Uworld NCLEX RN test

A new nurse is caring for an adolescent transgender client. What question would be appropriate when assessing the client's gender identity?

"How would you describe your gender?"

The nurse is assessing a client in the outpatient clinic who has a cast on for a distal humerus fracture. Which statements made by the client would be the priority to assess further?

"I am having problems extending my fingers since this morning." - Volkmann contracture occurs as a result of compartment syndrome associated with distal humerus fractures.

The nurse assesses a client who is receiving methotrexate for rheumatoid arthritis. Which statement by the client is most concerning?

"I have small, purple spots all over my skin."

The nurse is participating in an obstetrical emergency simulation in which a client is hemorrhaging after birth due to uterine inversion. When describing interventions, which statement by the nurse indicates a need for further education?

"I will administer a rapid infusion of IV oxytocin before the inverted uterus is corrected."

The nurse teaches a client about the use of regular and neutral protamine Hagedorn (NPH) insulin. Which statement by the client indicates that further teaching is needed?

"I will use the sliding scale to determine my NPH dose 4 times a day." - NPH is an intermediate-acting insulin with a duration of 12-18 hours. It is generally prescribed 2 times daily.

An adult client is admitted with back pain and found to have a metastatic tumor tumor on the spine. The health care provider (HCP) explains that the client has few months to live and is likely to become totally paralyzed below the waist soon. The next day, the client tells the nurse of wanting to be discharged despite the HCP's recommendation that the client stay a few more days. Which is the most appropriate initial response by the nurse?

"Tell me more about your need to leave the hospital."

The nurse has been providing care for the past month to a 7-year-old client recently diagnosed with type 1 diabetes mellitus. Initially, the family seemed devastated about the diagnosis and the client's parent stated, "Our lives will never be the same." Which statement made by the parent indicates that nursing interventions and education have been effective?

"We are working to manage this disease so that it cannot control our child's life."

Nursing interventions for exophthalmos

- HOB in a raised position to facilitate fluid drainage from the periorbital area - artificial tears to prevent corneal drying and abrasions/ulcers - tape client's eyelids shut during sleep if they do not close on their own. - patient teaching: regular ophthalmologist visits; anti-thyroid drugs to prevent exacerbation; smoking cessation; restrict sodium/salt; use dark glasses; perform intraocular muscle exercises

Nursing actions to improve fetal perfusion and oxygenation

- discontinue uterotonics (oxytocin or pitocin) to reduce uterine activity - changing maternal position to the left side to relieve compression of the inferior vena cava - administering oxygen at 8-10 L/min via nonrebreather mask - prescribed IV bolus of lactated ringers or NS to improve placental perfusion - notify HCP.

The nurse cares for a client who is experiencing exophthalmos as a complication of Graves' disease. Which nursing action(s) should be included in the client's plan of care? Select all that apply.

1. Administer artificial tears to moisten the conjunctiva. 2. If eyelids don't close during sleep, lightly tape them shut. 3. Recommend the use of dark glasses to prevent irritation. 4. Teach about the importance of smoking cessation.

The health care provider prescribes amoxicillin/clavulanate (liquid) twice a day for a child with acute sinusitis. What instructions are most important for the parents? Select all that apply.

1. Administer it with food if nausea or diarrhea develops. 2. Complete the medication course even if the child is better. 4. Shake the medication well before use.

The nurse is caring for a client at 39 weeks gestation in active labor who is receiving an oxytocin infusion. The nurse notes persistent late decelerations on the fetal monitor. Which of the following actions should the nurse take? Select all that apply.

1. Administer oxygen via a nonrebreather face mask. 2. Change maternal position to the left side. 3. Discontinue the oxytocin infusion 4. Notify the health care provider.

The nurse is reviewing the plan of care for a 4-year-old client who will receive daily dressing changes for an infected leg wound. Which of the following interventions should the nurse include in the plan of care for a preschool-age child? Select all that apply.

1. Allow the child's parents to stay during the procedure. 2. Emphasize that dressing changes are not punishment for misbehavior. 3. Encourage the child to voice questions and concerns about the procedure. 4. Have the child place bandages on a doll when reinforcing education.

The nurse is caring for a client who had a stroke two weeks ago and has moderate receptive aphasia. Which interventions shoudl the nurse include in the plan of care to help the client follow simple commands regarding activities of daily living (ADL)? Select all that apply.

