nclex pn fundamentals

A child with leukemia is experiencing nausea related to medication therapy. The nurse, concerned about the child's nutritional status, should offer which during an episode of nausea?

Cool, clear liquids

The nurse has given dietary instructions to a client to minimize the risk of osteoporosis. The nurse determines that the client understands the recommended changes if the client verbalizes to increase intake of which food?

Cottage cheese

The nurse is assigned to assist in caring for a client who has had an autograft placed on the anterior lower extremity. Which activity should the nurse include in the plan of care?

Elevate and immobilize the surgical extremity.

A client has the following laboratory values: a pH of 7.55, an HCO3- level of 22 mm Hg, and a PCo2 of 30 mm Hg. Which action should the nurse take?

Encourage the client to slow down breathing.

The nurse in the health care provider's office is measuring vital signs on a postoperative client who underwent mastectomy of her right breast 2 weeks ago. The client tells the nurse that she is very concerned because she has numbness in the area of the surgery and along the inner side of the arm from the armpit to the elbow. Which statement is appropriate for the nurse to tell the client?

"These sensations dissipate over several months and usually resolve after 1 year."

The nursing instructor asks the student to describe isotonic dehydration. The student correctly responds by stating which pathophysiological process?

"Water and electrolytes are lost in approximately the same proportion as they exist in the body."

The nurse is admitting a client to the hospital who has been scheduled for gastrointestinal (GI) surgery. When asking the client whether the client takes over-the-counter medications, which statement should concern the nurse?

"Yes, I take a full-strength aspirin every day."

An antihypertensive medication has been prescribed for a client with hypertension. The client tells the nurse that she would like to take an herbal substance to help lower her blood pressure. Which statement by the nurse is the most important to provide to the client?

"You will need to talk to your health care provider (HCP) before using an herbal substance."

A health care provider's prescription reads "cyanocobalamin (vitamin B12) 100 mcg intramuscular." The medication label reads "cyanocobalamin (vitamin B12), 0.5 mg/mL." The nurse administers how many milliliters to the client? Fill in the blank. Record the answer to one decimal place.

0.2

A health care provider has prescribed phytonadione 2.5 mg intramuscularly. The nurse reads the label on the medication vial and administers how many mL to the client? Refer to the figure and fill in the blank. Record your answer to two decimal places.

0.25

A client with a history of seizure disorder is taking phenytoin (Dilantin). The nurse reviews the laboratory results of the phenytoin level and determines that the client has been noncompliant with medication therapy if which laboratory result is noted?

5 mcg/mL

A client with hepatic cirrhosis has been consuming a diet with optimal amounts of protein. The nurse determines that the client's consumption of dietary protein has been most effective if the total protein level is which value?

6.8 g/dL

A licensed practical nurse (LPN) asks an unlicensed assistive personnel (UAP) to gather supplies in preparation for administering a tepid bath to a child with a fever. The LPN intervenes if the UAP obtains which unnecessary item(s)?

A bottle of alcohol

The hospice nurse is caring for five clients from various religious backgrounds. Which observations should the nurse expect for the clients of the various religious backgrounds? Select all that apply.

A client of the Muslim faith having their bed positioned toward Mecca A Hindu-believing family arranges to have the clients' body cremated within 24 hours of death

A client is to have an upper gastrointestinal (GI) series. Which nursing action should be done concerning the procedure?

Administer a laxative after the procedure because barium was administered.

The nurse is taking care of a client preoperatively. The client is NPO and tells the nurse that he takes detemir insulin (Levemir) and aspart insulin (NovoLog) at 0700 daily. The client's surgery is scheduled for 0900. Which is the best action for the nurse to take?

Call the health care provider for clarification.

The nurse is encouraging a client who is incontinent to participate in recreational therapy. Which nursing intervention should the nurse consider performing first?

Change the client's soiled disposable brief.

