NCLEX RN #02 ( U WORLD)

1

A client is 1-day postoperative abdominoplasty and is discharged to go home with a Jackson-Pratt (JP) closed wound system drain in place. The nurse teaches the client how to care for the drain and empty the collection bulb. Which statement indicates that the client NEEDS FURTHER INS-TRUCTION? 1. "I'll empty the JP bulb when it is totally full so that I don't have to unplug it so many times." 2. I'll pull the plug on the JP bulb and pour the drainage into the measurable specimen cup." 3. "I'll squeeze the JP bulb from side to side as I hold it in my hand." 4. "While the JP bulb is totally compressed, I'll clean the spout with alcohol and replace the plug."

1

A client is able to partially bear weight and follow the nurse's instructions Which would be the MOST APPROPRIATE method for the nurse to use to safely transfer this client? 1. 1 person stand and pivot with gait belt and walker. 2. 1 person standby assist with walker 3. 2 person motorized stand assist lift. 4. 2 person stand and pivot with gait belt and walker.

3

A client with a diagnosis of schizophrenia with catatonia has recently been admitted to the psychiatric unit. Which of the following is the PRIORITY nursing diagnosis? 1. Impaired social interaction 2. Impaired verbal communication 3. Risk for deficient fluid volume 4. Risk for impaired skin integrity

hands and knees

A client with a prolapsed umbilical cord should be placed on _________________(eg. knee-chest position) or Trendelenburg position to relieve pressure on the cord until emergency delivery.

4

A pregnant client comes to the labor and delivery unit stating the water just broke at home. On assessment of the client's perineal area, the nurse visualizes a loop of umbilical cord protruding from the vagina. Which nursing intervention would be appropriate? 1. Apply suprapubic pressure 2. Perform Leopold maneuvers 3. Perform the McRoberts maneuver 4. Position the client on hands and knees.

tumor necrosis factor

Infliximab, adalimumab and etanercept are _______________ inhibitors that suppress the inflammatory response in autoimmune diseases such as rheumatoid arthritis, Crohn disease and psoriasis. Due to the IMMUNOSUPPRESSIVE action of TNF inhibitors, clients taking these drugs are at increased RISK FOR INFECTION. A client with current, recent, or chronic infection should not take a TNF inhibitor.

1

The nurse is assessing a client with rheumatoid arthritis who is being considered for adalimumab therapy. Which statement made by the client needs FURTHER investigation? 1. "I am taking an antibiotic for a urinary tract infection." 2. "I had a negative tuberculosis skin test 2 weeks ago." 3. "I just received my yearly flu shot a week ago." 4. "I will continue taking naproxen at night to help with pain."

2

The nurse is caring for a 7 year old child diagnosed with nephrotic syndrome who will be discharged soon. which statement by the parent indicates the need for REINFORCEMENT of teaching/ 1. "Cutting down an added salt will be good for the whole family." 2. "I'll organize a lot of playdates to keep my child 's spirit up." 3. "I'll restrict my child's fluids if I notice swelling or weight gain." 4. :Ill test for protein in my child's urine everyday."

3

The nurse provides teaching about methotrexate to a 28 year old client with rheumatoid arthritis. Which client statement indicates the need for FURTHER instruction regarding this drug ? 1. "I know my resistance to germs will be lower, so I should get a flu shot this year." 2. "I should take precautions to prevent pregnancy while I take this medicine." 3. "I will have an eye examination every 6 months to check the damage caused by my medication." 4."It will be a difficult change for me, but I will not have wine with dinner anymore."

1,2,4,5

Which nursing interventions would the nurse implement when caring for a client newly diagnosed with acute, viral hepatitis B? SELECT ALL THAT APPLY 1. Offer small, frequent meals to prevent nausea 2. Promote rest periods between periods of activity 3. Provide a diet high in fat and low in carbohydrates 4. Teach the client not to share razors or tooth brushes with others 5. Teach the client to abstain from drinking alcohol

Leopold maneuvers

are used as a systematic approach to palpating the pregnant abdomen to go identify fetal presentation.

Mc Roberts maneuver

consist of sharply flexing the thigh onto the maternal abdomen to straighten the sacrum. It is used for shoulder dystocia and will not take pressure off a prolapsed umbilical cord.

Nephrotic syndrome

is characterized by massive proteinuria, edema and hypoalbuminemia. Home management includes a low sodium diet with attractive foods, infection prevention, fluid restriction for severe edema and monitoring of weight gain and proteinuria to detect relapse.