NCLEX study questions

A client has arrived in the emergency department with partial thickness burns to 52% of the body. Which central venous pressure reading would the nurse anticipate? - 1 - 2 - 6 - 10 mm of Hg

1 mm of Hg Normal CVP is 2-6 mm Hg. This CVP reading indicates fluid volume deficit. A client with 52% of the body burned with partial thickness burns would lose fluid from the vascular space out into the tissues

The nurse has been assigned four clients. Who should the nurse see first? - A client with diabetes admitted for debridement of a foot ulcer - A client with epilepsy reporting an odd smell in the room - A client with exacerbation of COPD reporting dyspnea - An adolescent client post appendectomy reporting pain

A client with epilepsy reporting an odd smell in the room

A nurse is preparing to administer an insulin infusion to a client. The nurse calculates the infusion pump setting as 9 mL/hr. What should the nurse do next? - Administer the calculated medication dosage - Call the HCP to clarify the dosage - Ask another nurse to calculate the dosage - Notify the pharmacy setting for the calculated dosage.

Ask another nurse to calculate the dosage. Insulin is a high alert drug.

A traumatized soldier goes to the infirmary after being told he almost died in a gun battle. He tells the nurse, "I do not remember any of the details of this event. What is wrong with me?" What is the nurse's best response? - I understand you are upset, but you will have to go back to your unit sooner or later - You are repressing this event because it was frightening and painful for you - In my professional opinion, you are trying to undo what happened in the battle. - You are splitting from the bad you, so that the good you survives

You are repressing this event because it was frightening and painful for you

The nurse is caring for a client with a diagnosis of major depression. The client began taking a selective serotonin reuptake inhibitor three days ago. The client states, "I am just not feeling well. My medicine is not working." Which reply by the nurse indicates adequate understanding of treatment? - I agree, your medication is not working - Your treatment may have to be changed - Most SSRIs take about 5 days to work - You should reach the desired effect in 1-3 weeks.

You should reach the desired effect in 1-3 weeks.

Cholelithiasis

gallstones The bile becomes super saturated with cholesterol. This leads to precipitation of cholesterol which presents as gall stones. Clients should avoid foods high in fat - fried foods, cheeses, milk, custard, ice cream, pies, and cakes, red meats, baked beans.

Which medications, if prescribed to a client, should indicate to a nurse that retention of CO2 is a possibility? Select all that apply. - Narcotics - Diuretics - Glucocorticoid steroids - Antiemetics - Hypnotics

- Narcotics - Antiemetics - Hypnotics Anything that effects breathing patterns

Rheumatic fever

An inflammatory disease that can develop later as a complication of untreated or inadequately treated Group A beta hemolytic strep infections such as strep throat and scarlet fever. Is not contagious

Which client should the nurse see first after receiving report on assigned clients? - Having dyspnea after surgery - Needing an IV started for the administration of blood - Crying with pain after back surgery - Vomiting dark brown, granular material

Having dyspnea after surgery - may be a pulmonary embolism

Sacubitril/valsartan

Entresto A combination medications used to reduce the risk of cardiovascular death and hospitalization for HF. Do not take this medication within 36 hours of any ACE inhibitor or other ARB med. Watch for hypotension, hyperkalemia, and impaired renal function.

Prior to removal of cataracts, the client is to receive eye drops in both eyes. The nurse knows what actions takes priority/ - Remove any exudate around eyes with warm water - Instill exact number of drops into lower conjunctival sac - Instruct client to look upward when drops are instilled - Avoid dropping the medication directly on the cornea

Avoid dropping the medication directly on the cornea. The most important safety consideration when instilling eye drops is to avoid dropping the medication directly onto the cornea. The extreme sensitivity of the cornea before, and after, eye surgery could cause serious eye problems.

How should the nurse assist a post-operative client in transferring from the bed to a chair? - Have the client look down and watch their feet as they move - Tell the client to bend at the waist to lower the center of gravity - Place a walker away from the bed so the client can lean forward while standing - Ensure the client's feet are as wide apart as the hips

Ensure the client's feet are as wide apart as the hips. -this maintains the client's horizontal center of gravity

A client is to be discharged following treatment for hepatitis A. The nurse knows teaching was successful when the client makes what statement? - I should never eat fresh salad in a restaurant - I must wait two years before traveling abroad - I will need blood work once a month for a year - I will be able to donate blood when I am well.

I will be able to donate blood when I am well. - Hep A is a virus acquired from food or water contaminated with fecal material, causing inflammation in liver cells. Though some antibodies will remain in the blood permanently, an individual can donate blood once fully recovered from the illness.

