NCLEX nursing process

Which would be the most appropriate measure for preventing the development of a paralytic ileus in a client who had renal surgery yesterday?

Encourage the client to ambulate every 2 to 4 hours.

A client tells the nurse on admission that she is uneasy about having to leave her children with a relative while being in the hospital for surgery. What should the nurse do?

Gather more information about the client's feelings about the childcare arrangements.

After assessing a newly admitted 5-year-old child, the nurse makes the nursing diagnosis of parental role conflict related to child's hospitalization. Which defining characteristic suggests this diagnosis?

Parents express feelings of inadequacy in caring for child

A client is scheduled for an appendectomy. What is the nurse's highest priority when planning preoperative teaching for this client?

The client should begin coughing and deep-breathing exercises as soon as the client is able to follow instructions.

This statement appears on a client's care plan: "Client will ambulate in the hall without assistance within 4 days." This statement is an example of

a client outcome.

A client is undergoing chemotherapy without responding to three different rounds of agents. The client proposes testing for specific serum metal levels based on a review of the history of symptoms and Internet research. The nurse recognizes that the client is demonstrating:

self-advocacy

How should the nurse proceed when instilling neomycin and polymyxin B sulfates and hydrocortisone optic suspension, two drops in the right ear?

verify the proper client and route; When giving medications, a nurse should follow the five "Rs" of medication administration: right client, right drug, right dose, right route, and right time. The drops may be warmed to prevent pain or dizziness, but this action isn't essential. An emesis basin would be used for irrigation of the ear. The client should be placed in the lateral position for five minutes, not semi-Fowler's position, to prevent the drops from draining.

A client who comes to the emergency department with multiple bruises on her face and arms, a black eye, and a broken nose says that these injuries occurred when she fell down the stairs. The nurse suspects that the client may have been physically assaulted. What should the nurse do next?

Ask the client specifically about the possibility of physical abuse.

A nurse is caring for a client with bronchogenic carcinoma. Which nursing intervention takes highest priority?

removing pulmonary secretions; Maintaining a patent airway is the first concern in a client with a condition that may compromise the airway. Therefore, adequate removal of pulmonary secretions is a priority. Although clients may exhibit fatigue, anxiety, or appetite loss, these need to be addressed, but are not the priority.

A nurse is providing follow-up teaching at a clinic visit for a client recovering from gastric resection. The client reports sweating, diarrhea, nausea, palpitations, and the desire to lie down 15 to 30 minutes after meals. The nurse suspects the client has dumping syndrome and instructs the client to:

sit upright at least 30 minutes after eating; Early manifestations of dumping syndrome occur 15 to 30 minutes after eating. Signs and symptoms include vertigo, tachycardia, syncope, sweating, pallor, palpitations, diarrhea, nausea, and the desire to lie down. There is no fluid restriction for this syndrome; fluids should be avoided during meals and clients should be encouraged to drink at least 4 cups between meals to prevent dehydration; dairy products, caffeine, and alcohol should be avoided.