1. Ask simple questions that require "yes" or "no" answers. 3. Remain calm and allow the client time to understand each instruction. 4. Show the client pictures of ADL or use gestures.

A 6-year-old client was diagnosed with type 1 diabetes mellitus 2 years ago. The nurse would like to encourage the client to participate in disease management. Which of the following diabetes care tasks are appropriate for the child to perform? Select all that apply.

1. Choose insulin injection site with parental oversight of rotation schedule. 2. Push plunger of insulin syringe after a parent inserts and stabilizes the needle. 3. Select and clean the site for finger-stick blood glucose testing 5. Verbalize two or three signs and symptoms of hypoglycemia.

The nurse is caring for a client who needs an indwelling urinary catheter inserted for urinary retention. Which tasks would be appropriate to delegate to the unlicensed assistive personnel? Select all that apply.

1. Document output from the urinary collection bag. 2. Hold adipose tissue out of the way during catheter insertion. 5. Secure the catheter to the client's thigh with an anchor.

Late deceleration

A decrease in FHR that begins after a contractions, reaches its lowest point (nadir) after the contraction peak, and then gradually returns to baseline. - indicate impaired fetal oxygenation associated with decreased uteroplacental perfusion - may be due to maternal hypotension after epidural placement, uterine tachysystole, or chronic uteroplacental insufficiency

The nurse performs tracheostomy care for a client with a disposable inner cannula and tracheostomy dressing. Place the steps in the correct order. All options must be used.

4. Gather supplies and position client. 2. Don mask, goggles, and clean gloves. 5. Remove soiled dressing 3. Don sterile gloves; remove old disposable cannula and replace with a new one. 1. Clean around stoma with sterile water or saline; dry and replace sterile gauze pad.

Stage of labor

1; Latent: 0-5 cm dilation 1; Active: 6-10 cm dilation 2; 10 cm (complete cervical dilation to birth 3; birth of baby to expulsion of placenta 4; 1-4 hours after birth, maternal physiologic readjustment.

A client is newly admitted to the mental health unit with a diagnosis of schizophrenia with persecutory delusions. Which nursing interventions should the nurse include in the client's plan of care with regard to the delusional thinking? Select all that apply.

2. Focus on reality and verbally reinforce it. 3. Focus on the client's feelings secondary to the delusions.

The nurse is interviewing a non-English speaking client. Which best practices will the nurse use when working with a professional medical interpreter for clients of limited English proficiency? Select all that apply.

3. Hold a pre-conference with the interpreter 4. Identify any gender or age preferences. 5. Speak in short sentences.

Exophthalmos

A complication of hyperthyroidism from Graves' disease - protrusion of the eyeballs caused by increased orbital tissue expansion and can be irreversible. The exposed cornea is at risk for dryness, injury, and infection.

The office nurse receives 4 telephone messages from clients. Which client should the nurse call back first?

78-year-old prescribed warfarin who reports increasing headaches and gait disturbance after falling a month ago. - A chronic subdural hematoma involves bleeding into the subdural space that can occur several weeks to months following a mild head trauma. Elderly clients and those taking anticoagulants are at high risk. - Manifestations: headache, gait disturbance, memory loss, decreased level of consciousness

Methotrexate

An antirheumatic drug prescribed to treat rheumatoid arthritis. Acts by interfering with folic acid metabolism, which inhibits DNA synthesis and cell production. - Adverse effects: bone marrow suppression, hepatotoxicity, GI irritation - managed by dose reduction or discontinuation of the medication

Lead poisoning

Blood Lead Level (BLL) screenings are recommended at ages 1 and 2, and up to age 6 - Elevated BLLs 5 mcg/dL or more are dangerous in young children due to immature development of the brain and nervous system - mild to moderate increase in BLL manifests as: hyperactivity and impulsiveness - prolonged low-level exposure can cause developmental delays, reading difficulties, and visual-motor issues. - Extremely elevated BLLs can lead to permanent cognitive impairment, seizures, or even death

A student nurse assesses and obtains a urine specimen from a client with methicillin-resistant Staphylococcus aureus (MRSA) who is on contact precautions. The registered nurse intervenes when the student performs which action?

Cleans the disposable stethoscope with chlorhexidine solution before reuse with a different client. - Contact precautions include standard precautions measures in addition to use of a gown and gloves and sing-client-use equipment

A nurse receives the following change-of-shift morning report for the assigned clients. Which client should the nurse assess first?

