Missed LWW NCLEX
A nurse is caring for a client who gave birth yesterday and had a right mediolateral episotomy performed. The client asks the nurse, "What can I do to get pain relief from my episiotomy?" Which response by the nurse would be most appropriate?
"Apply a cold pack to your perineum." Explanation: Applying a cold pack to an episiotomy during the first 24 hours after birth may reduce edema and tension on the incision line, thereby reducing pain. After the first 24 hours, a sitz bath may reduce discomfort by promoting circulation and healing
A client is receiving phenytoin. Which response by a client best indicates an understanding of the adverse effects of the medication?
"I need to see the dentist every 6 months." Explanation: Phenytoin can cause hypertrophy of the gums and gingivitis; therefore, regular dental checkups are essential.
Which iron-rich foods should the nurse encourage an anemic client requiring iron therapy to eat?
Lamb and dried peaches Explanation: Iron-rich foods include lamb and dried peaches.
The newly hired graduate nurse asks the nurse preceptor about heart sounds. Which information regarding heart sounds would the nurse preceptor include in his explanation?
"S1 is loudest at the apex, and S2 is loudest at the base."
A client with a history of colon cancer has a permanent colostomy. The nurse must irrigate the colostomy to prepare the client for diagnostic testing. When irrigating, how far into the stoma should the nurse insert the lubricated catheter?
2" to 4" Explanation: When irrigating a colostomy, the nurse should insert the catheter 2" to 4" into the stoma. Inserting it less than 2" may cause leakage. Inserting it more than 4" may cause trauma to the intestinal mucosa.
The nurse is caring for a client who underwent internal fixation of the right hip. Before administering the client's warfarin, the nurse checks the laboratory report for the client's International Normalized Ratio (INR) results. Which indicates the therapeutic range for this client
2.0 to 3.0 Explanation: Recent guidelines recommend an INR of 2.0 to 3.0 for clients without mechanical prosthetic heart valves who are receiving warfarin therapy.
What is the most likely reason for a temperature of 99.8° F (37.7° C) during the first 24 hours postpartum?
A slight temperature elevation from dehydration is common during the first 24 hours after delivery. Infection should be suspected if the client's temperature exceeds 100.4° F (38° C) for 2 successive days after delivery, excluding the first 24 hours.
A nurse is providing care for a client who has an epidural catheter postoperatively. Which sign or symptom should cause the nurse to suspect that the client is experiencing an adverse effect of the therapy?
An adverse effect of epidural analgesia is the spread of the medication above the intended level, which can result in respiratory difficulty. Increase in the work (effort) of breathing can signal this complication. Nausea is a postoperative side effect of anesthesia. Increased level of pain and petechiae are not adverse effects of epidural anesthesia. Add a Note
A nurse is caring for a 16-year-old adolescent with aortic stenosis. Which finding is associated with aortic stenosis when the teen is active?
Children with aortic stenosis may develop chest pain similar to angina when they're active. They're also at risk for hypotension, tachycardia, angina, syncope, left ventricular failure, dyspnea, fatigue, and palpitations. Poor left ventricular ejection leads to decreased cardiac output. Loud systolic murmurs are heard with ventricular septal defects.
The nurse is meeting with a 17 year-old client who has recently tested positive for human immunodeficiency virus (HIV). The client states, "What information will be disclosed to others." What information should be provided by the nurse?
Correct response: "In some jurisdictions laws may require you share this information with future sexual partners." Explanation: Most jurisdictions have laws requiring an HIV positive person to share their status with a contact prior to sexual activity. Sharing a positive HIV status is an obvious area of concern for a client. Studies have shown that those who disclose their status to friends and family experience a greater source of support and benefit from it. Disclosures to teachers, employers, friends and family is voluntary and not a requirement. Disclosures of a positive HIV status to past contacts is a courtesy and while recommended is not required.
While checking a 2-month-old infant's airway, a nurse finds that the child is not breathing. After two unsuccessful attempts to rescue breathe, how should the nurse proceed?
