Crisis 2: NCLEX Questions

A. hyperventilation

A burn client is receiving treatments of topical mafenide acetate to the site of injury. The nurse monitors the client, knowing that which finding indicates that a systemic effect has occurred? A. hyperventilation B. elevated BP C. local rash at the burn site D. local pain at the burn site

D. a white color to the skin which is insensitive to touch

A client arriving at the emergency department has experienced frostbite to the right hand. Which finding would the nurse note on assessment of the client's hand? A. a pink, edematous hand B. fiery red skin with edema in the nail beds C. black fingertips surrounded by an erythematous rash D. a white color to the skin which is insensitive to touch

C. take a shower immediately lathering and rinsing several times

A client calls the emergency department and tells the nurse that he came directly into contact with poison ivy shrubs. The client tells the nurse that he cannot see anything on the skin and asks the nurse what to do. The nurse should make which response? A. come to the emergency department B. Apply calamine lotion immediately to the exposed skin areas C. take a shower immediately, lathering and rinsing several times D. it is not necessary to do anything if you cannot see anything on your skin

C. increasing the amount of IV lactated ringers solution administered per hour

A client is undergoing fluid replacement after being burned on 20% of her body 12 hours ago. The nursing assessment reveals a blood pressure 90/50, a pulse rate of 110 beats/min and urine output of 20mL over the past hour. The nurse reports the findings to the health care provider and anticipates which prescription? A. transfusing 1 unit of packed RBC B. administering a diuretic to increase urine output C. increasing the amount of IV lactated ringer's solution administered per hour D. Changing the IV lactated ringers solution to one that contains 5% dextrose in water

B. lesion is highly metastiatic C. lesion is nevus that has changes in color

A client returns to the clinic for follow up treatment following a skin biopsy of a suspicious lesion performed 1 week ago. The biopsy report indicates that the lesion is a melanoma. The nurse understands that melanoma has which characteristics. Select all that apply A. lesion is painful to touch B. lesion is highly metastiatic C. lesion is nevus that has changes in color D. skin under the lesion is reddened and warm to touch E. Lesion occurs in body area exposed to outdoor sunlight

A. contact the surgeon B. instruct the client to remain quiet C. Prepare the client for wound closure D. Document the findings and actions taken

A client who has had abdominal surgery complains of feeling as though "something gave way" in the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel protruding through the incision. Which interventions should the nurse take? (Select all that apply) A. Contact the surgeon B. Instruct the client to remain quiet C. Prepare the client for wound closure D. Document the findings and actions taken E. Place a sterile saline dressing and ice packs over the wound F. Place the client in a supine position without a pillow under the head.

A. Hemoglobin, 8.0g/dL

A client who has undergone preadmission testing has had blood drawn for serum laboratory studies, including a complete blood count, coagulation studies, and electrolytes and creatinine levels. Which laboratory result should be reported to the surgeon's office by the nurse, knowing that it could cause surgery to be postponed? A.. Hemoglobin, 8.0g/dL (80mmol/L B. Sodium, 145mEq/L (145mmol/L) C. Serum creatinine, 0.8mg/dL (70.6umol/L) D. platelets, 210,000cells/mm3

D. obtain a telephone consent from a family memeber following agency policy

A client with a gastric ulcer is scheduled for surgery. The client cannot sign the operative consent form because of sedation from opioid analgesics that have been administered. The nurse should take which MOST APPROPRIATE action in the care of this client? A. Obtain a court order for the surgery B. Have the charge nurse sign the informed consent immediately C. Send the client to surgery without the consent being signed D. Obtain a telephone consent from a family member, following agency policy.