The nurse is reading the health care provider's (HCP's) progress notes in the client's record and sees that the HCP has documented "insensible fluid loss of approximately 800 mL daily." Which client is at risk for this loss?

Client with a fast respiratory rate

A client's preoperative vital signs are temperature 98.6° F orally, apical pulse 80 beats per minute with a regular rhythm, respiration rate 22 breaths per minute, and blood pressure 168/94 mm Hg in the right arm. Based on the interpretation of these findings, which action should the nurse take first?

Compare these values to those recorded previously.

A client who has calcium phosphate kidney stones tells the nurse, "Tell me what I can do, so that I never have this pain again." Which instructions should the nurse plan to include in the reinforcement of dietary instructions? Select all that apply.

Decrease sodium intake. Limit the intake of whole grains. Limit protein to 5 to 7 servings per week

The nurse is assigned to care for a client with a peripheral intravenous (IV) infusion. The nurse is providing hygiene care to the client and should avoid which while changing the client's hospital gown?

Disconnecting the IV tubing from the catheter in the vein

The nurse receives a telephone call from the admissions office and is told that a child with acute bacterial meningitis will be admitted to the pediatric unit. The nurse prepares for the child's arrival and plans to implement which type of precautions?

Droplet

A client is admitted to a long-term care facility with the diagnosis of weight loss secondary to anorexia. The health care provider inserts a nasogastric tube and prescribes a tube feeding of a standard formula feeding to run at 50 mL/hr. The nurse plans care, knowing that which is true regarding enteral feedings?

Enteral feedings require the normal digestive capabilities of the gastrointestinal (GI) tract.

The nurse is reinforcing instructions to a client regarding how to decrease the intake of phosphorus in the diet. The nurse should tell the client that which food item contains the least amount of phosphorus?

Oranges

The nurse monitors the postoperative client frequently, knowing that accumulated secretions can lead to which problem?

Pneumonia

A client returns from the recovery room following an abdominal surgical procedure. Following the arrival of the client to the nursing unit, Which is the initial nursing assessment?

Vital signs

The nurse is told that an assigned client is suspected of having methicillin-resistant Staphylococcus aureus (MRSA). Which precautions should the nurse institute during the care of the client?

Wear a gown and gloves.

The nurse is assisting with planning care for a client with an internal radiation implant. Which should be included in the plan of care? Select all that apply.

Wearing gloves when emptying the client's bedpan Keeping all linens in the room until the implant is removed Wearing a film (dosimeter) badge when in the client's room Wearing a lead apron when providing direct care to the clien

The nurse is observing a nursing student preparing to obtain a throat culture on a client suspected of having a beta-hemolytic Streptococcus infection. Which action indicates the need for further teaching regarding collecting this specimen? Select all that apply.

The student asks the client to tilt the head forward and to open the mouth. The student places the collection swab initially at the back of the client's tongue.

A Hispanic-American mother brings her child to the clinic for an examination. Which is most important when gathering data about the child?

Touching the child during the examination

A client is seen in the urgent care center for complaints of chest pain 2 days ago. Since that time, the client has not been feeling well and fatigues easily. The nurse reviews the results of the laboratory tests and suspects myocardial infarction at the time of chest pain 2 days ago if which comes back positive?

Troponin I

The nurse is caring for an elderly Hispanic client who is a migrant farm worker and has been admitted for asthma. The nurse is unfamiliar with the cultural practices and beliefs of the client's home land. Which questions are appropriate for the nurse to ask when caring for this client? Select all that apply.

What do you believe is causing your illness? Are there any remedies you have used in the past? Who do you usually see for help when you are sick

A client who has undergone a barium enema is being readied for discharge from the ambulatory care unit. Which statement by the client indicates understanding of the discharge instructions?

"I should take a laxative and my stool should return to normal color."

The nursing instructor is providing a session on cultural beliefs related to health and illness. Following the session, the instructor asks a nursing student to describe the beliefs of an African-American client with regard to illness. Which statement describes the beliefs of an African-American client with regard to illness?

