Saunders Comprehensive NCLEX-RN review
The nurse is caring for an older adult who has been placed in Buck's extension traction after a hip fracture. On assessment of the client, the nurse notes that the client is disoriented. What is the best nursing action based on this information?
Apply restraints to the client. Ask the family to stay with the client. Place a clock and calendar in the client's room. Ask the laboratory to perform electrolyte studies. An inactive older adult may become disoriented because of lack of sensory stimulation. The most appropriate nursing intervention would be to reorient the client frequently and to place objects such as a clock and a calendar in the client's room to maintain orientation. Restraints may cause further disorientation and would not be applied unless specifically prescribed; agency policies and procedures need to be followed before the application of restraints. The family can assist with orientation of the client, but it is inappropriate to ask the family to stay with the client. It is not within the scope of nursing practice to prescribe laboratory studies. Note the strategic word, best, and eliminate option 4 first because it is not within the realm of nursing practice to prescribe laboratory studies. Next, eliminate option 1 because restraints may add to the disorientation that the client is experiencing. It is inappropriate to place the responsibility of the client on the family, so eliminate option 2. Also, note the relationship between the word disoriented in the question and the implications of reorientation in the correct option.
The nurse is caring for a client with anorexia nervosa. Which behavior is characteristic of this disorder and reflects anxiety management?
Engaging in immoral acts Always reinforcing self-approval Observing rigid rules and regulations Having the need always to make the right decision Clients with anorexia nervosa have the desire to please others. Their need to be correct or perfect interferes with rational decision-making processes. These clients are moralistic. Rules and rituals help these clients manage their anxiety. Focus on the subject, managing anxiety. Eliminate options 2 and 4 because of the closed-ended word "always." Option 1 is not characteristic of a client with anorexia.
The nurse is assigned to care for a client in traction. The nurse creates a plan of care for the client and would include which action in the plan?
Ensure that the knots are at the pulleys. Check the weights to ensure that they are off the floor. Ensure that the head of the bed is kept at a 45- to 90-degree angle. Monitor the weights to ensure that they are resting on a firm surface. To achieve proper traction, weights need to be free-hanging, with knots kept away from the pulleys. Weights would not be kept resting on a firm surface. The head of the bed is usually kept low to provide countertraction. Focus on the subject, care for a client in traction. Attempt to visualize the traction, recalling that there must be weight to exert the pull from the traction setup. This concept will assist in eliminating options 1 and 4. Recalling that countertraction is needed will assist in eliminating option 3.
An adolescent client is diagnosed with conjunctivitis, and the nurse provides information to the client about the use of contact lenses. Which client statement indicates the need for further information?
I need to obtain new contact lenses." "I need to not wear my contact lenses." "My old contact lenses need to be discarded." "My contact lenses can be worn if they are cleaned as directed." If the adolescent wears contact lenses, the adolescent needs to be instructed to discontinue wearing them until the infection has cleared completely. Obtaining new contact lenses would eliminate the chance of reinfection from contaminated contact lenses and would lessen the risk of a corneal ulceration. Note the strategic words, need for further information. These words indicate a negative event query and ask you to select an option that is incorrect. Options 1, 2, and 3 are comparable or alike in that they relate to avoiding the use of contact lenses during infection.
The nurse reviews the arterial blood gas results of a client with emphysema and notes that the laboratory report indicates a pH of 7.30, Paco2 of 58 mm Hg, Pao2 of 80 mm Hg, and Hco3 of 27 mEq/L. The nurse interprets that the client has which acid-base disturbance?
Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis The normal pH is 7.35 to 7.45. Normal Paco2 is 35 to 45 mm Hg. In respiratory acidosis, the pH is low and Paco2 is elevated. Options 1, 2, and 4 are incorrect interpretations of the values identified in the question.
The nurse is setting up the physical environment for an interview with a client and plans to obtain subjective data regarding the client's health. Which interventions are appropriate? Select all that apply.