C. vitamin a

A client with severe acne is seen in the clinic and the health care provider (HCP) prescribes isotretinoin. The nurse reviews the client's medication record and would contact the HCP if the client is also taking which medication? A. digoxin B. Phenytoin C. vitamin a D. furosemide

C. Can you share with me what you've been told about your surgery

A preoperative client expresses anxiety to the nurse about upcoming surgery. Which response by the nurse is MOST LIKELY to stimulate further discussion between the client and the nurse? A. If it's any help, everyone is nervous before surgery B. I will be happy to explain the entire surgical procedure to you C. Can you share with me what you've been told about your surgery D. Let me tell you about the care you'll receive after surgery and the amount of pain you can anticipate

C. 36%

An adult client was burned in an explosion. The burn initially affected the clients entire face (anterior half of the head) and the upper half of the anterior torso, and there were circumferential burns to the lower half of both arms. The client's clothes caught on fire, and the client ran, causing subsequent burn injuries to the posterior surface of the head and the upper half of the posterior torso. Using the rule of nines. what would be the extent of the burn injury? A. 18% B. 24% C. 36% D. 48%

B. triglyceride level

Isotretinoin is prescribed for a client with severe acne. Before the administration of this medication, the nurse anticipates that which laboratory test will be prescribed? A. Potassium level B. Triglyceride level C. Hemoglobin A1C D. Total cholesterol level

A. tinnitus

Salicylic acid is prescribed for a client with a diagnosis of psoriasis. The nurse monitors the client, knowing that which finding indicates the prescence of systemic toxicity from this med? A. tinnitus B. diarrhea C. constipation D. decreased respirations

D. WBC 3000

Silver sulfadiazine is prescribed for a client with a burn injury. Which laboratory finding requires the need for follow-up by the nurse? A. glucose level of 99 B. magnesium level of 1.5 C. platelet level of 300,000 D. WBCs of 3000

C. the med is likely to cause stinging every time it is applied

Silver sulfadiazine is prescribed for a client with a partial-thickness burn and the nurse provides teaching about the medication. Which statement made by the client indicates a need for further teaching about the treatments? A. the med is an antibacterial B. the med will help heal the burn C. the med is likely to cause stinging every time it is applied D. the med should be applied to the wound

D. at least 30 min before sun exposure

The camp nurse asks the children preparing to swim in the lake if they have applied sunscreen. The nurse reminds the children that chemical sunscreens are most effective when applied at which times? A. immediate before swimming B. 5 min before exposure to the sun C. immediately before exposure to the sun D. at least 30 min before sun exposure

D. thinner and decrease in number of reddish papules E. scarce amount of silvery-white scaly patches on the arms

The clinic nurse assesses the skin of a client with psoriasis after the client has used a new topical treatment for 2 months. The nurse identifies which characteristics as improvement in the manifestations of psoriasis? Select all that apply A. presence of striae B. palpable radial pulses C. absence of any ecchymosis on the extremities D. thinner and decrease in number of reddish papules E. scarce amount of silvery-white scaly patches on the arms

A. itching

The clinic nurse is performing an admission assessment on a client and notes that the client is taking azelaic acid. The nurse determines that which 576client complaint may be associated with use of this medication? A. itching B. euphoria C. drowsiness D. frequent urination

B. serous drainage

The nurse assesses a client's surgical incision for signs of infection. Which finding by the nurse would be interpreted as a normal finding at the surgical site? A. Red, hard skin B. serous drainage C. Purulent drainage D. Warm, tender skin

C. I need to continue to take aspirin until the day of surgery

The nurse has conducted preoperative teaching for a client scheduled for surgery in 1 week. The client has a history of arthritis and has been taking acetylsalicylic acid. The nurse determines that the client NEEDS ADDITIONAL teaching if the client makes which statement? A. Aspirin can cause bleeding after surgery B.Aspirin can cause my ability to clot blood to be abnormal C. I need to continue to take aspirin until the day of surgery D. I need to check with my health care provider about the need to stop the aspirin before the scheduled surgery

A. Urinary output of 20mL/hr

The nurse has just reassessed the condition of a postoperative client who was admitted 1 hour ago to the surgical unit. The nurse plans to monitor which parameter MOST carefully during the next hour? A. Urinary output of 20ml/hr B. Temperature of 37.6 C (99.6 F) C. Blood Pressure of 100/70 mmHg D. Serous drainage on the surgical dressing

A. back D. soles of the feet E. palms of the hands

The nurse is applying a topical corticosteroid to a client with eczema. The nurse should apply the medication to which body area? Select all that apply. A. back B. axilla C. eyelids D. soles of the feet E. palms of the hands