"Illness is a disharmonious state that may be caused by demons and spirits."

A client is having trouble remembering his prescribed medication regimen. Which statement by the nurse is therapeutic?

"Let me go over your prescribed medications with you again."

A transcutaneous electrical nerve stimulation (TENS) is prescribed for a client with pain, and the nurse provides information to the client about the TENS unit. Which statement by the client indicates the need for further teaching?

"Needles are inserted in the subcutaneous tissue to stimulate the nerve."

A health care provider prescribes meperidine hydrochloride (Demerol), 40 mg intramuscularly stat, for a postoperative client in pain. The medication label states meperidine hydrochloride, 50 mg/mL. How many milliliters (mL) will the nurse prepare to administer to the client? Fill in the blank.

0.8

A health care provider prescribes atenolol (Tenormin) 0.05 g orally daily. The label on the medication bottle states, atenolol 50-mg tablets. How many tablet(s) will the nurse administer to the client? Fill in the blank.

1

Fentanyl 75 mcg intravenous push (IVP) has been prescribed by the health care provider. The medication ampule reads fentanyl 50 mcg/mL. The nurse should prepare how many milliliters to administer the correct dose? Fill in the blank and record your answer using one decimal place.

1.5

Penicillin G procaine, 1,000,000 units given intramuscularly, is prescribed for an adolescent with an infection. The medication label reads as follows: "1,200,000 units/2 mL." The nurse has determined that the prescribed dose is safe. How many milliliters per dose should the nurse administer to the adolescent?

1.66 mL

A client with a seizure disorder is taking phenytoin (Dilantin). A sample for a serum phenytoin level is drawn, and the nurse determines that the next dose of the medication may be administered if which laboratory result is noted?

17 mcg/mL

A client is scheduled to receive digoxin (Lanoxin), 0.125 mg by mouth. The licensed practical nurse (LPN) reads the medication label and notes that each tablet contains 0.25 mg.The LPN should perform which action?

Administer half of a medication tablet.

The nurse is told that a client will be admitted to the hospital for a radiation implant for bladder cancer. The nurse is asked to prepare for the admission of the client and plans which measure for this client?

Admit the client to a private room.

The nurse is assisting in preparing a client for a cardiac catheterization. The nurse understands that it is important to check the client's record for which history?

Allergy to shellfish

The nurse is preparing to assist a client of Orthodox Jewish faith with eating lunch. A kosher meal is delivered to the client. Which nursing action is appropriate when assisting the client with the meal?

Allowing the client to unwrap the utensils and prepare his own meal for eating

A child is receiving edetate calcium disodium (calcium EDTA) for the treatment of lead poisoning. Which laboratory result would be important to monitor during treatment?

Blood urea nitrogen (BUN) level

The nurse is preparing to clean up a blood spill on the client's bedside table. The spill occurred when a blood tube containing the client's blood specimen broke. The nurse avoids doing which action when cleaning up the blood spill?

Blotting up the spill with a face cloth or cloth towel

The nurse is assigned to care for a client on contact precautions. On review of the client's record, the nurse notes that the client has a hospital-acquired infection caused by methicillin-resistant Staphylococcus aureus (MRSA). The client has an abdominal wound that requires irrigation and has a tracheostomy attached to a mechanical ventilator and requires frequent suctioning. The nurse gathers supplies before entering the client's room and obtains which necessary protective items?

Gloves, mask, gown, and goggles

A client who has open draining lesions from Kaposi's sarcoma needs to be bathed and have bed linens changed. Which should the nurse wear to perform these tasks?

Gown and gloves

A client is receiving standard oral anticoagulant therapy with warfarin (Coumadin). The result of a newly drawn international normalized ratio is 3.8 seconds. The nurse anticipates carrying out a prescription to do which action?

Hold the next dose of warfarin.