Correct response: Administer five back blows. Explanation: The infant's airway is blocked despite the nurse's attempts to establish it with rescue breaths. The nurse should next clear the airway with five back blows and five chest thrusts. Abdominal thrusts should not be used on the infant. The nurse cannot administer breaths or ventilate the child with a handheld resuscitation bag until the airway is patent. After two attempts to establish the airway, the nurse can assume the airway is blocked.
When performing cardiopulmonary resuscitation on a 7-month- old infant, which location would the nurse use to evaluate the presence of a pulse?
Correct response: Brachial artery Explanation: The brachial artery is the best location for evaluating the pulse of an infant younger than age 1. A child of this age has a very short and often fat neck, so the carotid artery is inaccessible. The femoral artery is usually inaccessible because of clothing and diapers. The radial artery may not be palpable if cardiac output is low, even if there is a heartbeat.
A client with schizophrenia was admitted to the hospital 2 days ago and began medication treatment with haloperidol. When reviewing the progress record, the nurse notes the entry above. Which laboratory results would the nurse need to report immediately?
Correct response: CK and WBC Explanation: The client's symptoms and elevated CK level and WBC count indicate possible neuroleptic malignant syndrome (NMS), a potentially fatal reaction to antipsychotic medications. Signs and symptoms of NMS include elevated blood pressure, hyperthermia, muscle rigidity, diaphoresis, and pale skin. HCT and Hb are within normal range.
A client recovers from an episode of acute pulmonary edema and is prescribed enalapril. What does the nurse determine is the most important outcome of administration of this medication?
Decreased workload of the heart Explanation: Enalapril maleate is an angiotensin-converting enzyme (ACE) inhibitor that reduces blood pressure and decreases the workload of the heart.
A child presents in the emergency department after being hit in the head by a baseball. The child begins to excrete extremely large amounts of urine and becomes dehydrated. Which condition does the nurse suspect the child has developed?
Diabetes insipidus is the principal disorder caused by posterior pituitary hypofunction. The disorder results from hyposecretion of antidiuretic hormone, producing a state of uncontrolled diuresis. Diabetes insipidus can be acquired as the result of a head injury or tumor. Add a Note
A 3½-year-old Vietnamese child with a fever, decreased urine output, wheezing, and coughing is brought to the emergency department. On data collection, the nurse discovers red, round, weltlike lesions on the child's upper back and chest. The nurse would interpret these lesions to be caused by which of the following?
Correct response: Cultural practice Explanation: Many Vietnamese perform coining, a cultural practice in which a coin is repeatedly rubbed lengthwise on the oiled skin to rid the body of a disease. Coining can produce weltlike lesions on the child's back or chest, and children subjected to the practice are often thought to have been abused. Interviewing the family and assessing its cultural background helps distinguish between abuse and cultural practice. Shingles, a form of herpes zoster, is a communicable disease usually affecting immunocompromised individuals and older adults. The disease produces small crusty pustules on the lower back and trunk. Impetigo presents as honey-colored, crusted lesions. The description of the lesions doesn't fit those produced by an allergic reaction.
A toddler with bacterial meningitis is admitted to the inpatient u
Correct response: Droplet precautions Explanation: Because bacterial meningitis is transmitted by droplets from the nasopharynx, the nurse should prepare to use droplet precautions. This includes wearing a gown and gloves during direct client care and ensuring that everyone who enters the child's room wears a mask.
A client with lung cancer is experiencing excruciating pain due to the size of the tumor and is scheduled for a lung resection the next morning. What education should the nurse reinforce about the lung resection?
Correct response: Explain that the surgery will remove the tumor and as little surrounding tissue as possible. Explanation: The goal of surgical lung resection is to remove the cancerous lung tissue that has tumor in it while preserving as much surrounding tissue as possible. It may be necessary to remove alveoli and bronchioles, but care is taken to remove only what's absolutely necessary.
The nurse is interacting with a client experiencing delusions. Which action would be most appropriate for the nurse to do?
Correct response: Identify the meaning of the delusion. Explanation: Identifying the meaning of the delusion helps the client understand and begin to develop strategies for dealing with these thought processes. Never argue with or try to talk the client out of a delusion.