The nurse is admitting an 8 month old infant to the pediatric unit. For what major developmental stressor in this infant should the nurse plan interventions? - Fear of unknown - Loss of daily routine - Body image disturbance - Separation anxiety

Separation anxiety

The charge nurse on the pediatric unit has several tasks that need to be completed. What tasks can be assigned to the UAP? Select all that apply. - Obtain a urine sample from an infant - Empty a NG canister for client with ileus - Feed a child with bilateral burns of the hands - Change an ostomy appliance on child with stoma - Ambulate an adolescent two days post appendectomy

- Feed a child with bilateral burns of the hands - Ambulate an adolescent two days post appendectomy

Which side effect of vincristine should the nurse immediately report to the primary healthcare provider? - Nausea - Fatigue - Paresthesia - Anorexia

Paresthesia Vincristine - chemotherapeutic drug that could cause paresthesia - needs dose mod or d/c

`A post-operative client becomes anxious and reports acute onset of chest pain when taking a deep breath and shortness of breath. Initial vital signs obtained by the nurse reveals tachycardia, hemoptysis, and a pulse oximeter reading of 90%. What intervention should the nurse initiate first? - Administer oxygen - Obtain a blood pressure reading - Connect to cardiac monitor. - Raise head of bed to 90 degrees

Raise head of bed to 90 degrees - to facilitate maximum lung expansion and decrease venous return to the right side of the heart to decrease pressure in the pulmonary vascular system.

Following a passenger train derailment, local hospitals are notified to activate disaster protocols on all floors. Which actions should be instituted by each unit's charge nurse? Select all that apply. - Turn on local news for up-to-date information on the train derailment. - Prepare a list of clients who could quickly be discharged or transferred - Determine which personnel could be sent to the command center - Notify clients that the disaster plan has been put into effect - Alert all off-duty personnel to stand by in case of call-in

- Prepare a list of clients who could quickly be discharged or transferred - Determine which personnel could be sent to the command center - Alert all off-duty personnel to stand by in case of call-in.

A client has been admitted with a stroke on the left side of the brain. What clinical manifestations does the nurse expect to find when assessing this client? Select all that apply - Right sided hemiplegia - Depression - Impaired language comprehension - Impulsiveness - Impaired speech

- Right sided hemiplegia - Depression - Impaired language comprehension - Impaired speech

A client wishing to stop smoking receives a prescription for buproprion from the healthcare provider. What educational points should the nurse include regarding this medication? Select all that apply - This medication can cause a false positive drug screening test - Alcohol intake should be limited to two drinks per day - Nicotine gum may be prescribed in addition to bupropion - an increased interest in sexual activity occurs while taking this medication - Smoking can continue for 1 week after starting this medication

- This medication can cause a false positive drug screening test - Nicotine gum may be prescribed in addition to bupropion - Smoking can continue for 1 week after starting this medication

The nurse assesses a client post thyroidectomy for complications by performing which assessment? - Accucheck - Chovostek's - Ballottement - Ice water colonic

Chovestek's - positive is indicative of tetany and low calcium - This can occur when a couple of parathyroids are accidently removed when the thyroid is removed

Phototherapy

"Bili-light" helps breakdown excess bilirubin in the body of a newborn The infant is placed under the special fluorescent light, or blanket, wearing only a diaper. The infant's eyes must be covered during the session to prevent retinal damage. Because of an insensible water loss, body temperature must be checked every few hours to monitor for fever or dehydration. The HCP will order checks of bilirubin levels two or three times a day to verify the infant is responding to therapy If redness or rash appears, the therapy should be d/c and the HCP notified immediately Infants should be given small but frequent feedings every two or three hours to help their bodies eliminate the bilirubin. feeding up to 10 times per day is acceptable

In what order should the nurse assess assigned clients following shift report? What is the priority order? - Client two hour post lobectomy - Client on ventilator needing a nasogastric tube feeding - Client reporting shortness of breath after receiving a bronchodilator respiratory treatment - Newly admitted client diagnosed with esophageal cancer - Client with emphysema who has a pulse oximetry reading of 89%

1. Client reporting shortness of breath after receiving a bronchodilator respiratory treatment 2. Client two hour post lobectomy 3. Newly admitted client diagnosed with esophageal cancer 4. Client on a ventilator needing a nasogastric tube feeding 5. Client with emphysema who has a pulse oximetry reading of 89%

A medical-surgical LPN has been sent to a short-staffed pediatric unit. The charge nurse knows what client would be most appropriate for this LPN? - 3 month old child with nonorganic failure to thrive - 14 year old with exacerbation of cystic fibrosis - 5 year old newly admitted with epiglottitis - 10 year old with type 1 diabetes mellitus

10 year old with type 1 diabetes mellitus

Ballottement

Assessment technique used in examining the abdomen when ascites is present. It is done by palpating the abdomen to detect excessive amounts of fluid.

