NCLEX 1

When changing the diaper of a newly circumcised male client, the nurse reinforces teaching with the parents about when to contact the health care provider. Which statement by the nurse shows correct teaching reinforcement?

"Notify the health care provider immediately for redness, swelling, or discharge." Signs of infection, such as redness, swelling, or drainage, should be reported to the health care provider immediately. Infections that become systemic in infants are life-threatening, so any potential infection should be reported immediately.

The postoperative client with an epidural catheter has voided 20 ml every hour for three hours and reports "it feels like I need to go but I cannot". The nurse performs bladder scan tasks in what order? (Place each option in order, from first to last.)

1.Position the client flat and supine and palpate the bladder 2.Turn the scanner on and select "male" or "female" 3.Place the head of the scanner 1.5 inches about the symphysis pubis 4.Take several scans at different angles to confirm amount 5.Notify the health care provider of a residual greater than 400 mL

The school age child is prescribed ibuprofen 400 mg PO. The available dosage is 100 mg/5 mL. How many mL does the nurse administer? (Round to the nearest whole number.)

100 mg/ 5mL = 20 mg/1 mL. Ordered 400 mg. 400 mg/20 mg = 20 mL.

A client admitted with heart failure has bacon, eggs, and granola for breakfast. The nurse reviews the client's chart and notes that a general diet has been prescribed. Which diet revision does the nurse discuss with the health care provider?

A low-sodium diet Clients with heart failure experience fluid volume excess. Salt causes retention of fluid and should be decreased in clients with this medical diagnosis. Bacon and granola are high in sodium and should be avoided. The nurse should also reinforce teaching to the client that salt should not be added to the eggs and can suggest low-sodium alternativ

A client admitted with acute decompensated heart failure reports feeling worse than when admitted. Which data collected by the nurse supports this report?

Admission weight 74 kg. Current weight 78 kg. With heart failure, the heart is unable to adequately pump blood to meet tissue oxygenation needs. An increase in weight shows fluid retention and worsening heart failure. This sign correlates with the client's report of feeling worse. Bilateral crackles to mid lobes. With heart failure, the heart is unable to adequately pump blood to meet tissue oxygenation needs. One sign of this excess fluid is crackles in the lungs. If the crackles remain midway, this demonstrates continued large amounts of retained fluid and a worsening condition. Respiratory rate 32 breaths/min walking to bathroom. With heart failure, the heart is unable to adequately pump blood to meet tissue oxygenation needs. If the client become severely tachypnic with ambulation, this indicates that the fluid volume is worsening.

When reviewing the client's prescribed medications, the nurse notices the order "sertraline 50 mg PO". Which action should the nurse take?

Call the health care provider to clarify the frequency of the medication The six rights for safe medication administration are: right medication, right client, right time, right route, right dose, and right documentation. In this case, the health care provider has omitted clarification of timing. The person who can resolve this error is the health care provider.

The post-operative client after a bowel resection tells the nurse "it feels like something popped in my stomach". The nurse assesses the wound and notes protrusion of internal organs. Which actions does the nurse take?

Check the blood pressure, heart rate, and level of consciousness The client with an evisceration is at high risk of shock. Vital signs and level of consciousness should be monitored every 5-15 minutes until the client is transported to the operating room or intensive care unit. Call for help from the rapid response team Wound evisceration is a medical emergency. Best practice is to call for help from the rapid response team. The client is at high risk of shock and should be monitored by members of the response team. Stay with the client even after the team arrives to provide history and information.

The health care provider has prescribed a clean catch urine from an older female client. Which instructions will the nurse provide the client?