Client 2 days postoperative receiving fluids infusing at 125 mL/hr, with a Foley catheter and urine output of 100 mL during the last 8 hours.

The nurse has received report on 4 clients at the start of the shift. Which client should the nurse assess first?

Client in body cast who reports abdominal pain and bloating. - client is at risk for bowel obstruction, which can be caused by decreased peristalsis or by cast syndrome

The nurse receives handoff of care report on four clients. Which client should the nurse assess first?

Client with sickle cell disease whose pain rating has increased from 3 to 9 on a scale of 0-10 over the last hour.

Therapeutic hypothermia.

Following a cardiac arrest (particularly ventricular fibrillation or pulseless ventricular tachycardia), to prevent neurological injury, the client is cooled to 89.6-93.2 F for 24 hours before rewarming. -Accomplished by cooling blankets, ice placed in the groin, axillae, and sides of the neck, and cold IV fluids. - Nurse must closely assess the cardiac monitor because bradycardia is common. - monitor core body temp, blood pressure, and skin for thermal injury. - MAP to be kept >80 mm Hg - Apply neuroprotective strategies: elevate HOB to 30 degrees.

Drug induced bone marrow suppression

Methotrexate induced; leads to anemia, leukopenia, and thrombocytopenia

A 12-month-old is found to have moderately elevated blood lead level. Which of the following is the most serious concern for this child?

Neurocognitive impairment.

Four clients in labor are requesting pain relief. The nurse understands that which client can safely receive a dose of IV butorphanol tartrate, an opioid agonist-antagonist, at this time?

Nullipara at 7 cm dilation moaning with contractions. - Butorphanol tartrate crosses the placental barrier, peaking in 30-60 minutes; its duration of action is approximately 2-4 hours. If given near the time of birth, there is a risk for newborn respiratory depression, which may require naloxone. - IV opioids are best for clients in active labor or those with a well-established contraction pattern because opioid administration may slow labor progression in the latent phase.

The nurse is caring for a client who was just resuscitated following an out-of-hospital cardiac arrest. The client does not follow commands and remains comatose. What intervention does the nurse anticipate being added to the client's plan of care?

Obtaining equipment and cold fluids for induction of therapeutic hypothermia. - Neurologic injury is the most common cause of mortality in clients who have had cardiac arrest, particularly ventricular fibrillation or pulseless ventricular tachycardia. - inducing therapeutic hypothermia in these clients within 6 hours of arrest and maintaining it for 24 hours has been shown to decrease mortality rates and improve neurologic outcomes.

Volkmann contracture

Occurs as a result of compartment syndrome associated with distal humerus fractures. Swelling of antecubital tissue causes pressure within the muscle compartment, restricting arterial blood flow. The resulting ischemia leads to tissue damage, wrist contractures, and an inability to extend the fingers. It is a medical emergency if left untreated.

Intrapartum fetal heart rate monitoring: VEAL CHOP

Pattern: Variable decelerations Early decelerations Accelerations Late decelerations Clinical significance: (V) Cord compression/prolapse, oligohydramnios (E) Head compression (A) Okay (normal fetal oxygenation (L) Placental insufficiency

Uterine inverstion

Rare, obstetrical emergency that occurs after birth when the fundus collapses (partially or completely) into the uterine cavity, causing sudden hemorrhage, severe pelvic pain, and hypovolemic shock. Successful manual replacement of the inverted uterus through the vaginal canal by the health care provider is the first step in resolving the inversion and requires a soft, uncontracted uterus. Tocolytics or inhaled anesthetics may be needed to assist with uterine relaxation.

Sickle cell crisis

Sickled RBCs are prone to clump together and obstruct blood vessels, particularly during period of dehydration or stress (infection). - Indicators of SCC: severe, acute pain due to impaired capillary blood flow and tissue ischemia - may lead to irreversible tissue damage (myocardial infarction, limb necrosis, stroke) and death

Petechiae

Small, purple hemorrhagic spots.

Cast syndrome

Superior mesenteric artery (SMA) syndrome - a rare complication of an overly tight cast that involves compression of the duodenum by the SMA - immobilization of clients in body casts decreases peristalsis and may cause paralytic ileus.

Thrombocytopenia

platelet count <100,000/mm3 - characterized by petechiae, purpura, and/or other signs of bleeding like melena, hematemesis, bleeding gums.