The pediatric nurse is assessing a child following an appendectomy. What is the nurse's main priority following surgery? - Obtain vital signs every four hours - Assess the need for pain medication - Tally intake and output every eight hours - Auscultate lung sounds every four hours

Auscultate lung sounds every four hours - the potential for atelectasis and pneumonia following surgery means auscultating lung sounds is crucial.

The nurse assessing clients in a pediatric clinic would refer which child for further assessment? - A 20 month old who only says "no" - A 1 year old who says three words - A 9 month old who says "dada" and "mama" - A 4 month old who laughs out loud

A 20 month old who only says "no" By the age of 18 months, a child should be able to speak 10 or more words

A nurse is receiving morning report on the cardiovascular unit. What client should be the nurse's priority assessment? - A client with ejection fraction of 20% and dyspnea at rest - A client with a chest tube to suction and sub-q emphysema - A client two days past abdominal aortic aneurysm repair with decreased pedal pulses - A client coronary artery bypass graft three days ago with WBC 17k

A client two days past abdominal aortic aneurysm repair with decreased pedal pulses. - this may indicate a rupture of the graft or another tear in the aorta with impaired circulation to the lower extremities

The nursing supervisor is reviewing in which restraints have been used. The nurse is aware the only acceptable use of restraints is what? - An elderly male had a chest restraint applied after crawling over bed rails several times - An Alzheimer client's room door is closed to prevent wandering during shift change. - A confused client with a closed head injury had hand mitts applied after pulling out an IV - A dementia client with sundowners is placed in Geri-chair with lap belt at nurse's station.

A confused client with a closed head injury had hand mitts applied after pulling out an IV

Which client in the emergency department should the nurse identify as being highest priority/ - Client with emphysema reporting shortness of breath. - Client with a cut on the left calf with moderate bleeding - Client with onset of confusion 1 hour prior to arrival. - Client with facial swelling and rash after taking azithromycin

Client with facial swelling and rash after taking azithromycin

During client care rounds, the nurse reports that a client coughs frequently after taking anything by mouth. The dietician recommends a swallow evaluation for the client. The primary HCP writes the prescription. Which statement best describes this process? - Collaboration with the ancillary care providers - Collaboration between the primary HCP and dietician - Collaboration with the risk management team - Collaboration among members of the multi-disciplinary team.

Collaboration among members of the multi-disciplinary team.

The primary HCP prescribed phenytoin for a client with grand mal seizures. What intervention would the nurse plan for the client's care? - Offer the client frequent high calorie snacks - Check the apical pulse before each dose - Perform or assist with oral hygiene every shift - Give the medication 30 minutes prior to meal

Perform or assist with oral hygiene every shift A major side effect of phenytoin (anticonvulsant that slowing down impulses in the brain that cause seizures) is gingival hyperplasia. Weight gain or loss is not typically a concern Apical pulse is checked with digoxin, not phenytoin Phenytoin often causes gastric distress, needs to be taken with a meal, not before.

What preferred lab value would the nurse expect to see the primary healthcare provider prescribe for a client admitted with generalized malnutrition? - Albumin - Prealbumin - Iron - Calcium

Prealbumin - decreases more quickly when nutrition is not adequate Albumin can take weeks to drop

A child with acute lymphocytic leukemia (ALL) is receiving chemotherapy through a single lumen Groshong catheter. During the infusion, the child reports nausea and has vomited. The primary HCP has prescribed ondansetron IV. What action should the nurse take? - Ask the primary HCP for an oral antiemetic - Give ondansetron IVPB with the chemotherapy - Wait until chemotherapy is complete to infuse ondansetron - Stop chemotherapy temporarily and flush line to give ondansetron.

Stop chemotherapy temporarily and flush line to give ondansetron. A Groshong catheter is implanted when other venous access sites are no longer useable.

