NCLEX 1
UV light treatments are limited to how many days per week
2-3
A client is receiving phenobarbital sodium. Which finding on the nursing assessment would indicate that the client is experiencing a common side or adverse effect of this medication?
Drowsiness is a common side or adverse effect of phenobarbital, which is a barbiturate and anti-seizure medication
which pulse point do you assess in an infant younger than one?
brachial
neuromuscular manifestations of hypothyroidism
lethargy, slow or slurred speech, and impaired memory
skin manifestations of hypothyroidism
such as coarse, brittle hair; thick, brittle nails; coarse, scaly skin; delayed wound healing; periorbital edema; and face puffiness
The nurse has instructed a client with a continuous passive motion device applied to the leg about the device and its use. The nurse determines that the client has misunderstood one of the teaching points if the client asks which question?
A: How to reset the degree of flexion or extension according to comfort The client should not adjust the flexion and extension settings. These settings are determined by the orthopedic surgeon and are maintained as prescribed. The client is instructed about how to stop and start the machine and about the need to notify the nurse if the client experiences knee discomfort. The client also should be aware of proper positioning so that the nurse can be notified if the leg slips. Other important actions by the nurse with use of this device are to assess the neurovascular status of the extremity and to ensure that the device is padded with manufactured disposable padding before the client's leg is placed in the device
A client is scheduled to have alteplase. Which item should the nurse obtain to monitor side/adverse effects of the medication therapy?
A: Occult blood test strips Alteplase is a thrombolytic medication that dissolves thrombi or emboli. Bleeding is a frequent and potentially severe adverse effect of therapy. The nurse assesses for signs of bleeding in clients receiving this therapy using occult blood test strips to test urine, stool, or nasogastric drainage.
A client is complaining of pain underneath a cast in the area of a bony prominence. The nurse interprets that this client may need which intervention?
A: to have a window cut into the cast A window may be cut in a dried cast to relieve pressure in an area of a bony prominence, to assess pulses, to relieve discomfort, or to remove drains
how to collect urine from an infant
attach a collection device to the infant's perineum
When using a glucometer to get a blood stick, which part of the finger should be stuck?
lateral side of the finger and not the central tip. the central tip contains more nerves and may be more painful
Cardiac troponin in elevations indicate
myocardial injury or infarction
gastrointestinal manifestations of hypothyroidism
complaints of constipation, weight gain, and abdominal distention
which sign should the nurse note is the superficial venous thrombosis were present
enlarged, hardened veins
The nurse is monitoring a child with burns during treatment for burn shock. Which assessment provides the most accurate guide to determine the adequacy of fluid resuscitation
A: Capillary refill Parameters such as vital signs (especially heart rate), urinary output volume, adequacy of capillary filling, and state of sensorium determine adequacy of fluid resuscitation.
A client is admitted to the hospital emergency department after receiving a burn injury in a house fire. The skin on the client's trunk is tan, dry, and hard. It is edematous but not very painful. The nurse determines that this client's burn should be classified as which type?
Full-thickness burns involve the epidermis, the full dermis, and some of the subcutaneous fat layer. The burn appears to be a tan or fawn color, with skin that is hard, dry, and inelastic. Edema is severe, and the accumulated fluid compresses tissue underneath because of eschar formation. Some nerve endings have been damaged, and the area may be insensitive to touch, with little or no pain.
The nurse is collecting subjective and objective data from a client and notes that the client is taking capecitabine. The nurse determines that this medication has been prescribed to treat which condition?
Metastatic breast cancer
Ultraviolet (UV) light therapy is prescribed as a component of the treatment plan for a client with psoriasis, and the nurse provides instructions to the client regarding the treatment. Which statement by the client indicates a need for further instruction?
The UV light treatment are given on consecutive days
The nurse is caring for a client with acute respiratory distress syndrome (ARDS). What should the nurse expect to note in the client?
The earliest clinical sign of ARDS is an increased respiratory rate. Breathing becomes labored, and the client may exhibit air hunger, retractions, and cyanosis. Arterial blood gas analysis reveals increasing hypoxemia, with a PaO2 lower than 60 mm Hg.