Which cardiovascular sign should the nurse expect to note in a client with a diagnosis of hypocalcemia?

Hypotension

The nurse is assigned to care for an Asian-American client. The nurse develops a plan of care based on which belief?

Illness is caused by an imbalance between yin and yang.

The nurse is inserting an indwelling urinary catheter into a male client. As the catheter is inserted into the urethra, urine begins to flow into the tubing. The nurse should take which step next?

Insert the catheter 2.5 to 5 cm and inflate the balloon.

The nurse is assisting in the care of a group of clients on the nursing unit. The nurse determines that a client with which diagnosis is the one who has the least likely risk for developing third-spacing of body fluid?

Ischemic stroke

A child has been diagnosed with meningococcal meningitis. Which precautionary technique is appropriate to prevent transmission of the disease?

Isolation precautions for at least 24 hours after the initiation of antibiotics

The nurse is instructed to complete a medication reconciliation form on a newly admitted client. Why is it important for the nurse to ensure that this process is completed accurately?

It helps to make sure that the health care provider is aware of all of the medications the client is taking and has been taking at home.

The nurse assists the health care provider in performing a lumbar puncture on a 3-year-old child with leukemia suspected of central nervous system (CNS) disease. In which position should the nurse place the child during this procedure?

Lateral recumbent with the knees flexed to the abdomen and head bent with the chin resting on the chest

A nursing student is asked to identify the practices and beliefs of the Amish society. Which should the student identify? Select all that apply.

Many choose not to have health insurance. They believe that health is a gift from God They use both traditional and alternative health care, such as healers, herbs, and massage. Funerals are conducted in the home without a eulogy, flower decorations, or any other display. Caskets are plain and simple, without adornment

The nurse is preparing to change the neck ties on a tracheostomy tube. Which action should the nurse take?

Obtain a second health care team member to assist.

The nurse is caring for a postoperative client who is being monitored by pulse oximetry. Which is an expected measurement determined by the pulse oximeter?

Oxygen saturation 95% to 100%

The nurse is reading a client's urinalysis report. The nurse interprets which item found on the report to be considered abnormal?

Positive protein

The nurse is instructing a client on how to decrease the intake of magnesium in the diet. The nurse tells the client that which food item contains the least amount of magnesium?

Processed drinking water

The nurse educator is providing an in-service education to the nursing staff regarding transcultural nursing care. A staff member asks the nurse educator to describe the concept of acculturation. Which response is appropriate?

"It is a process of learning a different culture to adapt to a new or changing environment."

The medication prescribed is hydromorphone hydrochloride (Dilaudid), 3 mg intramuscularly, every 4 hours as needed. The medication label reads hydromorphone hydrochloride (Dilaudid), 4 mg/1 mL. The nurse should prepare to administer how many mL to the client? Fill in the blank.

0.75

The nurse hangs a 1000-mL intravenous (IV) bag of 5% dextrose in water (D5W) at 0700. The IV is to infuse at 100 mL/hr, and the nurse places a time tape on the IV bag. At noon the nurse should expect that the infusion line on the IV bag would be at which point? Refer to figure.

2

A health care provider prescribes 2000 mL of 5% dextrose in water to run over 24 hours. The drop (gtt) factor is 15 gtt/mL. The nurse plans to adjust the flow rate at how many drops per minute? Fill in the blank. Round answer to the nearest whole number.

21

The intravenous prescription is 1000 mL of 0.9% NaCl (normal saline) to run over 12 hours. The drop factor is 15 gtts/1 mL. The nurse plans to adjust the flow rate to how many gtts/minute? Fill in the blank and record the answer to the nearest whole number.

21

A postoperative client has a prescription to receive an intravenous (IV) infusion of 1000 mL normal saline solution over a period of 10 hours. The drop (gtt) factor for the IV infusion set is 15 gtts/mL. The nurse sets the flow rate at how many drops per minute? Fill in the blank.