The nurse is assigned five clients on a medical floor. When planning care, the nurse recognized which clients to be at greatest risk for ineffective oral hygiene? Select all that apply. - A client who has just had knee surgery taking opioids for pain - A right handed client who had a stroke affecting the right hemisphere of the brain - A client with breast cancer who is experiencing severe nausea and vomiting after chemotherapy - An elderly client experiencing loss of appetite - A client who take phenytoin for partial seizures

- A client with breast cancer who is experiencing severe nausea and vomiting after chemotherapy - A client who takes phenytoin for partial seizures.

The emergency department triage nurse encounters a client who says that he has received exposure to a liquid hazardous chemical at work. He reports that he is only 1 of about 20 people. What should the nurse do? Select all that apply. - Call the supervisor and inform of the possibility of contamination in the surrounding space - Obtain vital signs immediately - Call personnel trained in containment and decontamination immediately - Direct the individual to a bed space immediately - Instruct the client to remove clothing and put on disposable hospital gown.

- Call the supervisor and inform of the possibility of contamination in the surrounding space - Call personnel trained in containment and decontamination immediately

A nurse from the maternity unit is pulled to the medical-surgical unit for the first 4 hours of the shift. Which clients would be appropriate for the charge nurse to assign to the nurse from the maternity unit? Select all that apply. - Client with rheumatic fever - Client scheduled for an appendectomy - Client one day post cardiac catheterization - Client diagnosed with Methicillin-Resistant Staphylococcus Aureus - Client newly admitted with Guillian-Barre syndrome

- Client with rheumatic fever - Client scheduled for an appendectomy - Client one day post cardiac catheterization rheumatic fever is not contagious, MRSA is, Guillian barre syndrome is too complex

A client is admitted with atrial fibrillation and HF secondary to chronic hypertension. Current medications include: digoxin, carvedilol, furosemide, and warfarin. Based on this profile, what lab work is essential for the nurse to monitor? Select all that apply. - Digoxin level - Potassium level - PT/INR - aPTT - CPK-MB

- Digoxin, K, PT/INR aPTT needs monitored with heparin. CPK-MB would be elevated anyway because of the HF

A client in the emergency department with acute onset of fever, headache, stiff neck, N/V, and mental status changes. What interventions should the nurse initiate? Select all that apply. - Elevate HOB 30 degrees - Pad side rails - Provide sponge bath is temperature greater than 101 F - Initiate airborne isolation precautions - Darken room

- Elevate HOB to 30 degrees - Pad side rails - Provide sponge bath if temp is over 101 f - Darken room These symptoms indicate bacterial meningitis - elevate HOB to decrease ICP, implement seizure precautions, reduce fever to reduce risk of brain damage, darken room for photophobia. Droplet precautions should be initiated for the first 24 hours of antimicrobial therapy, not airborne precautions.

A client is suspected of having pheochromocytoma. The nurse is explaining the process of a Vanillylmandelic acid (VMA) urine test to be complete at home. What statements made by the client indicates the need for further teaching? Select all that apply. - I need to keep the urine in the fridge during the 24 hours - I will have to stay well-hydrated to get enough urine to test - It does not matter what I eat or drink during this process - I need to throw away my first voiding when I start this test - I should void at the end of the 24 hours and keep that urine.

- I need to keep the urine in the fridge during the 24 hours - I will have to stay well-hydrated to get enough urine to test - It does not matter what I eat or drink during this process The collected urine needs to be kept cold, but should never be placed in the refrigerator with the client's food. There is no minimum amount of urine needed for the test. The week before the test, the client needs to eliminate vanilla products.

An unresponsive 13 year old is brought into the emergency department. Based on the nursing assessment and current lab data, which interventions would be appropriate for the nurse to initiate? Select all that apply. - Administer kayexelate - Initiate IV of NS 100 mL with regular insulin 100 units at 10 mL/hr - Start oxygen at 2 liters per nasal cannula - Start a second IV for fluid resuscitation - Insert indwelling urinary catheter

- Initiate IV of NS 100 mL with regular insulin 100 units at 10 mL/hr - Start a second IV for fluid resuscitation - Insert indwelling urinary catheter This client is exhibiting Kussmaul respirations. Potassium and glucose are high. The client has ketones which are an acid. Blood gases reveal metabolic acidosis related to diabetic ketoacidosis and hypovolemic shock. This client needs isotonic solutions and regular insulin to decrease glucose and decrease potassium. The client needs fluid resuscitation due to polyuria seen with DKA. Indwelling urinary catheter needed to measure urine output. The pt does not need kayexelate because regular insulin IV shifts potassium from the blood into the cell