Which interventions should the nurse include in planning care of a client with mild preeclampsia
With mild cases of preeclampsia, the condition is monitored with self-care and bed rest at home. Before the need for hospitalization is discussed, the woman would need to be assessed for progression of the disease process. The nurse must assess blood pressure, weight, and the presence of protein in the urine because an increase in these areas would indicate a worsening condition
Clinical manifestations of COPD
hypoxemia, hypercapnia, dyspnea on exertion and at rest, oxygen desaturation with exercise, use of accessory respiratory muscles, and prolonged exhalation. Chest x-ray results indicate a hyperinflated chest and may indicate a flattened diaphragm if the disease is advanced.
thrombosis of superficial veins usually is accompanied by signs and symptoms of
inflammation, including swelling, redness, tenderness, and warmth of the involved extremity
position for lumbar puncture
side lying position with legs pulled up and head bent down onto chest this position helps open the spaces between the vertebrae and allows for easier needle insertion by the health care provider
what may be a cause of the high pressure alarm on a ventilator
tubing obstruction or kinks, breathing "out of phase" or "bucking the ventilator," accumulation of secretions, condensation of water in the ventilator tubing, coughing or Valsalva maneuvers, increased airway resistance, bronchospasms, decreased pulmonary compliance, and pneumothorax
The nurse is assessing the renal function of a client at risk for acute kidney injury. After noting the amount of urine output and urine characteristics, the nurse proceeds to assess which as the best indirect indicator of renal status?
A: BP The kidneys normally receive 20-25% of cardiac output, even under conditions of rest. For kidney function to be optimal, adequate renal perfusion is necessary. Perfusion can best be estimated by the blood pressure, which is an indirect reflection of the adequate of cardiac output.
In performing a physical assessment of a client with chronic kidney disease (CKD), which finding should the nurse anticipate?
CKD is a condition in which the kidneys have progressive problems in clearing nitrogenous waste products and controlling fluid and electrolyte balance within the body. Cardiovascular symptoms of heart failure and hypertension are caused by the fluid volume overload resulting from the kidneys' inability to excrete water. Signs and symptoms of heart failure include jugular venous distention, S3 heart sound, pedal edema, increased weight, shortness of breath, and crackles auscultated in the lungs. The typical signs and symptoms of CKD include proteinuria or hematuria, not glycosuria. The nurse would observe anorexia and nausea in this client, not polyphagia
ostomy care includes
cleaning the skin around the stoma, using a gentle soap and water, and then rinsing and drying well
in a client with venous disorder, the legs should be...
elevated above the level of the heart to assist with the return of venous blood to the heart
Atenolol hydrochloride is prescribed for a hospitalized client. The nurse should perform which action as a priority before administering this medication?
A: Check client BP Atenolol hydrochloride is a beta blocker that is used to treat hypertension. Therefore, the priority nursing action before administration of the medication is to check the client's blood pressure. The nurse also checks the client's apical heart rate. If the systolic blood pressure is lower than 90 mm Hg or the apical pulse is 60 beats/min or slower, the medication is withheld and the health care provider is notified. The nurse checks baseline renal and liver function tests. The medication can cause weakness, and the nurse would assist the client if weakness with activities occurs.
The nurse and an unlicensed assistive personnel (UAP) are assisting the respiratory therapist to position a client for postural drainage. The UAP asks the nurse how the respiratory therapist selects the position to be used for the procedure. The nurse responds that a position is chosen that will use gravity to help drain secretions from which primary areas
A: Lobes Postural drainage uses specific client positions that vary depending on the affected lobe or lobes. The positions usually place the head lower than the affected lung segments to facilitate drainage of secretions. Postural drainage often is done in conjunction with chest percussion for maximum effectiveness. The other options are incorrect
The nurse is assigned to care for a client with cytomegalovirus retinitis and acquired immunodeficiency syndrome who is receiving foscarnet, an antiviral medication. The nurse should monitor the results of which laboratory study while the client is taking this medication?
A: Serum Creatinine Foscarnet is toxic to the kidneys. The serum creatinine level is monitored before therapy, two or three times per week during induction therapy, and at least weekly during maintenance therapy. Foscarnet also may cause decreased levels of calcium, magnesium, phosphorus, and potassium. Thus, these levels also are measured with the same frequency.
A client is to undergo pleural biopsy at the bedside. When planning for any potential complications of the procedure, the nurse should have which item(s) available at the bedside?
A: chest tube and drainage system incase of the development of a hemothorax or pneumothorax Complications following pleural biopsy include hemothorax, pneumothorax, and temporary pain from intercostal nerve injury. The nurse should have a chest tube and drainage system available at the bedside for use if hemothorax or pneumothorax develops.
The nurse is caring for a client with Addison's disease. The client asks the nurse about the risks associated with this disease, specifically about addisonian crisis. Regarding prevention of this complication, how should the nurse inform the client?
