Here's some more of them NCLEX questions
Pyloric stenosis.
Hypertrophy of the pylorus that results in stenosis of the passage between the stomach and the duodenum. Symptoms become evident 2-8 weeks after birth. It starts with occasional vomiting that eventually becomes forceful/projectile vomiting as the obstruction become complete. Dehydration and electrolyte imbalance result. The thickened pyloric muscle can sometimes be palpated and can be confirmed with ultrasound.
The RN is teaching the parent of a 6-year-old about behavioral strategies for treating fecal incontinence due to functional constipation. Which statement by the parent indicates a need for further teaching? - I will give my child a picture book to look at during toilet time - I will give my child a reward for each bowel movement while sitting on the toilet - I will keep a log of my child's bowel movements, laxative use, and episodes of soiling - I will schedule regular toilet time for my child.
I will give my child a reward for each bowel movement while sitting on the toilet.
A client with poorly controlled diabetes mellitus gives birth to a newborn at term gestation. When caring for the 2-hour-old newborn, which clinical finding requires the nurse to intervene? - cyanosis of the hands and feet - HR of 165/min while crying - Jitteriness - RR of 60/min
Jitteriness
The nurse is reinforcing teaching to a client with a hiatal hernia. Which statement by the client indicates that further teaching is needed? - I need to raise the head of my bed on blocks by at least 6 inches - I will remain sitting up for several hours after I eat any food - If my reflux and abdominal pain don't improve, I might need surgery - Losing weight may reduce my reflux, so I plan to take a weight-lifting class.
Losing weight may reduce my reflux, so I plan to take a weight-lifting class
A community mental health nurse is a member of a mobile crisis team providing services to victims of a category 4 hurricane. Of these strategies, which would be the priority action for the team to utilize in reaching those who need mental health services? - Contacting other social service agencies - Knocking on doors - Putting up flyers - Reporting in to the local command center
Reporting in to the local command center
The nurse is caring for a client who reports severe abdominal pain and vaginal spotting. The client had a positive urine pregnancy test at home, and her last menstrual period was 8 weeks ago. Which client report to the nurse is most concerning? - Abdominal pain rated as 8 out of 10 - History of pelvic inflammatory disease - Intermittent nausea and vomiting for the past 7 days - Right shoulder pain and dizziness
Right shoulder pain and dizziness - signs of ruptured ectopic pregnancy - referred shoulder pain results from irritation of the diaphragm by intraabdominal blood - is a surgical emergency and requires immediate evaluation
The nurse is forming a plan of care for an 82-year-old client with a history of anxiety, hypertension, urinary incontinence, and arthritic back pain. Which nurse diagnosis should be addressed first? - Anxiety - chronic pain - Risk for acute confusion - Risk for falls.
Risk for falls.
The nurse is reinforcing education to a client with irritable bowel syndrome who is experiencing diarrhea. Which of these meals selected by the client indicates an understanding of diet management? - Beans, yogurt, and a fruit cup - Beef, broccoli, and a glass of wine - Eggs, a bagel, and black coffee - Steak, tomato basil soup, and cornbread.
Steak, tomato basil soup, and cornbread. - foods that are generally well tolerated include proteins, breads, and bland foods.
A client who is intubated and on mechanical ventilation is receiving continuous enteral tube feedings at 30 mL/hr via a small-bore nasogastric tube. Which actions should the nurse take to prevent aspiration in this client? Select all that apply. - Assess abdominal distension every 4 hours - Check gastric residual every 12 hours - Keep head of the bed at >30 degrees or more - Maintain endotracheal tube cuff pressure - Use caution when administering sedatives
- Assess abdominal distention every 4 hours - Keep head of the bed at >30 degrees or more - Maintain endotracheal cuff pressure - Use caution when administering sedatives.
A client in the postoperative period after an open reduction and internal fixation of a left wrist fracture reports constant, severe arm pain that is unrelieved by prescribed morphine administered 30 minutes ago. The client's nail beds appear dusky. What are the nurse's appropriate actions? Select all that apply. - Apply a heating pad and encourage range-of-motion exercises - Assess the temperature and movement of the fingers - Elevate the arm on pillows above the level of the heart - Notify the health care provider - Reassure the client, document the findings, and reassess in 1 hour.