25

The nurse is assigned to care for a client experiencing episodes of postural hypotension. Which action should the nurse take to ensure safety while transferring the client from the bed to the chair?

Allow the client to dangle the legs in a sitting position on the bed before transfer to a chair.

A tuberculin skin test is administered to an individual infected with human immunodeficiency virus (HIV). Seventy-two hours later, the nurse checks the test site and documents the results as positive, indicating that the individual has been exposed to tuberculosis. Which findings did the nurse identify to make this interpretation?

An area of induration at the test site measuring 7 mm

A lethargic, pale child is brought to the health care provider's office with symptoms of periorbital edema and reduced quantity of urine output. The urine is cloudy and smoky in color. The nurse asks the mother if the child has had any recent infections, to which the mother responds that the child had a very sore throat a few weeks ago. The health care provider suspects that the child might have acute poststreptococcal glomerulonephritis. Which laboratory test would rule out a past streptococcal infection in the child?

Antistreptolysin titer

The skin surrounding a postoperative client's abdominal wound is becoming irritated in the area where the dressing tape is being reapplied with each dressing change. Which is the appropriate nursing action?

Apply Montgomery ties.

Which nursing action would avoid pressure on the popliteal nerve when applying the safety strap across the client's legs on the operating table?

Apply the safety strap 2 inches above the knees.

A client has been diagnosed with metabolic alkalosis. Which laboratory value(s) is most important for the nurse to monitor for this client?

Arterial blood gases (ABGs)

The nurse is caring for a client who has a wound infection. Contact precautions are being followed. Which are correct actions by the nurse when using personal protective equipment (PPE)? Select all that apply.

Perform hand hygiene after removal of PPE. Perform hand hygiene before donning any PPE. When removing PPE, always remove gloves first Protective eyewear and face shield are indicated if there is risk of splatter.

The nurse is preparing to suction a client through a tracheostomy tube. The nurse should avoid which action when performing this procedure?

Placing suction on the catheter while introducing the catheter into the tracheostomy tube

The nurse is planning to administer an oral glucose tolerance test (OGTT) to a client to rule out or confirm diabetes mellitus. The nurse knows that the client needs more information when the client makes which statement? Select all that apply.

I can at least drink fluids during the test." "I have 30 minutes to drink the glucose load. "I will have blood drawn every 5 minutes for the next 3 hours."

The nurse is preparing to give a bed bath to an immobilized client with tuberculosis (TB). The nurse should plan to wear which items when performing this care?

Particulate respirator, gown, and gloves

The nurse is assigned to assist in caring for a client who recently returned from the operating room. On data collection, the nurse notes that the client's vital signs are as follows: blood pressure (BP) 102/62 mm Hg, pulse 91 beats per minute, respirations 16 breaths per minute. Preoperative vital signs were BP 124/78 mm Hg, pulse 74 beats per minute, respirations 20 breaths per minute. Which action should the nurse plan to take first?

Recheck the vital signs in 15 minutes.

The nurse is preparing to administer an intermittent tube feeding to a client. The nurse aspirates 90 mL of residual from the tube. What should the nurse do with the aspirated residual?

Reinstill the residual and administer the feeding.

The nurse is assisting to admit a client with a diagnosis of Guillain-Barré syndrome. The nurse knows that if the disease is severe enough, the client will be at risk for which acid-base imbalance?

Respiratory acidosis

The nurse is caring for a client with a diagnosis of chronic obstructive pulmonary disease (COPD). The nurse should monitor the client for which acid-base imbalance?

Respiratory acidosis

The nurse is caring for a client who is nervous and is hyperventilating. The nurse should monitor the client for signs of which acid-base imbalance?

Respiratory alkalosis

The nurse consults with a dietitian regarding the dietary preferences of an Asian-American client. Which food should the nurse suggest to include in the diet plan?

Rice

Which equipment should the nurse plan to have at the bedside when initiating a clear liquid diet in a postoperative client who has had general anesthesia?