Set the room temperature at a comfortable level. Remove distracting objects from the interviewing area. Place a chair for the client across from the nurse's desk. Ensure comfortable seating at eye level for the client and nurse. Provide seating for the client so that the client faces a strong light. Ensure that the distance between the client and nurse is at least 7 feet (2.1 meters). When preparing the physical environment for an interview, the nurse would set the room temperature at a comfortable level. The nurse would provide sufficient lighting for the client and nurse to see each other. The nurse would avoid having the client face a strong light because the client would have to squint into the full light. Distracting objects and equipment need to be removed from the interview area. The nurse would arrange seating so that the nurse and client are seated comfortably at eye level, and the nurse avoids facing the client across a desk or table, because this creates a barrier. The distance between the nurse and the client would be set by the nurse at 4 to 5 feet (1.2 to 1.5 meters). If the nurse places the client any closer, the nurse will be invading the client's private space and may create anxiety in the client. If the nurse places the client farther away, the nurse may be seen as distant and aloof by the client.
A client is about to undergo a lumbar puncture. The nurse describes to the client that which position will be used during the procedure?
Side-lying with a pillow under the hip Prone with a pillow under the abdomen Prone in slight Trendelenburg's position Side-lying with the legs pulled up and the head bent down onto the chest A client undergoing lumbar puncture is positioned lying on the side, with the legs pulled up to the abdomen and the head bent down onto the chest. This position helps open the spaces between the vertebrae and allows for easier needle insertion by the primary health care provider. The nurse remains with the client during the procedure to help the client maintain this position. The other options identify incorrect positions for this procedure. Focus on the subject, lumbar puncture. Recalling that a lumbar puncture is the introduction of a needle into the subarachnoid space will direct you to the correct option. It is reasonable that the position of the client must facilitate this, and the correct option is the only position that flexes the vertebrae and widens the spaces between them.
The nurse is teaching a client with emphysema about positions that help breathing during dyspneic episodes. The nurse instructs the client that which positions alleviate dyspnea? Select all that apply.
Sitting up and leaning on a table Standing and leaning against a wall Lying supine with the feet elevated Sitting up with the elbows resting on knees Lying on the back in a low-Fowler's position The client would use the positions outlined in options 1, 2, and 4. These allow for maximal chest expansion. The client would not lie on the back because this reduces movement of a large area of the client's chest wall. Sitting is better than standing, whenever possible. If no chair is available, leaning against a wall while standing allows accessory muscles to be used for breathing and not posture control. Focus on the subject, the positions that could alleviate dyspnea. Remember that upright positions are best. Also, note that options 1, 2, and 4 are comparable or alike in that they all address upright positions.
On the second postpartum day, a client complains of burning on urination, urgency, and frequency of urination. A urinalysis indicates the presence of a urinary tract infection. The nurse instructs the client regarding measures to take for the treatment of the infection. Which client statement indicates to the nurse the need for further instruction?
"I need to urinate frequently throughout the day." "The prescribed medication must be taken until it is finished." "My fluid intake needs to be increased to at least 3000 mL daily." "Foods and fluids that will increase urine alkalinity need to be consumed." A client with a urinary tract infection must be encouraged to take the prescribed medication for the entire time it is prescribed. The client would also be instructed to drink at least 3000 mL of fluid each day to flush the infection from the bladder and to urinate frequently throughout the day. Foods and fluids that acidify the urine need to be encouraged. Recall that foods and fluids that acidify the urine need to be consumed, rather than foods and fluids that cause urine alkalinity.
A client who is positive for human immunodeficiency virus (HIV) delivers a newborn infant. The nurse provides instructions to help the client with care of the infant. Which client statement indicates the need for further instruction?