- Assess the temperature and movement of the fingers - Notify the health care provider.
The nurse is preparing to discharge a client following a first trimester miscarriage. Which of the following statements should the nurse include in discharge teaching for the client and partner? Select all that apply - Attending a support group with other people who had a pregnancy loss can be helpful - Genetic counseling is recommended for couples after their first miscarriage - One of the most important things you can do right now is communicate with your partner - The grieving period only lasts about 6 months following a miscarriage - Trying to conceive again can help you cope by giving you something to look forward to.
- Attending a support group with other people who had a pregnancy loss can be helpful - One of the most important things you can do right now is communicate with your partner.
Which actions are appropriate for the registered nurse to delegate to an experienced licensed practical nurse? Select all that apply. - Administer heparin continuous infusion to a client with a venous thromboembolism - Auscultate bowel sounds 2 days after repair of an inguinal hernia - Discuss concerns about last shift's care with an irate family member - Monitor flow rate and drainage in a client receiving bladder irrigation - Teach Kegel exercises after a client has a catheter removed
- Auscultate bowel sounds 2 days after repair of an inguinal hernia - Monitor flow rate and drainage in a client receiving bladder irrigation
The nurse has just received shift report. Which client should be seen first? - Client 1 day post-op abdominal aortic aneurysm (AAA) repair who has hypoactive bowel sounds in all 4 quadrants - Client 2 days postoperative below-the-knee amputation who reports same-leg foot pain rated as 7 on the pain scale - Client with a deep venous thrombosis (DVT) who is up to use the bathroom for the second time - Client with Raynaud's phenomenon who reports throbbing, tingling, and swelling of fingers in both hands.
- Client 2 days post-op BKA who reports same-leg foot pain rated as 7 on the pain scale
The nurse is planning care for an 8-year-old client with mild cognitive impairment who is hospitalized for diagnostic testing. Which of the following interventions are appropriate to include in the plan of care? Select all that apply. - Consistently assign the same nurse and unlicensed assistive personnel to care for the client - Give direct procedural education and explanations to the parent rather than the client - Provide appropriate toys based on developmental level rather than chronological age - Reinforce parental limit-setting measures for preventing self-injurious behavior - Use a picture board to facilitate communication and promote understanding of procedures.
- Consistently assign the same nurse and unlicensed assistive personnel to care for the client - Provide appropriate toys based on developmental level rather than chronological age - Reinforce parental limit-setting measures for preventing self-injurious behavior - Use a picture board to facilitate communication and promote understanding of procedures.
The charge nurse on the cardiac floor is orienting a new graduate nurse. The charge nurse describes various roles of the interdisciplinary team. In which situations would the nurse "case manager" be consulted? Select all that apply - Facilitating communication between health care providers - Obtaining health information from the client's nursing home - Reconciliation of home medications - Referral for home health after discharge - Visiting the client daily while hospitalized
- Facilitating communication between health care providers - Obtaining health information from the client's nursing home - Referral for home health after discharge.
A nurse is evaluating the teaching of weight reduction strategies to a client with obesity. Which of the following statements indicate that the client understands the teaching? Select all that apply. - Fruit juice is a good substitute for soda - I will aim to lose 1-2 lb per week - I will keep healthy snacks on hand in case I get hungry - I will skip breakfast to save calories for later in the day - I will take the stairs instead of the elevator.
- I will aim to lose 1-2 lb per week - I will keep healthy snacks on hand in case I get hungry - I will take the stairs instead of the elevator.
A healthy 50-year-old client asks the nurse, "What must I do in preparation for my screening colonoscopy?" Which statement by the nurse correctly answer the client's question? Select all that apply - No food or drink is allowed 8 hours prior to the test - Prophylactic antibiotics are taken as prescribed - Smoking must be avoided after midnight - The day prior to the procedure your diet will be clear liquids - You will drink polyethylene glycol as directed the day before.
- No food or drink is allowed 8 hours prior to the test - The day prior to the procedure your diet will be clear liquids - You will drink polyethylene glycol as directed the day before.
A nurse is teaching a client with a surgically repaired undescended testis about testicular self-examination (TSE). Which instructions should be included in the teaching? Select all that apply. - Perform the examination during a warm bath - Perform the examination monthly on the same day - Report if one testis is slightly larger than the other - Report if there is a hard mass over the testis - Use both hands to feel each testis separately.