The nurse is caring for a client with multiple episodes of diarrhea and suspected Clostridium Difficile (C. diff). Which interventions should be included in the plan of care? Select all that apply. - Institute contact precautions only after confirmation of stool culture - Instituting contact precautions for all who enter the client's room - Using alcohol based foam for hand hygiene - Dedicating equipment for use only in the client's room - Requesting antidiarrheal medication for the client

- Instituting contact precautions for all who enter the client's room - Dedicating equipment for use only in the client's room. antidiarrheals could cause further irritation

A newly hired nurse has been instructed by the preceptor nurse on burn dressing techniques. The nurse knows teaching has been effective when the new nurse performs wound care in what order? - Wash hands and apply sterile gloves - Remove the old dressing and discard - Medicate client with pain medication - Set up sterile field and open packages - Wash hands and apply clean gloves - Clean burn and place sterile dressing.

- Medicate client with pain medication - wash hands and apply sterile gloves - set up sterile field and open packages - remove the old dressing and discard - wash hands and apply sterile gloves - clean burn and place sterile dressing.

Which signs/symptoms should the nurse assess for the presence of in a client diagnosed with valvular heart disease? Select all that apply. - Orthopnea - Paroxysmal nocturnal dyspnea - Petechiae on the trunk - Increasing CVP with decreasing BP - Pericardial friction rub - Widening pulse pressure

- Orthopnea and paroxysmal nocturnal dyspnea petechiae on the trunk is a sign of endocarditis Increasing CVP with decreasing BP is a sign for cardiac tamponade Pericardial friction rub is a sign of pericarditis Widening pulse pressure is a sign of increased ICP

The parents of a child admitted with rheumatic fever ask why the child has been placed on bedrest. The nurse explains that bedrest serves what primary purpose for the client? - Prevents permanent joint damage - Decreases workload on the heart - Helps regulate body temperature - Reduces joint pain and body aches

Decreases workload on the heart Group A beta-hemolytic strep can cause inflammation in the myocardium or epicardium, ultimately affecting the valves of the heart, particularly the mitral valve. The resulting thickening and fibrosis leads to cardiac stenosis which could lead to HF.

A nurse is planning care for a laboring client who is about to be started on oxytocin. What interventions should the nurse include in this plan of care? Select all that apply. - Piggy back oxytocin into main IV fluid - Monitor for early decelerations - D/C if contractions last longer than 90 seconds - Maintain one on one care - Check fetal heart tones hourly

- PB oxytocin into main IV fluid (so when oxy is d/c the main IV fluid is resumed quickly) - D/C if contractions last longer than 90 seconds (to avoid hyperstimulation of the uterus and fetal distress) - Maintain 1:1 care (to monitor for complications) External fetal monitoring should begin prior to oxytocin administration. A reactive fetal heart rate tracing should be obtained over 30 minutes

Place the steps in order that the nurse should take to administer a subcutaneous injection. - Perform hand hygiene - Inject the needle and administer the medication - Hold syringe and pinch the skin with nondominant hand - Remove the needle cap by pulling it straight off - Apply gloves and locate the injection site - Cleanse site with antiseptic swab - Dispose the syringe in sharps container.

- Perform hand hygiene - Apply gloves and locate the injection site - Cleanse site with antiseptic swab - Remove the needle cap by pulling it straight off - Hold syringe and pinch the skin with nondominant hand - Inject the needle and administer the medication - Dispose the syringe in sharps container.

The nurse is observing a new RN explain phototherapy to the mother of a newborn with a bilirubin of 12 mg/dL one day after birth. The nurse determines the new Rn understands the phototherapy process when what statements are made to the mother? Select all that apply. - The infant's eyes must be covered throughout the session - The heat from the light may cause some harmless swelling in the arms - Body temperature must be checked frequently to monitor for fever - It is important to restrict feedings during the phototherapy sessions - We check bilirubin levels several times daily to be sure it's decreasing.

- The infant's eyes must be covered throughout the light session - Body temperature must be checked frequently to monitor for fever - We check bilirubin levels several times daily to be sure it's decreasing.

Which interventions should be included in the nutritional teaching plan to accomplish the goal of a diet lower in fat? Select all that apply - Use 2% milk instead of whole milk - Eat air-popped popcorn instead of potato chips - Eat more red meat instead of fish - Incorporate plant sources of protein - Use olive oil instead of vegetable oil when frying

- Use 2% milk instead of whole milk - Eat air-popped popcorn instead of potato chips - Incorporate plant sources of protein

Which interventions decrease risk of infection or damage to delicate tissue when the nurse is changing a wound dressing? Select all that apply. - Warm cleansing solutions to body temperature - Clean the wound when there is drainage present - Use cotton balls to clean the suture site - Use sterile gauze squares to dry the wound - Use sterile forceps when cleaning the wound.