Suction equipment

A client is seen in the clinic for a physical examination. Laboratory studies are performed and reveal that the hemoglobin and hematocrit are low, indicating the need for further diagnostic studies and a blood transfusion. The client is a Jehovah's Witness and refuses to have a blood transfusion. Which should be an appropriate action by the clinic nurse?

Support the client's decision not to receive a blood transfusion.

The nurse is assigned to care for a client who has just returned to the nursing unit following a renal biopsy. The nurse plans to do which action to properly care for this client for the remainder of the shift?

Test the urine for occult blood.

A client with diabetes mellitus calls the clinic nurse to report that the blood glucose level is 150 mg/dL. After obtaining further data from the client, the nurse determines that the client ate lunch approximately 2 hours ago. How should the nurse interpret the data?

The blood glucose level is slightly higher than the normal value.

Cloxacillin sodium 100 mg orally every 8 hours is prescribed for a child with an elevated temperature who is suspected of having a respiratory tract infection. The child weighs 17 pounds. The safe pediatric dosage is 50 mg/kg/day. Which statement accurately describes the prescribed dosage for this child?

The dosage is within the safe dosage range.

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 nurse is assigned to reinforce instructions to a client and the family about the management of home intravenous (IV) infusion therapy. The nurse begins the process by teaching the client and family principles related to what actions first?

Proper hand-washing technique

The nurse is performing oral care for a newly admitted client who is undergoing chemotherapy for thyroid cancer. The nurse should take which actions while performing oral care? Select all that apply.

Provide a soft toothbrush. Check oral mucous membranes. Check for missing teeth and cavities

A client with heart disease is instructed regarding a low-fat diet. The nurse determines that the client understands the diet if the client states to avoid which food item?

Cheese

The nurse is preparing a client for a magnetic resonance imaging (MRI) examination. Which action by the nurse is important?

Remove metallic objects from the client.

The nurse is reviewing the laboratory studies of a client receiving epoetin alfa (Epogen). When should the nurse expect to note a therapeutic effect of this medication?

Two months after therapy

Which are the most important interventions that can help reduce the incidence of hospital-acquired urinary catheter infections? Select all that apply.

Use indwelling urinary catheters judiciously. Remove indwelling catheters when no longer needed. Use strict aseptic technique when inserting all urinary catheters.

The nurse is caring for a non-English speaking client. Best practices for client safety and quality of care incorporates which actions by the nurse? Select all that apply.

Use interpreters who are familiar with health care. Avoid the use of relatives as interpreters to prevent misinterpretation. Use dialect-specific interpreters who are the same gender if possible. Become familiar with common health care words used in the client's language

The nurse is caring for a postoperative client who had a pelvic exenteration. The health care provider has changed the client's diet from nothing by mouth (NPO) to clear liquids. The nurse checks which before administering the clear liquids?

Bowel sounds

The nurse will perform a sterile dressing change after removing the old dressing with clean gloves. The nurse removes the gloves, uses alcohol-based hand sanitizer to perform hand hygiene, and prepares to perform open sterile gloving. The nurse removes the gloves from the outer package. The nurse is right-handed. Arrange the steps the nurse should follow in the open sterile gloving process. All options must be used.

Open inner wrapper and flatten wrapper to expose the gloves. Pick up right glove at cuff with left thumb and forefinger. Pick up right glove at cuff with left thumb and forefinger. Insert right hand into right glove. Insert right hand into right glove. Place gloved right hand under the cuff of left glove. Place gloved right hand under the cuff of left glove. Insert left hand into left glove. Insert left hand into left glove. Pull down cuffs of gloves maintaining sterility. Pull down cuffs of gloves maintaining sterility

A health care provider prescribes potassium chloride (KCl) elixir, 20 mEq orally daily. The medication label states potassium chloride (KCl), 30 mEq/15 mL. How many milliliters should the nurse prepare to administer the dose? Fill in the blank.

10