NCLEX CRITICAL THINKING

The nurse is monitoring the laboratory results of a client preparing to receive chemotherapy. The nurse determines that the white blood cell count (WBC) is normal if which result is present?

5000 mm3 (5 × 109/L)

A nurse discussing options with a mother of a child with cystic fibrosis (CF) asks if she understands the education. Which statement by the mother indicates a need for further teaching?

"I can give my child whatever foods he likes to eat, since he gets enzymes anyway."

The nurse determines a child is in the "preoperational" phase of Piaget's cognitive developmental theory when the child makes which statement?

"The moon follows me, and goes to bed when I go to bed".

The nurse is assessing a client's postoperative pain using the PQRSTU method. Using this method, which questions should the nurse ask the client? Select all that apply. Refer to video. Click on the Question Video button to view a video showing preparation procedures.

"What does the pain feel like?" "Where is the pain located?" "How does the pain affect you?" "What makes your pain better or worse?"

The client arrives at the ambulatory care center complaining of flulike symptoms. On data collection, the client tells the nurse that he was bitten by a tick and is concerned that the bite is causing the sick feelings. The client requests a blood test to determine the presence of Lyme disease. Which question should the nurse ask next?

"When were you bitten by the tick?"

The nurse is caring for a client with respiratory insufficiency. The arterial blood gas (ABG) results indicate a pH of 7.50 and a Pco2 of 30 mm Hg (30 mm Hg), and the nurse is told that the client is experiencing respiratory alkalosis. Which additional laboratory value should the nurse expect to note?

A potassium level of 3.0 mEq/L (3.0 mmol/L)

A client with rheumatoid arthritis is taking acetylsalicylic acid on a daily basis. Which medication dose should the nurse expect the client to be taking?

4 g daily

Which client is at risk for developing thyrotoxicosis?

A client with Graves' disease who is having surgery

The nurse's assignment is to visit a new mother at home who was recently discharged from the hospital. Which finding should the nurse expect to note in a healthy breastfeeding mother and newborn?

A mother breastfeeding with the newborn in a tummy-to-tummy position without signs of cracked nipples; the baby demonstrates bursts of sucking followed by a pause and swallow

A client was just admitted to the hospital to rule out a gastrointestinal bleed. The client has brought several bottles of medications prescribed by different specialists. During the admission assessment, the client states, "Lately, I have been hearing some roaring sounds in my ears, especially when I am alone." Which medication should the nurse determine to be the cause of the client's complaint?

Acetylsalicylic acid

The nurse is caring for a client experiencing a partial placental abruption. The client is uncooperative and is refusing any interventions until her husband arrives at the hospital. The nurse analyzes the client's behavior as likely the result of which situation?

Acute anxiety and the need for support

A client is suspected of having myasthenia gravis, and the primary health care provider administers edrophonium to determine the diagnosis. After administration of this medication, which sign/symptom would indicate the presence of myasthenia gravis?

An increase in muscle strength

Which individual is least at risk for the development of Kaposi's sarcoma?

An individual working in an environment where exposure to asbestos exists

Which finding indicates a side effect associated with the use of latanoprost eye drops?

Brown pigmentation of the iris

The nurse is monitoring a client with a blunt head injury sustained from a motor vehicle crash. Which would indicate a basal skull fracture as a result of the injury? Select all that apply.

Bruising behind ears ("Battle's sign") Bruising around eyes ("raccoon eyes") Bloody or clear drainage from the auditory canal

The nurse is assessing a pediatric client with a diagnosis of retinoblastoma. The nurse assesses for which most common clinical finding for a child with this diagnosis?

Cat's-eye reflex

A client receiving nitrofurantoin calls the primary health care provider's office complaining of side effects related to the medication. Which side effect indicates the need to stop treatment with this medication?

Chest pain

A client has experienced pulmonary embolism. The nurse should assess for which symptom that is most commonly reported?

Chest pain that occurs suddenly

The nurse is collecting data on a client diagnosed with Parkinson's disease. Which finding indicates a serious complication of this disorder?

Congested cough and coarse rhonchi heard during auscultation

A licensed practical nurse (LPN) is assisting in the care of a client who is receiving oxytocin to induce labor. The LPN plans to notify the registered nurse immediately if which signs and symptoms are noted? Select all that apply.

Decreased blood pressure, increased pulse Contractions greater than 1 minute in duration

The nurse is monitoring for fluid volume deficit in an infant who is vomiting and having diarrhea. The nurse weighs the infant's diaper after each voiding and stool and carefully calculates fluid volume based on which knowledge?

Each gram of diaper weight is equivalent to 1 mL of urine.

A primipara is being evaluated in the clinic during her second trimester of pregnancy. Which occurrence indicates an abnormal physical finding that necessitates further testing?

Fetal heart rate of 180 beats per minute

The nurse notes that a client is being treated with nesiritide. The nurse should expect this client to be experiencing which disorder?

Heart failure

The nurse is reviewing the serum electrolyte laboratory results of a client and finds that the client has an elevated magnesium level. Which part of the client's history is likely associated with this problem?

