nurse should identify that which of the following actions by the client indicates safe usage of this equipment?
D. The client has slightly flexed elbows when ambulating with the crutches
A nurse is evaluating the development of a group of clients. The nurse should understand that, according to Erikson, the developmental task of intimacy vs. isolation occurs during which of the following stages of development?
D. Young adulthood
annual mammogram.
Women age 45 years and older At age 55 change to every 2 years or continue with annual
pap test every 3 years
Women age 30 to 65
high-frequency sounds are more easily heard with
a diaphragm.
Learning a socially productive skill relates to Erikson's developmental task for
school-aged children, which is industry vs inferiority.
A nurse is conducting a health promotion class for a group of college students. Which of the following statements by a student indicates a potential problem with achieving Erikson's developmental task for this age group?
B. "I go home on the weekends to be with my family because I don't have any good friends here on campus."
A nurse is caring for a group of clients in a long-term care facility. The nurse should understand that which of the following clients is eligible for hospice services at this time?
B. A client who has end-stage cirrhosis
A nurse is assisting with planning a community presentation for parents. When suggesting a discussion of controlling impulses and cooperating with others, the nurse should plan to relate it to Erikson's developmental task for which of the following age groups?
B. Preschoolers
A nurse is supervising a newly licensed nurse who is caring for a client with streptococcal pharyngitis on transmission-based precautions. Which of the following actions by the newly licensed nurse indicates an understanding of droplet precautions?
C.Assigning another client with the same infection to share the room with the client
Moro reflex
The newborn extends both arms and legs outward and then draws them back inward in response to a loud noise such as a sudden clap. This is a general indication that the newborn heard the noise.
for an opened incision in the abdominal area- Apply sterile gauze over the incision
The nurse should soak sterile gauze in sterile 0.9% sodium chloride irrigation and apply it to the wound.
Dextran and albumin are plasma volume expanders.
They help correct hypovolemia in emergency situations such as after hemorrhage or burns.
Rooting
Touching the newborn's cheek makes the head turn to the side where the touch occurs. This feeding reflex disappears after the age of 4 months.
Tonic neck
When a newborn is supine and his head turns to one side, the opposite side's arm and leg are in flexion. This postural reflex disappears between the ages of 4 and 6 months.
CANE- The nurse should instruct the client to place the cane at
about 15 cm (6 in) from the side of the foot to provide balance and support.
Establishing a sense of sexual identity relates to Erikson's developmental task
adolescents, which is identity vs role confusion.
Complete proteins such as eggs, soybeans, and yogurt contain
all of the essential amino acids necessary for the synthesis of protein in the body.
broad-spectrum anti-infectives are
ampicillin and cefixime.
CANE- The nurse should instruct the client to walk
by stepping with the affected leg before the unaffected leg to maintain stability.
Kohlberg's theory of moral development
preconventional, conventional, postconventional
The oral route is not appropriate for use in
children under the age of 3 years.
Low sodium levels can cause
confusion and lead to seizures, coma, and death.
Clients who have a MRSA infection require
contact precautions.
DOWN STAIRS WITH CRUTCHES- The client should move the
crutches onto a step first when descending stairs, followed by the affected leg.
muscle relaxants are
cyclobenzaprine and metaxalone.
beta-adrenergic blockers are
propranolol and carvedilol.
An audible clicking sound occurs in clients who have
prosthetic valve replacement surgery.
MRSA does not spread via
droplet or aerosol
Tail of Spence
extension of breast tissue into the axilla
High Fowler's positioning permits
full chest and lung expansion and makes breathing easier.
Erikson's developmental task for young adults is
intimacy vs isolation.
Reversibility
is a characteristic of the concrete operations period for children between the ages of 7 and 11 years.
When an equipment is malfunctioning what should the nurse do?
it must be tagged and removed.
A potassium level expected reference range
3.5 to 5 mEq/L.
MRSA- Anyone who will have actual contact with this client must wear
a gown.
A protective environment requires at least
12 air exchanges per hour.
A nurse is caring for a client who requires a protective environment. Which of the following precautions should the nurse implement for this client?
D. Make sure the client wears a mask when outside his room
A nurse is helping a client change his hospital gown. The client has an IV infusion on an infusion pump. Which of the following actions should the nurse take first?
A. Remove the sleeve of the gown from the arm without the IV line
A nurse is reinforcing teaching with a client about the use of a straight-legged cane. Which of the following client actions indicates an understanding of the teaching?
A. The client holds the cane on the unaffected side.
A nurse is helping a client perform range-of-motion exercises of the neck. For evaluating neck flexion, which of the following motions should the nurse instruct the client to perform?
A. Touching his chin to his chest
A nurse is collecting data from a term newborn who is 8 hours old. Which of the following reflexes should the nurse identify as a preliminary indication that during gestation, the newborn developed the ability to hear?
D. Moro
A nurse is performing a physical examination of a client. To evaluate the client's skin moisture, the nurse should use which of the following techniques?
D. Palpation
A nurse is auscultating the heart sounds of a client who has developed chest pain that worsens with inspiration. The nurse hears a high-pitched scratching sound with the diaphragm of the stethoscope placed at the third intercostal space of the left sternal border. Which of the following heart sounds should the nurse document?
D. Pericardial friction rub
Establishing and maintaining an economic standard of living relates to Erikson's developmental task for middle adults
middle adults, which is generativity vs stagnation.
Flexion of the neck is
moving the chin down so that it rests on the chest.
Lateral flexion of the neck is
moving the head sideways toward the shoulder as far as possible.
Extension of the neck is
moving the head to an erect position after flexing or hyperextending it.
crutch palsy
paralysis of the brachial plexus due to pressure from prolonged use of a crutch
A nurse is reinforcing teaching with a client who has a new colostomy. Which of the following statements should the nurse identify as an indication that the client understands the instructions?
D."I will make sure to replace my pouch around 4 hours after I eat."
A nurse has received a prescription for dextran to administer to a client. The nurse should recognize that dextran belongs to which of the following functional classifications? A. Skeletal muscle relaxants B. Beta-adrenergic blockers C. Broad-spectrum anti-infectives D.Plasma volume expanders
D.Plasma volume expanders
A nurse is caring for a client who requires a protective environment. The nurse should place the client in a private room that provides
positive-pressure airflow.
Position the client supine with the knees in flexion for an opened incision in the abdominal area
reduces any strain that could cause further opening of the incision and worsening of the evisceration.
The nurse should wear an N95 respirator mask when caring for clients
who require airborne precautions (e.g. those who have tuberculosis), not a protective environment.
Babinski
With this reflex, the newborn's toes fan out when the nurse strokes the sole of the foot. If this response persists after the age of 1 year, it could indicate upper motor neuron damage.
Swallowing eases the passage of
a nasogastric tube past the client's oropharynx.
Seriation (Piaget)
is a characteristic of the concrete operations period for children between the ages of 7 and 11 years.
Self-consciousness.
is a characteristic of the formal operations period for children from the age of 11 years to adulthood.
Eye examination screening
is essential for monitoring vision and checking for glaucoma. Annual examinations from the age of 65 onward.
The client's admission to the facility where the surgery is to take place
is part of the preoperative phase and typically occurs outside of the surgical suite.
Examples of incomplete proteins include
lentils, vegetables, grains, nuts, and seeds.