- Warm cleansing solutions to body temperature (enhances the healing process by not lowering the temperature of the wound and enhancing circulation to the wound bed.) - Clean the wound when there is drainage present (drainage and exudate can create an environment where bacteria can thrive.) - Use sterile forceps when cleaning the wound

The nurse is cleaning and dressing a foot ulcer of a diabetic client. Which actions are appropriate? Select all that apply. - Uses a clean basin and washcloth to clean the ulcer - Wears sterile gloves to clean the ulcer - Cleans ulcer with normal saline - Warms saline bottle in microwave for 1 minute - Cleans ulcer in a full circle, beginning in the center and working toward the outside

- Wears sterile gloves to clean the ulcer - Cleans ulcer with normal saline - Cleans ulcer in a full circle, beginning in the center and working toward the outside. Normal saline solution is the preferred cleansing agent because, as an isotonic solution, it doesn't interfere with the normal healing process.

A client taking phenelzine is admitted to the hospital. Which healthcare provider prescription should the nurse question? - Take blood pressure lying, sitting, and standing once per shift - Order a complete blood count and liver profile studies - Eliminate foods containing tyramine from diet - Discontinue phenelzine. Begin fluoxetine 20 mg by mouth at bedtime

Discontinue phenelzine. Begin fluoxetine 20 mg by mouth at bedtime. Phenelzine is a MAOI Fluoxetine is an SSRI taken in combination, they can cause serotonin syndrome

What room assignment by the charge nurse is most appropriate for a client who is being admitted with poor appetite, malaise, and temperature of 101.5 F - Private room - Room with a client who has biliary colic - Room with a client who is 3 days post operative hip replacement - Room with a client who is in skeletal traction due to a broken femur

Private room

The nurse is planning care for a preschool aged child who is being treated in the hospital for RSV. What should the nurse recognize as the child's likely view of this illness in order to properly plan care? - Punishment - Disturbance to body image - Rejection from parents - Change in routine with friends

Punishment

A client has been admitted to the labor and delivery unit with a diagnosis of preeclampsia. During afternoon rounds, which assessment finding by the nurse should be reported to the primary HCP immediately? - Deep tendon reflexes of plus 3 - Urine output of 80 mL over four hours - RR of 24 breaths/min - Severe headache with blurred vision

Urine output of 80 mL over four hours. Indicates possible kidney failure

What should the nurse tell a 68 year old client who states that they have started experiencing tremors? - This is nothing to worry about and is common with aging - You should increase your intake of potassium - We need to let your primary HCP know because it may indicate a problem - Have someone check your blood pressure the next time you experience tremors.

We need to let your primary HCP know because it may indicate a problem

A client diagnosed with Addison's disease has been prescribed prednisolone. Which statement by the client indicates that the client's medication instructions for prednisolone have been effective? - I should avoid foods high in protein - I will take prednisolone in thr morning - I need to schedule an eye examination every 2 years - Infections will be reduced while taking prednisolone

I will take prednisolone in the morning. The body's production of cortisol is at a higher level in the morning. Clients should be encouraged to consume a high protein diet to avoid decreased muscle mass and help wound healing. Yearly eye examinations are recommended. Prolonged therapy can result in cataracts and glaucoma. Prednisolone is an anti-inflammatory and immune suppressant. Can mask infection symptoms.

A client with a new single chamber pacemaker is receiving instructions prior to discharge. What statement by the client indicates to the nurse the need to review the instructions again? - I can use a cell phone on the side opposite my pacemaker - I must check and then record my heart rate every day - It is safe for me to go through the new airport security - I need monthly pacemaker checks to assess pacer function

It is safe for me to go through the new airport security

Which assessment finding in a client 5 hours post open cholecystectomy would require the nurse to notify the surgeon? - Absent bowel sounds - Jackson Pratt drain has 90 mL of blood - Urinary output of 180 mL since return from surgery - Client report of abdominal pain of 8/10

Jackson Pratt drain has 90 mL of blood - An open cholecystectomy will usually result in the placement of a drain. The drainage should be green (bile). Blood is a problem and needs immediate intervention.

Which intervention should the nurse recommend to the adult child who is caring for an elderly parent diagnosed with Alzheimer's disease (AD)? - Give parent small dog for company and comfort - Reset the water heater to 125 degrees F to prevent burns - Place mirrors in multiple locations so parent sees image of self - Make floors and walls different colors.