History of chronic laxative use

The client diagnosed with acquired immunodeficiency syndrome (AIDS) is prescribed intravenous (IV) pentamidine isethionate. The nurse assigned to care for the client should primarily monitor for signs of which toxic effect related to the administration of this medication?

Hypoglycemia

The nurse is caring for an adult client with respiratory distress syndrome. A review of the arterial blood gas results indicates that the client is experiencing respiratory alkalosis. The nurse should then examine the results of serum electrolytes to see whether which electrolyte imbalance is present?

Hypokalemia

The nurse is caring for a client who has been taking diuretics on a long-term basis. Which finding should the nurse expect to note as a result of this long-term use?

Increased specific gravity of the urine

A clinic nurse is reviewing the record of a client recently diagnosed with a cataract. Which clinical manifestations associated with this disorder should the nurse expect to be documented in the client's record? Select all that apply.

Increasing nearsightedness Need for more light when reading Painless progressive loss of vision

A comatose client received therapeutic hypothermia after a cardiac arrest. The nurse anticipates which primary complications associated with this treatment? Select all that apply.

Infection Bleeding Metabolic and electrolyte disturbances

Which data indicate to the nurse that a client is experiencing effective coping following the loss of a spouse? Select all that apply.

Looks at old snapshots of family Visits the spouse's grave once a month Visits the senior citizens' center once a month

The nurse is monitoring a client receiving a blood transfusion for circulatory overload. The nurse understands that which is a clinical indication of circulatory overload?

Moist, productive cough

A client with cancer is receiving daunorubicin intravenously. The nurse assigned to assist in caring for the client monitors for which commonly expected side effect?

Nausea and vomiting

An adult client has increased fluid in the middle ear that is causing vertigo. The nurse checks this client for which associated signs and symptoms of this condition?

Nausea and vomiting

The nurse is preparing to collect data on a client with a possible diagnosis of ectopic pregnancy. Which should the nurse check first?

Pulse

The nurse is monitoring a child following a tonsillectomy. Which finding would indicate that the child is bleeding?

Restlessness

A client with type 1 diabetes mellitus has had a left above-the-knee amputation. The nurse carefully inspects the residual limb for which complication because of the history of diabetes?

Separation of wound edges

The nurse is assigned to care for the client diagnosed with cytomegalovirus retinitis and acquired immunodeficiency syndrome (AIDS) who is receiving foscarnet. The nurse should monitor the results of which laboratory study while the client is taking this medication?

Serum creatinine level

The nurse is gathering data on a client with a diagnosis of tuberculosis. The nurse should review the results of which diagnostic test to confirm this diagnosis?

Sputum culture

A client is admitted to the hospital with possible rheumatic endocarditis. The nurse should check for a history of which type of infection?

Streptococcal infection

A child has been diagnosed with bacterial conjunctivitis. Which clinical manifestations of bacterial conjunctivitis should the nurse expect to note? Select all that apply.

Swollen lids Inflamed conjunctiva Serous (watery) drainage Crusting on eyelids, especially in the morning

A 45-year-old woman delivered her first baby by cesarean section 5 days ago. The postpartum recovery has been complicated by thrombophlebitis in her left leg. She cries frequently and requests to have her newborn infant stay in the nursery. The nurse recognizes that the mother may have intensified "postpartum blues" because of which situation?

The client is required to stay on bed rest.

The clinic nurse is preparing to discuss cardiovascular changes of pregnancy in a prenatal class. Which information is appropriate for the nurse to present to this group? Select all that apply.

The number of red blood cells will be increased during pregnancy. At term, the heart rate has increased by 15 to 20 beats per minute. In a supine position, some degree of compression of the vena cava will occur.

A child is scheduled for a tonsillectomy. Which should present the highest risk of aspiration during surgery?

The presence of loose teeth

Which client complaint should alert the nurse to a possible hypoglycemic reaction?

Tremors and double vision

The nurse is working in the emergency department and is caring for a child who has been diagnosed with epiglottitis. Which is an indication that the child may be experiencing airway obstruction?

Tripod positioning and dyspnea

The nurse assigned to care for a child with mumps is monitoring the child for the signs and symptoms associated with the common complication of mumps. The nurse monitors for which sign/symptom that is indicative of this common complication?

Nuchal rigidity

The nurse is collecting data from a client recently diagnosed with paranoid schizophrenia. Which information best supports that the client is at risk for harming another individual?

Sibling stating, "I don't feel safe around my brother."

The nurse is reviewing the history and physical examination on a client diagnosed with polycystic kidney disease. Which data should the nurse expect to see? Select all that apply.

Hematuria Flank or lumbar pain History of urinary tract infections

The nurse is monitoring the respiratory status of a client following insertion of a tracheostomy. The nurse understands that oxygen saturation measurements obtained by pulse oximetry may be inaccurate if the client has which coexisting problems? Select all that apply.

Hypotension Use of peripheral vasoconstrictors

A client is admitted to the hospital with a venous stasis leg ulcer. The nurse is reviewing the physical examination in the medical record. Which symptom is least likely to be noted by the primary health care provider?

Sharp pain in the leg