"I will be sure to wash my hands before and after bathroom use." "I need to chest-feed with my milk, especially for the first 6 weeks postpartum." "Support groups are available to assist me with understanding my diagnosis of HIV." "My newborn infant needs to be on antiviral medications for the first 6 weeks after delivery." The mode of perinatal transmission of HIV to the fetus or neonate of an HIV-positive parent can occur during the prenatal, intrapartal, or postpartum period. HIV transmission can occur during chest-feeding. In the United States and most developed countries, HIV-positive clients are encouraged to bottle-feed their infants (the primary health care provider's prescription is always followed). Frequent handwashing is encouraged. Support groups and community agencies can be identified to assist the parents with the newborn infant's home care, the impact of the diagnosis of HIV infection, and available financial resources. It is recommended that infants of HIV-positive clients receive antiviral medications for the first 6 weeks of life. Note the strategic words, need for further instruction. These words indicate a negative event query and ask you to select an option that is incorrect. Recalling the methods of transmission of HIV and that chest-feeding with the client's own milk is discouraged in the HIV-positive parent will direct you to the correct option.
During a routine prenatal visit, a client complains of gums that bleed easily with brushing. The nurse performs an assessment and teaches the client about proper nutrition to minimize this problem. Which client statement indicates an understanding of the proper nutrition to minimize this problem?
"I will drink 8 oz of water with each meal." "I will eat three servings of cracked wheat bread each day." "I will eat two saltine crackers before I get up each morning." "I will eat fresh fruits and vegetables for snacks and for dessert each day." Fresh fruits and vegetables provide vitamins and minerals needed for healthy gums. Drinking water with meals has no direct effect on gums. Cracked wheat bread may abrade the tender gums. Eating saltine crackers can also abrade the tender gums. Focus on the subject, dental health during pregnancy. Eliminate options 2 and 3 first because these measures could irritate fragile gums. From the remaining options, eliminate option 1 by remembering that drinking water with meals has no direct effect on gums and does not provide needed vitamins and minerals.
The nurse teaches a client newly diagnosed with type 1 diabetes about storing Humulin N insulin. Which statement indicates to the nurse that the client understood the discharge teaching?
"I would keep the insulin in the cabinet during the day only." "I know I have to keep my insulin in the refrigerator at all times." "I can store the open insulin bottle in the kitchen cabinet for 1 month." "The best place for my insulin is on the windowsill, but in the cupboard is just as good." An insulin vial in current use can be kept at room temperature for 1 month without significant loss of activity. Direct sunlight and heat must be avoided. Therefore, options 1, 2, and 4 are incorrect. Note the subject, client understanding of discharge instructions related to storage of insulin. Noting the closed-ended words "only" in option 1 and "all" in option 2 will assist you in eliminating these options. Recalling that direct sunlight and heat need to be avoided will assist you in eliminating option 4.
The nurse provides instructions to a malnourished pregnant client regarding iron supplementation. Which client statement indicates an understanding of the instructions?
"Iron supplements will give me diarrhea." "Meat does not provide iron and should be avoided." "The iron is best absorbed if taken on an empty stomach." "On the days that I eat green leafy vegetables or calf liver I can omit taking the iron supplement." Iron is needed to allow for transfer of adequate iron to the fetus and to permit expansion of the maternal red blood cell mass. During pregnancy, the relative excess of plasma causes a decrease in the hemoglobin concentration and hematocrit, known as physiological anemia of pregnancy. This is a normal adaptation during pregnancy. Iron is best absorbed if taken on an empty stomach. Taking it with a fluid high in ascorbic acid such as tomato juice enhances absorption. Iron supplements usually cause constipation. Meats are an excellent source of iron. The client needs to take the iron supplements regardless of food intake. Note the subject, iron supplementation during pregnancy. Focus on the words understanding of the instructions. Knowledge of basic principles related to nutrition during pregnancy will assist in eliminating options 2 and 4. From the remaining options, remember that iron causes constipation.
A 6-year-old child has just been diagnosed with localized Hodgkin's disease, and chemotherapy is planned to begin immediately. The parent of the child asks the nurse why radiation therapy was not prescribed as a part of the treatment. The nurse would plan to make which best response?