Make floors and walls different colors.

A client who has a long leg cast is reporting unrelieved pain. What should the nurse do first? - Apply a cool compress - Elevate and reposition the leg - Assess for breakthrough bleeding on the cast - Monitor extremity for paresthesia.

Monitor extremity for paresthesia (compartment syndrome) The 5 Ps: pain, pallor, pulse, paresthesia, and paralysis.

The nurse is assessing a client admitted yesterday with a diagnosis of closed head injury and fractured pelvis following a motorcycle accident. Today the nurse observes a small petechial rash on the client's chest. What specific indications of a serious complication should the nurse report immediately to the healthcare provider? Exhibit: Time: 0730; BP: 130/85; P: 90; RR: 24; Pox: 97%; Temp: 100.1 Time: 0745; BP: 140/75; P: 105; RR: 28; Pox: 94%; Temp: 101.0 Time: 0810; BP: 145/70; P: 110; RR: 32; Pox: 92%; Temp: 101.8 - An increased blood pressure with tachycardia - A widening pulse pressure with increasing pulse - A petechial rash with an increase in temperature - A rapid respiratory rate with dropping oxygen levels

A petechial rash with an increase in temperature The client is experiencing an increase in the systolic blood pressure along with tachycardia and tachypnea. The petechial rash, decreasing oxygen saturation levels and even fever further indicate the client has most likely developed a fat embolism. A widening pulse pressure is an indication of increasing ICP; however, if the client was developing Cushing's triad, the pulse would decrease rather than increase.

A client admitted for debridement of a leg wound has been diagnosed with vancomycin-resistant enterococci (VRE). What is the nurse's priority action? - Place with another client in contact isolation for MRSA - Move the client to a private room with contact precautions - Alert staff to use masks, goggles, and gown to provide care - Notify family members to gown and glove before entering room

Move the client to a private room with contact precautions

Based on expected growth and development for a 7 month old infant, what would the nurse anticipate that the mother would report at the infant's well-baby visit? - Has slight head lag when pulled to sitting position - Walks holding onto furniture - Able to sit, leaning forward on both hands - Has neat pincer grasp

Able to sit, leaning forward on both hands

A client is admitted to the hospital due to a deep vein thrombosis (DVT). Which intervention should the nurse initiate? - Ambulate client around room every 2 hours - Asses Homans' sign every 8 hours - Place sequential compression device on both legs - Apply intermittent warm, moist soaks to affected area.

Apply intermittent warm, moist soaks to affected area. - decrease edema and ease the discomfort Client should be placed on bedrest with a gradual increase in ambulation over several days to allow time for the clot to adhere to the vessel wall which will prevent embolization; manipulating the leg to determine Homans' sign can dislodge the clot; SCDs could cause the clot to break loose or dislodge.

A client who has had a stroke presents with lethargy, facial droop, and slurred speech. The client has a history of gastroesophageal reflux disease (GERD). From this history, what does the nurse recognize as an increased risk for this client? - Diminished colonic motility - Esophageal hemorrhage - Aspiration pneumonia - Stress ulcers

Aspiration pneumonia esophageal hemorrhage is seen with esophageal varices, not reflux disease

The pathology report on a client diagnosed with urolithiasis reveals calcium oxalate stones. Which food selections by the client would indicate to the nurse that the client understands the prescribed low oxalate diet? - Spinach - Raspberries - Almonds - 100% bran cereal - Bananas - Raisins

Bananas and raisins - fruits provide valuable amounts of water, fiber, and antioxidants, all of which may help lower your risk for kidney stone symptoms. Many fruits are considered low-oxalate, which means they contain less than 2 milligrams per serving -- bananas, cherries, grapefruit, grapes, mangoes, melons, green and yellow plums, and nectarines. Raspberries are the most significant fruit source of oxalate - 1 cup contains 48 mg

The nurse is preparing to administer scheduled medications for a client. Which medication would require clarification prior to administration? Exhibit: Client chart information: Diagnosis: Heart failure. Current vital signs: BP 110/64, HR 70, R 18 Allergies: Sulfonamides Lab results: Glucose 98; Sodium 142; K 3.8; Digoxin level 0.8 Diet: 2 gm sodium - Digoxin - Sacubitril/valsartan - Bumetanide - Potassium chloride

Bumetanide - a loop diuretic - and can cause a cross sensitivity in a person allergic to sulfonamides

The nurse is teaching a family member of a client with a terminal illness the signs of impending death. Which statement by a family member indicates the need for further teaching? - I will continue to talk in normal tones - Decreases in respirations my happen - Death is soon, if their shoulders are cool - They may prefer to sleep rather than talk

Death is soon, if their shoulders are cool The systems of the body will begin to function erratic and slower as death approaches. As the feedback of the circulatory system fails, the client will have fluctuating temperature control. As death process continues, the circulatory system in the extremities will fail. The arms and legs will become cooler. The family member will require further teaching regarding indicators of approaching death.