Clean perineal area from front to back three times, using a fresh towelette each time. Proper cleaning prior to a clean catch urine specimen for a woman includes cleaning with a towelette from front to back three times. To avoid recontamination, a fresh towelette should be used for each pass. Prior to cleaning the perineal area and while voiding, spread the labia apart. Spreading the labia is important for clean catch urine specimens in women as it provides access to the urethral meatus. The client should be instructed to spread the labia with the non-dominant hand and clean with the dominant hand. This procedure is easiest for most clients. Use your call light to inform staff when you have obtained the specimen. Bacteria grows quickly in urine and should be received by the laboratory within 30 minutes. The client needs to notify staff when the specimen is collected to avoid false results. Specimens that cannot be delivered to lab within 30 minutes should be refrigerated in a specimen refrigerator, but refrigeration should not exceed two hours. Begin urination, and then pass the container into the stream, collecting 30-60 mL. The purpose of a clean catch specimen is to obtain urine from the bladder. The initial stream flushes out microorganisms from the urethral meatus and prevents transfer of these organisms into the specimen.

The nurse enters the client's room and finds the client lying on the floor. Which action does the nurse perform first?

Determine that the environment is safe When a client has fallen, the nurse should first assess the environment in order to prevent injury to themself. Even in a code situation, the nurse is obliged to ensure the scene is safe prior to continuing to assess and provide care for the client.

The nurse is preparing to give prescribed metoprolol sustained release to a client with ischemic heart failure. Which actions will the nurse perform prior to administration of the medication?

Determine the client's blood pressure. Metoprolol sustained release is a sustained release beta blocker that decreases blood pressure and heart rate. Prior to administration, the nurse must check the client's blood pressure and heart rate. Count an apical heart rate for 60 seconds. Metoprolol sustained release is a sustained release beta blocker that decreases blood pressure and heart rate. Prior to administration, the nurse must check the client's blood pressure and heart rate.

The nurse cares for a group of clients. The nurse maintains which clients on standard precautions?

Hives, or urticaria, are an immune response triggered by food, medication, insect bites, latex, or other allergen trigger.. Hives require management, typically with an antihistamine or a steroid. They are not contagious. This client has psoriasis. Psoriasis is a persistent skin disorder resulting in red plaques and white scales. The elbows and torso are often affected. Exacerbations are thought to be secondary to stressors to the immune system. Psoriasis is not contagious to others.

The unlicensed assistive personnel reports that a client with diabetes is confused and has slurred speech. Which action does the nurse complete first?

Obtain a fingerstick glucose level. The first priority for the client with diabetes presenting with confusion and slurred speech is determining the blood glucose level. These symptoms also mimic a stroke. Clients with diabetes are at higher risk of stroke because of their impaired circulation. The nurse should not assume that the blood sugar is low, but should have a value before following the facility policy for hypoglycemia.

The client with pneumonia on a ventilator is signaling to the nurse with their hands. The nurse does not understand what the client is trying to communicate. Which action does the nurse take?

Obtain paper and pencil so the client can communicate with writing Communication with clients who are unable to speak due to aphasia or mechanical ventilation is a top nursing priority. Hand gestures, mouthing words, and communication boards are all appropriate methods of communication with these clients. If one method of communication does not work for a particular client, the nurse should investigate other options.

The client reports feeling nauseated. Which prescribed PRN medication does the nurse administer?

Ondansetron Ondansetron is used to treat or prevent nausea. Docusate sodium is a stool softener used to treat or prevent constipation. Omeprazole is a protein pump inhibitor used to treat acid reflux. Calcium carbonate is used to treat heartburn. The best medication to administer for a client reporting nausea is ondansetron.

The nurse reviews the middle-aged client's morning lab results. Which value should be reported to the health care provider immediately?

Potassium 2.4 mEq/L The potassium level is critically low. Potassium is essential in electrical impulses of the heart. Critically low potassium levels can lead to sudden cardiac death from dysrhythmias. The health care provider needs to be notified immediately.

The nurse cares for an adult client reporting difficulty breathing. What is the nurse's priority action? (Listen to the audio clip.)

Prepare to assist in the placement of an advanced airway Stridor is often a medical emergency because it is the manifestation of a narrowed or partially obstructed upper airway. The nurse should prepare to assist the health care provider in placing an advanced airway. If less invasive measures are successful, that is great, but the nurse first prepares for emergency airway management.

The client reports dizziness after receiving a dose of atenolol. The nurse notes a blood pressure of of 86/50 mmHg and a heart rate of 50 beats/min. Which items does the nurse include in the documentation of this event?