- Perform the examination during a warm bath or shower - Perform the examination monthly on the same day - Report if there is a hard mass over the testis - Use both hands to feel each testis separately
Acceptable techniques for performing chest compressions on a newborn or infant.
1. Two thumbs are placed on the middle third of the sternum, with the fingers encircling the chest and supporting the back. The thumbs should be positioned side by side, just below the nipple line. This technique is preferred because it may result in improved cardiac perfusion. if the newborn or infant is extremely small or the rescuer's thumbs are extremely large, the thumbs may be superimposed. The xiphoid portion of the sternum should not be compressed because this may damage the liver 2. If the rescuer's hands are too small to encircle the chest, place only the index and middle fingers of one hand on the sternum just below the nipple line. The other hand should support the back. This technique is preferred if umbilical cord access is needed or in single rescuer situations
The nurse admits an adult client with partial thickness burns to the anterior surface of the right leg and the anterior and posterior torso. The client weighs 198 lb. The total body surface area burned is calculated using the rule of nines. How many mL of IV fluid will the client require in the first 24 hours using the Parkland formula protocol (4 mL x body weight [kg] x BSA burned [%])?
16200 lb to kg = 90 anterior torso + posterior torso + leg = 45% TBSA burned 90 x 45 x 4 = 16200 mL
Several clients check into the emergency department at the same time. Which client should be seen first? - 8-month-old with persistent vomiting and diarrhea for several days - 5-year-old who has a foreign body in the right naris - 7-year-old who is restless after tonsillectomy surgery 3 days ago - 9-year-old with a second-degree burn to the arm who is crying inconsolably.
7-year-old who is restless after tonsillectomy surgery 3 days ago A client who is status post tonsillectomy and adenoidectomy is at risk for hemorrhage up to 14 days after surgery. Because of the location of the surgery, hemorrhage can lead to life-threatening airway compromise. S/S of hemorrhage: restlessness, frequent swallowing or throat-clearing, vomiting of blood, and pallor.
A mother reports to the pediatric nurse that her 3-year-old child coughs at night at times until he vomits. The symptoms have not improved over the past 2 months despite multiple over-the-counter cough medications. What should the nurse explore related to a possible etiology? - Ask about exposure to triggers such as pet dander - Assess for the presence of a butterfly rash - History of intolerance to wheat food products - Palpate for an abdominal mass from pyloric stenosis.
Ask about exposure to triggers such as pet dander.
The nurse is caring for a client newly admitted with an acute manic episode of bipolar disorder. The nurse identifies which dinner selection as the most appropriate to promote client nutrition? - Baked sweet potato, kale, yeast roll, water - Cheeseburger, apple, vanilla milkshake - Spaghetti with meatballs, fruit salad, milk - Vegetable soup, salad, dinner roll, iced tea
Cheeseburger, apple, vanilla milkshake.
The nurse is inserting an indwelling Foley urinary catheter into a male. After inserting the catheter about 6 in, the nurse notes drops of urine in the tubing. What action should the nurse take next? - Further insert the catheter 1-2 in - Have the client hold his breath - Immediately inflate the 5 m balloon - Secure the tubing to the client's leg.
Further insert the catheter 1-2 in
A client with a history of obsessive-compulsive personality disorder (OCPD) is seeking treatment for a gastrointestinal disorder and is scheduled for a colonoscopy at 10:00 AM. Due to a computer glitch, the procedure is postponed to 3:00 PM. Which response would be characteristic of an individual with OCPD? - How dare they change my appointment? I insist that the procedure be done at 10:00 AM - That's fine. I can come in whenever it is convenient for everyone - This is unacceptable. I had my whole day planned out - Why are they doing this to me?
This is unacceptable. I had my whole day planned out.
The nurse cares for a group of clients in a medical surgical unit. The client with which diagnosis and condition requires the most immediate assistance by the nurse? - Post cholecystectomy, reporting incision pain of a 5 on a scale of 1-10 - Post open reduction of the right femur, reporting nausea - Type 1 diabetes mellitus with a blood glucose of 55 mg/dL - Type 2 diabetes mellitus with a blood glucose of 250 mg/dL
Type 1 diabetes mellitus with a blood glucose of 55 mg/dL
