NCLEX Review Study Guide 4

A client is taking gentamicin sulfate (Genoptic) for the treatment of pelvic inflammatory disease. What does the nurse ask the client during assessment for adverse effects of the medication?

"Are you having any difficulty hearing?"

As a nurse prepares to administer medications to an assigned client, the client asks, "Why don't you just leave me alone?" What is the best response by the nurse?

"I can see that you're upset. Would you like to talk about it?"

A client experiencing delusions says to the nurse, "I am the only one who can save the world from all of the terrorists." What is the appropriate response by the nurse?

"I don't think anyone can save the world from the terrorists by himself."

Oral candidiasis (thrush) develops in a client infected with HIV, and the nurse provides instruction to the client about measures to relieve the discomfort. Which statement by the client indicates a need for further instruction?

"I should put ice in my drinks to help soothe the discomfort."

A nurse has provided nutrition instructions to a mother of an infant. Which statement by the mother indicates to the nurse that the mother requires further instruction?

"It's best to use cow's milk, as long as it's whole milk and not skim."

A client who recently underwent coronary artery bypass graft surgery comes to the physician's office for a follow-up visit. On assessment, the client tells the nurse that he is feeling depressed. Which response by the nurse is therapeutic?

"Tell me more about what you're feeling."

A nurse provides information to a client with peripheral vascular disease about ways to limit the disease's progression. Which of the following measures does the nurse tell the client to take? Select all that apply.

-Engaging in exercise such as walking on a daily basis -Washing the feet daily with a mild soap and drying them well

A physician prescribes a dose of morphine sulfate 2.5 mg stat to be administered intravenously to a client in pain. The nurse preparing the medication notes that the label on the vial of morphine sulfate solution for injection reads "4 mg/mL." How many milliliters (mL) must the nurse draw into a syringe for administration to the client? Type the answer in the space provided.

0.625mL

A physician writes a prescription for 1000 mL of 0.9% normal saline solution to be administered intravenously (IV) to a client over 10 hours. The drop factor for the infusion set is 15 gtt/mL. At what drip rate does the nurse set the infusion?

25 gtt/min

An adult client with renal failure who is oliguric and undergoing hemodialysis is under a fluid restriction of 700 mL/day. How many milliliters of fluid does the nurse allow the client to have between 7 a.m. and 3 p.m.? Type your answer in the space provided.

350mL

A nurse is caring for a client who sustained burn injuries on the anterior lower legs and anterior thorax. What percentage of the client's body, according to the Rule of Nines, has been affected?

36%

NPO status is imposed 8 hours before the procedure on a client scheduled to undergo electroconvulsive therapy (ECT) at 1 p.m. On the morning of the procedure, the nurse checks the client's record and notes that the client routinely takes an oral antihypertensive medication each morning. The nurse should:

Administer the antihypertensive with a small sip of water

A nurse is performing an assessment of a newborn with a diagnosis of esophageal atresia (EA) and tracheoesophageal fistula (TEF). Which findings does the nurse expect to note in the infant? Select all that apply.

Drooling Excessive oral secretions

An emergency department (ED) nurse is monitoring a client with suspected acute myocardial infarction (MI) who is awaiting transfer to the coronary intensive care unit. The nurse notes the sudden onset of premature ventricular contractions (PVCs) on the monitor, checks the client's carotid pulse, and determines that the PVCs are not resulting in perfusion. The appropriate action by the nurse is:

Asking the ED physician to check the client

The nurse is performing a sterile change of an abdominal dressing. Once the dressing has been removed and discarded in a waterproof bag, which action should the nurse take next?

Assessing the wound

A client who was involved in a high-speed motor vehicle crash is brought to the emergency department. Which of the following findings indicates to the nurse that the client has sustained flail chest?

Asymmetrical chest movement

A nurse reviews the results of a total serum calcium determination in a client with renal failure. The results indicate a level of 12.0 mg/dL. In light of this result, which finding does the nurse expect to note during assessment?

Bounding, full peripheral pulses

An intravenous dose of adenosine (Adenocard) is prescribed for a client to treat Wolff-Parkinson-White syndrome. Which piece of equipment does the nurse make a priority of obtaining before administering the medication?

Cardiac monitor

Vasopressin (Pitressin) is prescribed to a client with diabetes insipidus. For which sign, indicative of an adverse effect of the medication, does the nurse monitor the client?

Chest pain

A nurse in a physician's office is talking to a client who underwent mastectomy of the right breast 2 weeks ago. The client says to the nurse, "I hate looking at this incision. I feel that I'm not even myself anymore." The nurse interprets this statement to mean that the client is experiencing which problem?

Distorted body image

A nurse assessing the deep tendon reflexes of a pregnant client notes that the reflexes are 1+ (i.e., reflex present, hypoactive). On the basis of this finding, the nurse would:

Document the findings

Cyclobenzaprine (Flexeril) is prescribed to a client with multiple sclerosis for the treatment of muscle spasms. For which common side effect of this medication does the nurse monitor the client?

Drowsiness

A client says to the nurse, "My doctor just left. He told me that my abdominal scan showed a mass in my pancreas and that it's probably cancer. Does this mean I'm going to die?" The nurse interprets the client's initial reaction as:

Fear

A nurse reviews the medical record of a client with histoplasmosis. Which clinical manifestation of this infection does the nurse expect to see documented?