"It's very costly, and chemotherapy works just as well." "I'm not sure. I'll discuss it with the primary health care provider." "Sometimes age has to do with the decision for radiation therapy." "The primary health care provider would prefer that you discuss treatment options with the oncologist." Radiation therapy is usually delayed, whenever possible, until a child is 8 years old to prevent retardation of bone growth and soft tissue development. Options 1, 2, and 4 are inappropriate responses to the parent and place the parent's question on hold.
The nurse is caring for a client scheduled for a transsphenoidal hypophysectomy. The preoperative teaching instructions would include which statement?
"Your hair will need to be shaved." "You will receive spinal anesthesia." "You will need to ambulate after surgery." "Brushing your teeth needs to be avoided for at least 2 weeks after surgery." A transsphenoidal hypophysectomy is a surgical approach that uses the nasal sinuses and nose for access to the pituitary gland. Based on the location of the surgical procedure, spinal anesthesia would not be used. In addition, the hair would not be shaved. Although ambulating is important, specific to this procedure is avoiding brushing the teeth to prevent disruption of the surgical site. Focus on the subject, a preoperative instruction. Consider the anatomical location and the surgical procedure itself to eliminate options 1 and 2. Although you may be tempted to select option 3, note the location of the surgery to direct you to the correct option.
A breast-feeding/chest-feeding parent of an infant with lactose intolerance asks the nurse about dietary measures. What foods would the nurse tell the parent are acceptable to consume while breast-feeding/chest feeding? Select all that apply.
1% milk Egg yolk Dried beans Hard cheeses Green leafy vegetables Breast-feeding or chest-feeding parents with lactose-intolerant infants need to be encouraged to limit dairy products. Milk and cheese are dairy products. Alternative calcium sources that can be consumed by the parent include egg yolk, dried beans, green leafy vegetables, cauliflower, and molasses. Focus on the subject, foods acceptable for a breast-feeding or chest-feeding parents with a lactose-intolerant infant. Recall that lactose is the sugar found in dairy products. Also note that options 1 and 4 are comparable or alike and are dairy products.
A client received 20 units of Humulin N insulin subcutaneously at 08:00. At what time would the nurse plan to assess the client for a hypoglycemic reaction?
10:00 11:00 17:00 24:00 Humulin N is an intermediate-acting insulin. The onset of action is 60 to 120 minutes, it peaks in 6 to 14 hours, and the duration of action is 16 to 24 hours. Hypoglycemic reactions most likely occur during peak time. Focus on the subject, characteristics of Humulin N insulin, and use knowledge regarding the onset, peak, and duration of action. Recalling that it is an intermediate-acting insulin and recalling that peak action is between 6 and 14 hours will direct you to the correct option.
Levothyroxine is prescribed for a client diagnosed with hypothyroidism. Upon review of the client's record, the nurse notes that the client is taking warfarin. Which modification to the plan of care would the nurse review with the client's primary health care provider?
A decreased dosage of levothyroxine An increased dosage of levothyroxine A decreased dosage of warfarin sodium An increased dosage of warfarin sodium Levothyroxine accelerates the degradation of vitamin K-dependent clotting factors. As a result, the effects of warfarin are enhanced. If thyroid hormone replacement therapy is instituted in a client who has been taking warfarin, the dosage of warfarin would be reduced. Focus on the subject, the use of levothyroxine concurrently with warfarin. Recalling that levothyroxine enhances the effects of warfarin will direct you to the correct option.
A client with terminal cancer arrives at the emergency department dead on arrival (DOA). After an autopsy is prescribed, the client's family requests that no autopsy be performed. Which response to the family is most appropriate?