A client was started on captopril three weeks ago and has returned to the health clinic for a checkup. What symptom noted during assessment would the nurse consider of priority concern? - Rash on both arms - Fever of 102.0 F - Dry hacking cough - Tachycardia

Fever of 102.0 F One potentially life-threatening side effect of captopril is infection secondary to neutropenia.

A client is scheduled for a colonoscopy with biopsy of a large tumor that is completely blocking the large intestine in the morning. Which preoperative prescription should the nurse question? - Administer tap water enemas until clear at 6 AM - Nothing by mouth - IV of D1/2 NS at 75 mL/hour with a 20 guage catheter - Give magnesium citrate 296 mL at 3 PM today

Give magnesium citrate 296 mL at 3 PM today

A client admitted with biliary atresia has just arrived on the pediatric unit. The unit is very busy and the other RNs are busy with other clients at this moment. What action by the charge nurse would be most appropriate? - Instruct the unlicensed assistive personnel to obtain clients vital signs and weight - Assign an LPN/VN to perform the initial nursing history and physical assessment - Have an LPN/VN collect data on the client and report results to RN - Inform one of the RNs that a new client is on the floor and that a nursing history should be completed as soon as possible.

Have an LPN/VN collect data on the client and report results to RN

A nurse is caring for a client who has chest pain. Which statement made by the client leads the nurse to suspect angina instead of a myocardial infarction? - I became dizzy when I stood up - I was nauseated and began vomiting - The pain started in my chest and stopped after I sat down - The pain was not relieved after taking 3 nitroglycerine tablets.

The pain started in my chest and stopped after I sat down. - Chest pain brought on by exercise and stopped with rest is the hallmark of angina. If it were an MI the pain would continue even with rest or position changes. - Dizziness indicates orthostatic hypotension and is not definitive for angina or MI - Vomiting is a symptom of an MI and is a bad sign related to the acute pain from the MI. This type of pain stimulates the vagus nerve, which causes the HR, BP, and cardiac output to decrease

The son of a client diagnosed with Alzheimer's disease who is listed as a person who has access to the client's health information asks the nurse why his father has been prescribed donepezil. What response should the nurse make? - Depression is often treated with this medication - This medication is used to treat confusion - Behavioral problems are diminished when the client receives this medication - This medication will address sleep disturbances.

This medication is used to treat confusion. Donepezil is a cholinesterase inhibitor. It improves the function of nerve cells in the brain. It works by preventing breakdown of acetylcholine. People with dementia usually have lower levels of this chemical, which is important for the processes of memory, thinking, and reasoning. Used to treat mild to moderate dementia caused by AD Zolpidem is the most common prescription used to help with sleep disturbances found with AD

Bupropion

Wellbutrin An antidepressant medication prescribed for major depressive disorder and seasonal affective disorder. Used to help people stop smoking by reducing craving and other withdrawal effects Can cause a false positive drug screen Nicotine gum or patches may also be prescribed - bupropion is a nicotine free prescription The client can continue to smoke for about 1 week after starting the medicine. Recommended length of therapy for smoking cessation is 7 to 12 weeks. Drinking alcohol may increase the risk of seizures, especially if the client drinks a lot and then quits suddenly

The nurse is talking with the mom of a preschooler at the well-child visit. The mom reports that her 3 year old has a lot of energy and sleeps 9 hours per night. What assessment questions should the nurse ask in response to this comment? Select all that apply. - Nothing, as this is normal for preschoolers - Does your child take naps during the day? - Does your child wake up spontaneously or do you wake her? - Does your child appear rested upon awakening? - Does your child have trouble settling down for sleep?

options 2-5 Preschoolers typically require 11-13 hours of sleep per day. The child may be supplementing nighttime sleep with long naps. It is important to determine if the child has to be awakened after nine hours or if the child awakens spontaneously. The child may have to be awakened due to mom's work schedule. The adequacy of rest should be determined, as the child is sleeping less than is typical.