D. move the victim to a sage area away from the snake and encourage the victim to rest

The nurse is conducting a session about the principles of first aid and is discussing the interventions for a snakebite to an extremity. The nurse should inform those attending the session that the FIRST PRIORITY intervention in the event of this occurance is which action? A. immobilize the affected extremity B. remove jewelry and constricting clothing from the victim C. place the extremity in a position so that it is below the level of the heart D. move the victim to a safe area away from the snake and encourage the victim to rest

D. the best results are achieved when sitting up or with the head of the bed elevated 45 to 90 degrees

The nurse is conducting preoperative teaching with a client about the use of an incentive spirometer. The nurse should include which piece of information in discussions with the client? A. Inhale as rapidly as possible B. Keep a loose seal between the lips and the mouthpiece C. After maximum inspiration, hold the breath for 15 seconds and exhale D. The best results are achieved when sitting up or with the head of the bed elevated 45 to 90 degrees

C. have the client void immediately before going into surgery

The nurse is creating a plan of care for a client scheduled for surgery. The nurse should include which activity in the nursing care plan for the client on the day of Surgery? A. avoid oral hygiene and rinsing with mouthwash B. verify that the client has not eaten for the last 24 hrs C. have the client void immediately before going into surgery D. Report immediately any slight increase in blood pressure or pulse

A. increase restlessness

The nurse is monitoring the status of a postoperative client in the immediate postoperative period. The nurse would become MOST concerned with which sign that could indicate an evolving complication? A. Increasing restlessness B. A pulse of 86 beats/min C. Blood pressure of 110/70mm Hg D. Hypoactive bowel sounds in all 4 quadrants

A. return of distal pulses

The nurse is preparing to care for a burn client scheduled for an escharotomy procedure being performed for a third-degree circumferential arm burn. The nurse understnds that which finding is the anticipated therapeutic outcome of the escharotomy? A. return of distal pulses B. brisk bleeding from the site C. decreasing edema formation D. formation of granulation tissue

A. Prednisone

The nurse is reviewing a surgeon's prescription sheet for a preoperative client that states that the client must be nothing by mouth (NPO) after midnight. The nurse should call the surgeon to clarify that which medication should be given to the client and not withheld? A. Prednisone B. Ferrous sulfate C. Cyclobenzaprine D. Conjugated estrogen

A. Use of an incentive spirometer will help prevent pneumonia

The nurse is teaching a client about coughing and deep-breathing techniques to prevent postoperative complications. Which statement is MOST APPROPRIATE for the nurse to make to the client at this time as it relates to these techniques? A. Use of an incentive spirometer will help prevent pneumonia B. Close monitoring of your oxygen saturation will detect hypoxemia C. Administration of intravenous fluids will prevent or treat fluid imbalance D. Early ambulation and administration of blood thinners will prevent pulmonary embolism

A. assess the patency of the airway

The nurse receives a telephone call from the postanesthesia care unit stating that a client is being transferred to the surgical unit. The nurse plans to take which action FIRST on arrival of the client A. Assess the patency of the airway B. Check tubes or drains for patency C. Check the dressing to assess for bleeding D. Assess the vital signs to compare with preoperative measurements

D. a pearly papule with a central crater and a waxy border E. location in the bald spot atop the head that is exposed to outdoor sunlight

When assessing a lesion diagnosed as basal cell carcinoma, the nurse MOST LIKELY expects to note which findings? Select all that apply A. an irregularly shaped lesion B. a small papule with a dry, rough scale C. a firm nodular lesion topped with crust D. a pearly papule with a central crater and a waxy border E. location in the bald spot atop the head that is exposed to outdoor sunlight

D. 100% O2 via a tight fitting nonrebreather face mask

a client arrives at the emergency department following a burn that occurred in the basement at home and an inhalation injury is suspected. What would the nurse anticipate to be prescribed for the client? A. 100% O2 via aerosol mask B. O2 via nasal cannula at 6L/min C. O2 via nasal cannula at 15L/min D. 100% O2 via a tight fitting nonrebreather face mask

