NCLEX

The nurse is caring for a client at the end of life. Which skin changes would the nurse expect to note? Select all that apply.

1.Dry skin 2.Warm skin 3.Waxlike texture (correct) 4.Mottling of arms, legs, hands, and feet (correct) 5.Cyanosis of the nose, nail beds, and knees (correct)

The nurse is asked to prepare for the admission of a child to the pediatric unit with a diagnosis of Wilms' tumor. The nurse assists in developing a plan of care for the child and suggests including which intervention in the plan of care?

1.Monitor the temperature for hypothermia. 2.Monitor the blood pressure for hypotension. 3.Inspect the urine for the presence of hematuria at each voiding. (correct) 4.Palpate the abdomen for an increase in the size of the tumor every 8 hours.

The nurse notes in the medical record that a client with Cushing's syndrome is experiencing fluid overload. Which interventions should be included in the plan of care? Select all that apply.

1. Monitoring daily weight (correct) 2.Monitoring intake and output (correct) 3.Maintaining a low-sodium diet (correct) 4.Maintaining a low-potassium diet 5.Monitoring extremities for edema (correct)

The nurse is planning the client assignments for the day. The assignment that the nurse communicates to the unlicensed assistive personnel (UAP) includes which clients? Select all that apply.

1.A 9-year-old client with cystic fibrosis who requires assistance with toileting (correct) 2.A 5-year-old client admitted for diarrhea and dehydration who requires intravenous fluids 3.An 8-year-old client 2 hours post-tonsillectomy who requires frequent monitoring for hemorrhage 4.A 12-month-old client admitted 3 days ago with respiratory syncytial virus (RSV) who requires a bath (correct) 5.A 10-month-old admitted for spasmodic laryngitis who is scheduled for discharge the following day who requires feeding (correct)

The nurse is caring for a homebound older postoperative cardiovascular client. The caregiver's daughter says to the nurse, "My mother has fallen out of bed three times." Which actions should the nurse reinforce to prevent falls? Select all that apply.

1.Provide adequate lighting. (correct) 2.Apply a restraint to keep her in bed at night. 3.Ensure that frequently used items are easily accessible. (correct) 4.Have the bedside stand and overbed tray table within reach. (correct) 5.Leave the side rails down to reach books stacked on the floor by the bed.

A client is recovering at home after suffering a brain attack (stroke) 2 weeks ago. A home caregiver tells the home health nurse that the client has some difficulty swallowing food and fluids. Which nursing action would be appropriate?

Observe the client feeding himself or herself.