Addison's disease is a result of adrenocortical insufficiency, and management is focused on treating the underlying cause. Hormone therapy is used for replacement. Hydrocortisone has both glucocorticoid and mineralocorticoid properties and needs to be taken 3 times daily, with two thirds of the daily dose taken on awakening. Fludrocortisone is taken once daily in the morning. Salt additives are necessary, particularly during times of stress, to compensate for excess heat or humidity as a result of the condition. There needs to be an increased dose of cortisol given for stressful situations such as surgery or hospitalization
A client is taking cetirizine. The nurse should inform the client of which side effect of this medication?
Cetirizine is an antihistamine; frequent side effects are drowsiness or sedation. Others include blurred vision, hypertension (and sometimes hypotension), dry mouth, constipation, urinary retention, and sweating. Therefore, the other options are incorrect
The client delivered a newborn baby 3 hours ago. The assigned nurse is reviewing the electronic health record to determine if the new mother is a candidate for Rh immune globulin administration. Which criteria must be present in order to administer this medication correctly?
Following the birth of a first child, if eligible, the mother should receive Rh immune globulin as a protection against the development of Rh isoimmunization in her next child. To be a candidate, the mother must be Rh negative, the newborn must be Rh positive, and the father must be Rh positive. The indirect Coombs' test should be negative and not contain any Rh antibodies
A client arrives at the postpartum unit after delivery of her infant. On performing an assessment, the nurse notes that the client is shaking uncontrollably. Which nursing action is appropriate?
In the postpartum period, a woman may experience a shaking, uncontrollable chill immediately after birth. The exact cause of this fairly common event is not known; however, it is thought to be associated with a nervous system reaction such as a vasovagal response. If the chill is not associated with an elevated temperature, it is of no clinical significance. The appropriate nursing action is to provide a warm blanket to the client and a warm drink if oral intake is not contraindicated.
The nurse is caring for a client who is at risk for increased intracranial pressure (ICP) after a stroke. Which activities performed by the nurse will assist with preventing increases in ICP?
Measures aimed at preventing increased ICP in the poststroke client include hyperoxgenating before suctioning to avoid transient hypoxemia and resultant ICP elevation from dilation of cerebral arteries; maintaining the head in a midline, neutral position to help promote venous drainage from the brain; and keeping the HOB elevated to between 25 and 30 degrees to prevent a decreased blood flow to the brain. Clustering activities can be stressful for the client and increase ICP. Maintaining 20 degree flexion of the knees increases intraabdominal pressure and consequently ICP
Rho(D) immune globulin is prescribed for a client after delivery and the nurse provides information to the client about the purpose of the medication. The nurse determines that the woman understands the purpose if the woman states that it will protect her next baby from which condition?
Rh incompatibility can occur when an Rh-negative mother becomes sensitized to the Rh antigen. Sensitization may develop when an Rh-negative woman becomes pregnant with a fetus who is Rh positive. During pregnancy and at delivery, some of the fetus's Rh-positive blood can enter the maternal circulation, causing the mother's immune system to form antibodies against Rh-positive blood. Administration of Rho(D) immune globulin prevents the mother from developing antibodies against Rh-positive blood by providing passive antibody protection against the Rh antigen.
how should the nurse position the client for a pericardiocentesis to treat cardiac tamponade
The client undergoing pericardiocentesis is positioned supine with the head of bed raised to a 45- to 60-degree angle. This places the heart in close proximity to the chest wall for easier insertion of the needle into the pericardial sac. Options 1, 2, and 3 are incorrect positions.
nail and foot care
The nurse should first perform hand hygiene and apply gloves to perform foot and nail care. The nurse would assess the condition of the skin and nails before the procedure, paying particular attention to areas of dryness, inflammation, or cracking. The nurse would inspect areas between the toes, the heels, and the sides of the foot. The nurse would also inspect the nails and feet after the procedure to ensure cleanliness and skin integrity and to note any remaining rough edges around the nails. The feet are soaked for 10 to 20 minutes in warm water for easy removal of dead cells and easy manipulation of the cuticle. Soaking longer than this time frame can cause maceration of the skin and skin breakdown. The nurse would clean under the nails with a plastic stick while the fingers are immersed in water; this allows for easy removal of debris under the nails. The stick is used gently to remove the debris and a plastic stick rather than a wood stick is used because wood could cause splintering. A soft nail brush is used to clean around the cuticles to prevent cuticle inflammation. Nails are filed straight across; filing the corners of nails can damage tissue. The nurse would also teach the client about the procedure and document the procedure and observations
The nurse is caring for a client who had tuberculin skin testing 48 hours ago on admission to the nursing unit. The nurse reads the test result as positive. Which action by the nurse has the highest priority?