Remind the client to call for help when getting up If a client is hypotensive and dizzy, the client should be reminded not to get out of bed without assistance. Dizziness and hypotension place the client at risk for falls. The client may become orthostatic when up, so it is essential that the client call for help. Placing the client in a supine position Lowering the head of the bed helps a client who is complaining of dizziness, especially if the dizziness is caused by hypotension. Keeping the client flat and in bed is important. It is not necessary to place the client in reverse trendelenburg. Vital signs prior to administration of the medication Blood pressure and heart rate should be checked prior to the administration of any beta blocker, such as atenolol. Most likely, this information would already have been documented, but, if not, it should be included with the documentation of the nurse to show how much of a change in blood pressure and heart rate occurred. This may assist the health care provider in determining a more appropriate dosage for this client.

A client with a demand pacemaker reports feeling dizzy. The client's radial pulse is 56 beats/min. Which actions does the nurse take?

Review the telemetry monitor The ECG should be reviewed for failure to sense or failure to fire. Additionally, the client may be experiencing ventricular dysrhythmias, which contribute to both a lower heart rate and feeling of dizziness. Obtain a blood pressure The client's report combined with bradycardia may indicate pacemaker dysfunction. The cardiac data, including an apical pulse, blood pressure, and telemetry, reading should be obtained in response to the client's report. Verify the apical heart rate The client's report combined with bradycardia may indicate pacemaker dysfunction. The cardiac data, including an apical pulse, blood pressure, and telemetry, reading should be obtained in response to the client's report.

Five minutes after beginning ampicillin via intravenous infusion, the client reports throat swelling and itching. Which intervention does the nurse do first?

Stop the ampicillin infusion The symptoms exhibited by the patient are concerning for anaphylaxis. Antibiotics in the penicillin family are especially prone to anaphylactic reactions. The first intervention in anaphylaxis is to stop the probable causative agent, in this case, the ampicillin.

The nurse is caring for a client three hours after a colon resection. Which data does the nurse report to the health care provider?

Temperature of 101.5 F (38.6 C) A client experiencing a fever after surgery is concerning. This is a sign of a potential infection, which can be life-threatening in the post-operative period. The nurse should notify the health care provider after completing additional data collection, such as blood pressure, heart rate, and drainage or redness from the surgical site. Blood pressure of 84/50 mmHg A hypotensive post-operative client is experiencing fluid volume deficit as a response to pain medications. The nurse should complete data collection, including urine output, temperature, and signs of bleeding, and review medications administered prior to notifying the provider. Urine output of 60 mL Urine output of 60 mL in three hours is below the acceptable range of 30-50 mL/hour and should be reported to the health care provider. The client may be experiencing fluid volume deficit or bleeding, and this should be communicated to the provider.

When reinforcing teaching of insulin administration using an insulin pen, which action by the client suggests a need for additional information?

The client attaches the needle and dials up the prescribed dose of medication. Once the needle has been attached to the pen, the client needs to prime the needle with 1-2 units of insulin. This ensures that the client will receive the full prescribed dose. The ordered dose should not be dialed until the needle has been primed.

The nurse reviews the client's chart before receiving report. Which data is of most concern to the nurse? (See exhibit.)

The morning lab results. The greatest concern are the morning labs, particularly the low platelet level for a client receiving enoxaparin. Heparin induced thrombocytopenia is a life-threatening side effect of enoxaparin and this is the priority concern.

The health care provider has prescribed removal of the client's abdominal Jackson-Pratt (JP) drain. While removing the drain, the nurse encounters resistance. Which action does the nurse take?

Verify that all sutures have been removed Before notifying the health care provider, make sure that all sutures have been removed. When removing the sutures, it is not uncommon to miss one stitch, especially if under the drainage device.

The nurse is reviewing the middle aged female client's morning lab results. Which result is the most concerning?

WBC 1800/mm3. While all of the listed lab values are low, the white blood cell count is critically low. A white blood cell count of less than 2000 puts the client at severe risk of infection.The health care provider needs to be notified immediately.