Flulike pulmonary symptoms

A client who is scheduled to undergo chemotherapy asks the nurse, "Is my hair going to fall out?" The nurse responds by telling the client that:

Her hair may fall out but will regrow after the chemotherapy is discontinued

A client with advanced chronic renal failure (CRF) and oliguria has been taught about sodium and potassium restriction between dialysis treatments. The nurse determines that the client understands this restriction if the client states that it is acceptable to use:

Herbs and spices

Oral prednisone 10 mg/day is prescribed for a client with an acute exacerbation of rheumatoid arthritis. The nurse, providing information to the client about the medication, tells the client that it is best to take it:

In the morning, before 9:00 a.m.

A nurse provides instructions to a client who will be taking levothyroxine (Synthroid) for hypothyroidism. The nurse tells the client that it is best to take the medication:

In the morning, before breakfast

A nurse is monitoring a child with intussusception for signs of peritonitis. For which of the following findings, indicative of this complication, does the nurse notify the physician?

Increased heart rate

A nurse is preparing to provide information to a client who has been found to have stable angina. The nurse plans to tell the client that this type of angina:

Is often managed medically with medications such as calcium channel blockers and beta-blocking medications

A client being seen in the clinic complains of fatigue and weakness. Laboratory studies are performed because the physician suspects iron-deficiency anemia. Which finding indicative of this type of anemia does the nurse expect to find on reviewing the laboratory results?

Microcytic red blood cells (RBCs)

The physician will probably withhold the aspirin until the symptoms have subsided, then resume the aspirin at a lower dosage

Notifies the emergency department physician

A client with depression is anorexic. Which measure does the nurse take to assist the client in meeting nutritional needs?

Offering high-calorie and high-protein foods and fluids frequently throughout the day

A nurse admitting a newborn to the nursery notes that the physician has documented that the newborn has a gastroschisis. The nurse performs an assessment, expecting to note that the viscera are:

Outside the abdominal cavity, not covered with a sac

A nurse in the cardiac care unit is told that a client with a diagnosis of myocardial infarction will be admitted from the emergency department. Which item does the nurse give priority to placing at the client's bedside?

Oxygen cannula and flowmeter

A child with a diagnosis of Wilms' tumor is being admitted to the pediatric unit. The nurse prepares the room for the child and places a sign at the child's bedside that tells staff to avoid:

Palpating the abdomen

A nurse is caring for a client who has had a cast applied to the left leg and is at risk for acute compartment syndrome. For which early sign of this complication does the nurse monitor the client?

Paresthesia

A postpartum nurse provides information to a client who has delivered a healthy newborn about normal and abnormal characteristics of lochia. Which of the following findings does the nurse tells the client to report to the physician?

Reddish lochia on postpartum day 8

A client has been given a prescription for lovastatin (Mevacor). Which of the following foods does the nurse instruct the client to limit consumption of while taking this medication?

Steak

A hospitalized client scheduled for surgery is told by the physician that she is extremely anemic and will need a blood transfusion. The client, a Jehovah's Witness, tells the nurse that she is refusing the transfusion. What is the most appropriate initial nursing action?

Supporting the client's decision to refuse the transfusion

A nurse is caring for a client with a diagnosis of abruptio placentae. For which early signs of hypovolemic shock does the nurse closely monitor the client? Select all that apply.

Tachycardia Diminished peripheral pulses

A nurse working the evening shift is helping clients get ready for sleep. A female client with mania is hyperactive and pacing the hallway. The appropriate nursing action is to:

Take the client to the bathroom and provide her with a warm bath

A client on the mental health unit says to the nurse, "Everything is contaminated." The client scrubs her hands if she is forced to touch any object. While planning care, the nurse remembers that compulsive behavior:

Temporarily eases anxiety in the client

The mother of an adolescent with type 1 diabetes mellitus tells the nurse that her child is a member of the school soccer team and expresses concern about her child's participation in sports. The nurse, after providing information to the mother about diet, exercise, insulin, and blood glucose control, tells the mother:

That the child should eat a carbohydrate snack about a half-hour before each soccer game

A nurse is preparing a pregnant client in the third trimester for an amniocentesis. The nurse explains to the client that amniocentesis is often performed during the third trimester to determine:

The degree of fetal lung maturity

A female client with rheumatoid arthritis is taking 3.6 g of acetylsalicylic acid (aspirin) daily in a divided dose. At the physician's office, the client tells the nurse that she has been experiencing ringing in the ears over the past few days. The nurse tells the client that:

The physician will probably withhold the aspirin until the symptoms have subsided, then resume the aspirin at a lower dosage

Empyema develops in a client with an infected pleural effusion, and the nurse prepares the client for thoracentesis. What characteristics of the fluid removed during thoracentesis should the nurse, assisting the physician with the procedure, expect to note?

Thick and opaque

A nurse provides home care instructions to a client with mild preeclampsia. The nurse tells the client that:

Urine output must be measured and that the physician should be notified if output is less than 500 mL in a 24-hour period

A nurse is reviewing the medical record of an infant in whom hypertrophic pyloric stenosis (HPS) is suspected. Which characteristics associated with the disorder does the nurse expects see documented in the infant's medical record? Select all that apply.

Weight loss Projectile vomiting Distended upper abdomen

A client living in a long-term care facility shouts at the nurse, "Get out of my room! I don't need your help!" What is the appropriate way for the nurse to document this occurrence in the client's record?

Writing down the client's words and placing them in quotation marks