NCLEX Questions Test 4

The nurse observes the UAP positioning the client with increased ICP. Which position would require intervention by the nurse? 1. Head midline 2. Head turned to the side 3. Neck in neutral position 4. Head of the bed elevated 30 to 45 degrees

2. Head turned to the side

The nurse is monitoring for bleeding in a child after surgery to remove a brain tumor. The nurse checks the head dressing for the presence of blood and notes a colorless drainage on the back of the dressing. Which nursing action is appropriate? 1. Reinforce the dressing 2. Notify the RN 3. Document the findings and continue to monitor 4. Circle the area of drainage and continue to monitor

2. Notify the RN

The nurse is assisting with caring for a client who is receiving intravenous fluids and who has sustained full-thickness burn injuries of the back and legs. The nurse understands that which would provide the most reliable indicator for determining the adequacy of the fluid resuscitation? 1. Vital signs 2. Urine output 3. Mental Status 4. Peripheral Pulses

2. Urine output

Th client was seen and treated in the emergency department for a concussion. Before discharge, the nurse explains the signs and symptoms of a worsening condition. The nurse determines that the family needs further teaching they state they will return to the ED if the client experiences which sign and symptom? 1. vomiting 2. minor headache 3. difficulty speaking 4. difficulty awakening

2. minor headache

The nurse is interviewing the laboratory results a client with leukemia who has received a regimen of chemotherapy. Which laboratory finding is indicative of the massive cell destruction that occurs with chemotherapy? 1. Anemia 2. Decreased platelets 3. Increased Uric acid level 4. Decreased Leukocyte Count

3. Increased Uric acid level

The nurse is reviewing the doctor's orders for a client admitted to the hospital with a diagnosis of acute pancreatitis. Which of the following orders should the nurse verify noted in the clients chart? 1. NPO status 2. An anticholinergic medication 3. Position the client supine and flat 4. Prepare to insert a nasogastric tube

3. Position the client supine and flat

A client arrives at the emergency department and had experienced frost bite to the right hand. What should the nurse expect to find when inspecting the client's hand? 1. A pink, edematous hand 2. Fiery red skin with edema in the nail beds 3. Black fingertips surrounded by an erythematous rash 4. A white color of the skin which is sensitive to touch

4. A white color of the skin which is sensitive to touch

The nurse reinforces instructions to the parents of a child with sickle cell anemia regarding the precipitating factors related to pain crisis. Which, if identified by a parent as a precipitating factor, indicates the need for further teaching? 1. Stress 2. Trauma 3. Infection 4. Fluid Overload

4. Fluid Overload

The client has clear fluid leaking from the nose after a basilar skull fracture. the nurse determine that this is cerebrospinal fluid (CSF) if the fluid meets which criteria? 1. Is grossly bloody and has a pH of 6 2. Clumps together on the dressing and has a pH of 7 3. Is clear in appearance and tests negative for glucose 4. Separates in to concentric rings and tests positive for glucose

4. Separates in to concentric rings and tests positive for glucose

The nurse is reviewing the prescriptions of a client admitted to the hospital with a diagnosis of acute pancreatitis. Which interventions should the nurse expect to be prescribed? SATA 1. Administer antacids, as prescribed 2. Encourage coughing and deep breathing 3. Administer anticholinergics, as prescribed 4. Maintain the client in a supine and flat position 5. Encourage small, frequent, high-calorie feedings

1. Administer antacids, as prescribed 2. Encourage coughing and deep breathing 3. Administer anticholinergics, as prescribed

The nurse is reviewing the client's record and notes that the primary health care provider has documented that the client has a renal disorder. Which laboratory results would indicate a decrease in renal function? SATA 1. Elevated serum creatinine level 2. Elevated thrombocyte cell count 3. Decreased red blood cell count 4. Decreased white blood cell count 5. Elevated BUN level

1. Elevated serum creatinine level 3. Decreased red blood cell count 5. Elevated BUN level

The nurse is providing dietary instructions to a client with gout. The nurse should tell the client to avoid which food item? 1. Scallops 2. Chocolate 3. Cornbread 4. Macaroni Proudcts

1. Scallops A patient with gout should avoid purine foods. Seafood, organ meats, oatmeal, and bananas.

The nurse is caring for client who has undergone craniotomy with a supratentorial incision. the nurse should plan to place the client in which position postoperatively? 1. Head of bed flat, head and neck midline 2. head of bed flat, head turned to nonoperative side 3. Head of bed elevated 30 - 45 degrees, head and neck midline 4. Head of bed elevated 30-45 degreed, head turned to non-operative side

3. Head of bed elevated 30 - 45 degrees, head and neck midline

The nurse reinforces home care instructions to parents of a 3-year-old child who has been hospitalized with hemophilia. Which statement by a parent indicates the need for further teaching? 1. I will supervise my child closely 2. I will pad the corners of the furniture 3. I will remove household items that can easily fall over 4. I will avoid immunizations and dental hygiene treatments for my child

4. I will avoid immunizations and dental hygiene treatments for my child

The nurse is caring for a client with ICP. Which change in vital signs would occur if ICP is rising? 1. Increasing temperature, increasing pulse, increasing respirations, decreasing BP 2. Decreasing temperature, decreasing pulse, increasing respirations, decreasing BP 3.Decreasing temperature, increasing pulse, decreasing respirations, increasing BP 4. Increasing temperature, decreasing pulse, decreasing respirations, increasing BP

4. Increasing temperature, decreasing pulse, decreasing respirations, increasing BP

The client recovering from a head injury is arousable and participating in care. The nurse determines that the client understands measures to prevent elevations in ICP if the nurse observes the client doing which of the following? 1. Blowing the nose 2. Isometric exercises 3. coughing vigorously 4. exhaling during repositioning

4. exhaling during repositioning