The nurse who obtains a positive test reading should call the HCP immediately. The HCP will prescribe a chest x-ray study to determine whether the client has clinically active tuberculosis (TB) or old, healed lesions.
Which signs or symptoms if noted in the client will alert the nurse to the presence of thyroxtoxic crisis (thyroid storm)?
Thyrotoxic crisis (thyroid storm) is an acute, potentially life-threatening state of extreme thyroid activity that represents a breakdown in the body's tolerance to a chronic excess of thyroid hormones. The clinical manifestations include fever with temperatures greater than 100°F, severe tachycardia, flushing and sweating, and marked agitation and restlessness. Delirium and coma can occur
The nurse is preparing to assist a client with a cuffed tracheostomy tube to eat. What intervention is the priority before the client is permitted to drink or eat?
Tracheostomy tubes are available in many sizes and are made of plastic or metal. The tubes may be reusable; however, most tubes are disposable. A tracheostomy tube may or may not have a cuff. It also may have an inner cannula. For clients receiving mechanical ventilation, a cuffed tube is used. A noncuffed tube may be used when mechanical ventilation is not required. If a client with a tracheostomy is allowed to eat and the tracheostomy has a cuff, the nurse should inflate the cuff to prevent aspiration of food or fluids. The cuff would not be deflated because of the risk of aspiration. Although the nurse would ensure that the meal tray is in a comfortable position for the client, this would not be the priority intervention. The head of the bed should always be elevated; low Fowler's position could lead to aspiration
a rapid pulse with low pressure is a potential sign of...
excessive blood loss
heart failure may be precipitated or exacerbated by
physical or emotional stress, dysrhythmias, infections, anemia, thyroid disorders, pregnancy, Paget's disease, nutritional deficiencies (thiamine, alcoholism), pulmonary disease, and hypervolemia
The nurse is performing an assessment on a client who has returned from the dialysis unit following hemodialysis. The client is complaining of headache and nausea and is extremely restless. Which is the priority nursing action?
A: Notify the HCP Disequilibrium syndrome may be caused by rapid removal of solutes from the body during hemodialysis. These changes can cause cerebral edema that leads to increased intracranial pressure. The client is exhibiting early signs and symptoms of disequilibrium syndrome and appropriate treatments with anticonvulsive medications and barbiturates may be necessary to prevent a life-threatening situation. The HCP must be notified. Monitoring the client, elevating the head of the bed, and assessing the fistula site are correct actions, but the priority action is to notify the HCP
The nurse is teaching a pregnant client about the physiological effects and hormonal changes that occur during pregnancy. The client asks the nurse about the role of estrogen in pregnancy. Which responses should the nurse give the client about the role of estrogen
A: it increases the blood flow to mucous membranes and causes them to swell and soften and it stimulates uterine development to provide an environment for the fetus and stimulates the breasts to prepare for lactation Estrogen is a very important hormone of pregnancy. It is responsible for vasocongestion of the mucous membranes. Estrogen stimulates uterine development to provide an environment for the fetus and stimulates the breasts to prepare for lactation. Progesterone maintains the uterine lining for implantation and relaxes all smooth muscle. Human placental lactogen stimulates the metabolism of glucose and converts the glucose to fat; it is antagonistic to insulin. Human chorionic gonadotropin prevents involution of the corpus luteum and maintains the production of progesterone until the placenta is formed
The client with acquired immunodeficiency syndrome (AIDS) and Pneumocystis jiroveci infection has been receiving pentamidine. The nurse caring for the client should monitor the client most closely for signs of which adverse effect of the medication?
Acquired immunodeficiency syndrome is a viral disease caused by the human immunodeficiency virus (HIV), which destroys T cells, thereby increasing susceptibility to infection and malignancy. Pneumocystis jiroveci pneumonia (PCP) is a fungal infection and is a common opportunistic infection. Pentamidine is an antiinfective medication. Adverse effects of pentamidine include leukopenia, thrombocytopenia, and anemia. The client should be monitored routinely for signs and symptoms of infection. The client also should have ongoing monitoring of a number of parameters because of the nature and side effects of the medication, including complete blood cell count; liver function; blood glucose; blood urea nitrogen; and serum creatinine, calcium, and magnesium levels. The items in the remaining options are not associated with an adverse effect of this medication.