The decision is made by the medical examiner." "An autopsy is mandatory for any client who is DOA." "I will contact the medical examiner regarding your request." "It is required by federal law. Tell me why you don't want the autopsy done." An autopsy is required by state law in certain circumstances, including the sudden death of a client and a death that occurs under suspicious circumstances. A client may have provided oral or written instructions regarding an autopsy after death. If an autopsy is not required by law, these oral or written requests will be granted. If no oral or written instructions were provided, state law determines who has the authority to consent for an autopsy. Most often, the decision rests with the surviving relative or next of kin. Note the strategic words, most appropriate. Use knowledge regarding the laws and issues surrounding autopsy and therapeutic communication techniques to answer the question. Eliminate options 2 and 4 because these statements are not completely accurate and are not therapeutic in this situation. From the remaining options, the correct option is the therapeutic and appropriate response to the family.
The nurse recognizes that which interventions are likely to facilitate effective communication between a dying client and family? Select all that apply.
The nurse encourages the client and family to identify and discuss feelings openly. The nurse assists the client and family in carrying out spiritually meaningful practices. The nurse removes autonomy from the client to alleviate any unnecessary stress for the client. The nurse makes decisions for the client and family to relieve them of unnecessary demands. The nurse maintains a calm attitude and one of acceptance when the family or client expresses anger. Maintaining effective and open communication among family members affected by death and grief is of the greatest importance. Option 1 describes encouraging discussion of feelings and is likely to enhance communication. Option 2 is also an effective intervention because spiritual practices give meaning to life and have an impact on how people react to crisis. Option 5 is also an effective technique because the client and family need to know that someone will be there who is supportive and nonjudgmental. The remaining options describe the nurse removing autonomy and decision making from the client and family, who are already experiencing feelings of loss of control in that they cannot change the process of dying. These are ineffective interventions that could impair communication further. Focus on the subject, the interventions that will facilitate effective communication. The use of therapeutic communication techniques and a focus on the subject will assist you in answering correctly. The incorrect options remove control from the client and family.
The nurse is creating a plan of care for a client in skin traction. The nurse would monitor for which priority finding in this client?
Urinary incontinence Signs of skin breakdown The presence of bowel sounds Signs of infection around the pin sites Skin traction is achieved by Ace wraps, boots, or slings that apply a direct force on the client's skin. Traction is maintained with 5 to 8 lb (2.3 to 3.6 kg) of weight, and this type of traction can cause skin breakdown. Urinary incontinence is not related to the use of skin traction. Although constipation can occur as a result of immobility and monitoring bowel sounds may be a component of the assessment, this intervention is not the priority assessment. There are no pin sites with skin traction. Note the strategic word, priority. Eliminate option 4 first because there are no pin sites with skin traction. Visualizing the traction setup and knowledge of the complications associated with this type of traction will direct you to the correct option.
A pregnant client at 10 weeks' gestation calls the prenatal clinic to report a recent exposure to a child with rubella. The nurse reviews the client's chart. What is the nurse's best response to the client? Refer to chart. History and Physical Gravida, Term Births, Preterm Births, Abortions, Living Children (GTPAL) 1,0,0,0,0 Weight 135 lb (61 kg) Positive Goodell and Chadwick Laboratory and Diagnostic Results Venereal Disease Research Laboratory (VDRL) nonreactive Rubella immune Rh positive, type O Medications Prenatal Vitamins
You need to avoid all school-age children during pregnancy." "There is no need to be concerned if you don't have a fever or rash within the next 2 days." "You were wise to call. Your rubella titer indicates that you are immune and your baby is not at risk." "Be sure to tell the primary health care provider in 2 weeks, as additional screening will be prescribed during your second trimester." Rubella virus is spread by aerosol droplet transmission through the upper respiratory tract and has an incubation period of 14 to 21 days. The risks of maternal and subsequent fetal infection during the first trimester include hearing loss and congenital anomalies; these risks decrease after the first 12 weeks of pregnancy. Rubella titer determination is a standard prenatal test for pregnant women during their initial screening and entry into the health care delivery system. As noted in this client's chart, she is immune to rubella. The correct option is the only option that helps clarify maternal concerns with accurate information. Note the strategic word, best, and recall knowledge regarding the transmission of rubella virus to the fetus. Also, the use of therapeutic communication techniques will direct you to the correct option. The correct option addresses the client's concerns.