B. a skin infection of the dermis and underlying hypodermis

a client is being admitted to the hospital for treatment of acute cellulitis of the lower left leg. During the admission assessment, the nurse expects to note which finding A. an inflammation of the epidermis only B. a skin infection of the dermis and underlying hypodermis C. an acute superficial infection of the dermis and lymphatics D. an epidermal and lymphatic infection caused by staph

B. assess airway patency C. administer O2 as prescribed E. elevate extremities if no fractures are present

a client is brought to the emergency department with partial thickness burns to his face, neck, arms, and chest after trying to put out a care fire. The nurse should implement which nursing actions for this client? Select all that apply A. restrict fluids B. assess airway patency C. administer O2 as prescribed D. place a cooling blanket on the client E.elevate extremities if no fracture are present F. prepare to give oral pain medication as prescribed

B. positive culture results

the clinic nurses notes that the health care provider has documented a diagnosis of herpes zoster (shingles) in the client's chart. Based on an understanding of the cause of this disorder, the nurse determines that this definitive diagnosis was made by which diagnostic test. A. positive patch tst B. positive culture results C. abnormal biopsy results D. woods light exam indicative of infection

D. partial-thickness skin loss of the dermis

the evening nurse reviews the nursing documentation in a clients chart and notes that the day nurse has documented that the client has a stage 2 pressure ulcer in the sacral area. Which finding would the nurse expect to note on assessment of the clients sacral area A. intact skin B. full-thickness skin loss C. exposed bone, tendon, or muscle D. partial-thickness skin loss of the dermis

B. use sunscreen when participating in outdoor activitites C. wear a hat, opaque clothing, and sunglasses when in the sun E. examine your body monthly for any lesions that may be suspicious

the health education nurse provides instructions to a group of clients regarding measures that will assist in preventing skin cancer. Which instructions should the nurse provide? Select all that apply? A. sunscreen should be applied every 8 hours B. use sunscreen when participating in outdoor activities C. wear a hat, opaque clothing, and sunglasses when in the sun D. avoid sun exposure in the late afternoon and early evening hours E. examine your body monthly for any lesions that may be suspicious

B. urine output

the nurse is administering fluids IV as prescribed to a client who sustained superficial partial-thickness burn injuries of the back and legs. In evaluating the adequacy of fluid resuscitation, the nurse understands that which assessment would provide the MOST reliable indicator for determining the adequacy A. vital signs B. urine output. C. mental status D. peripheral pulses

C. immobilization of the affected leg

the nurse is caring for a client following an autograft and grafting to a burn wound on the right knee. What would the nurse anticipate to be prescribed for the client A. out-of-bed activities B. bathroom privileges C. immobilization of the affected leg D. placing the affected leg in a dependent position

B. flushing

the nurse is caring for a client who suffered an inhalation injury from a wood stove. The carbon monoxide blood report reveals a level of 12%. Based on this level, the nurse would anticipate noting which sign in the client? A. coma B. Flushing C. dizziness D. tachycardia

D. elevated hematocrit levels

the nurse is caring for a client who sustained superficial partial-thickness burns on the anterior lower legs and anterior thorax. Which finding does the nurse expect to note during the resuscitation/emergent phase of the burn injury. A. decrease heart rate B. increased urinary output C. increased blood pressure D. elevated hematocrit levels

C. wearing gloves and a gown only when giving direct care to the client

the nurse manager is observing a new nursing graduate caring for a burn client in protective isolation. The nurse manager intervenes if the new nursing graduate planned to implement which unsafe component of protective isolation techniques? A. using sterile sheets and linens B. performing strict hand-washing technique C. wearing gloves and a gown only when giving direct care to the client D. wearing protective garb, including a mask, gloves, cap, shoe covers, gowns, and plastic apron

C. the nurse who never had chickenpox E. the nurse who never received the varicella-zoster vaccine

the nurse manager is planning the clinical assignments for the day. Which staff members cannot be assigned to care for a client with herpes zoster? Select all that apply A. the nurse who never had roseola B. the nurse who never had mumps C. the nurse who never had chickenpox D. the nurse who never had german measles E. the nurse who never received the varicella-zoster vaccine