A client is receiving an I.V. infusion of mannitol after undergoing intracranial surgery to remove a brain tumor. To determine whether this drug is producing its therapeutic effect, the nurse should consider which finding the most significant?
Correct response: Increased urine output Explanation: The therapeutic effect of mannitol is diuresis, which is confirmed by an increased urine output.
For which adverse reaction should the nurse monitor a client during the initial phase of lithium carbonate therapy?
Correct response: Nausea and vomiting Explanation: During the initial phase of lithium therapy, the nurse should monitor the client for GI symptoms such as nausea and vomiting, which occur most frequently in the initial stages of therapy and after dosage adjustments. GI symptoms are associated with increasing blood levels of lithium. Lithium therapy may cause leukocytosis, not anemia. The drug isn't associated with dehydration or decreased cerebral perfusion. Lithium toxicity may cause confusion, but it isn't due to decreased cerebral perfusion.
A client comes to the clinic with back pain that has been unrelieved by continuous ibuprofen use over the past several days. Current prescription medications include captopril and hctz.
Correct response: blood urea nitrogen (BUN) of 26 mg/dL and serum creatinine of 2.35 mg/dL Explanation: Nonsteroidal antiinflammatory drugs can decrease the antihypertensive effect of angiotensin-converting enzyme inhibitors and predispose clients to the development of acute renal failure as indicated by the increased levels of BUN and serum creatinine. The other lab values do not reflect damage to the kidneys.
A nurse is caring for a client diagnosed with borderline personality disorder. Which condition is most likely to coexist with the client?
Correct response: depression Explanation: Chronic feelings of emptiness and sadness predispose this client to depression. About 40% of the clients with borderline personality disorder struggle with depression. They tend to disregard boundaries and limits. Avoidance isn't an issue with these clients. They don't tend to develop delirium or become disoriented. These conditions are only a possibility if the client becomes intoxicated.
A client has been diagnosed with croup and is experiencing increased respiratory distress. What would the nurse expect to see in this client?
Correct response: intercostal retractions Explanation: Intercostal retractions occur as the child's breathing becomes more labored and the use of other muscles is necessary to draw air into the lungs. A barking cough occurs in a child with croup and in itself isn't a sign that the condition is worsening.
The physician prescribes lithium carbonate for a client who has just been diagnosed with bipolar disorder. Now the nurse is teaching the client about signs and symptoms of lithium toxicity, which include:
Correct response: lethargy, vomiting, and diarrhea. Explanation: Lethargy is an early sign of lithium toxicity; if it goes undetected, vomiting and diarrhea soon develop.
A child is admitted to the pediatric unit with an unknown mass in the lower left abdomen. Which action should be the nurse's priority?
Correct response: place a "Do Not Palpate Abdomen" sign over the child's bed Explanation: The nurse must take measures to prevent palpation of the mass, if possible. If the mass is a malignant tumor, a do-not-palpate warning will help prevent trauma and rupture of the suspected tumor capsule. Rupture of the tumor capsule may cause seeding of cancer cells throughout the abdomen. Obtaining the history and vital signs and scheduling laboratory work are important but not the priority.
A client following the administration of an opioid analgesic has a PaCO2 value of 80 mm Hg upon drawing blood gases. What does this blood gas value indicate?
Correct response: the danger of respiratory arrest Explanation: A client about to go into respiratory arrest will have inefficient ventilation and will be retaining carbon dioxide. The PaCO2 value expected would be around 80 mm Hg. It is not indicative of hyperventilation as the CO2 is high, and it does not rise in pneumonia. Remediation:
A nurse is reviewing the laboratory results of a client with anemia and anticipates which lab value would be decreased?
Erythrocyte count of 3.1 × 106/µL (3.10 × 1012/L) Explanation: Anemia is defined as a decreased number of erythrocytes (RBC).
The nurse is caring for an adolescent, age 14. Which emotional response is typical during early adolescence?
Explanation: During early adolescence, a child may become moody. Frequent anger and combativeness are more typical of middle adolescence. Cooperativeness typically occurs during late adolescence.
The nurse educator asks the graduate nurse which factor is important when restraining a violent client? The educator concludes the graduate is following appropriate action pertaining to restraints when she makes which statement?
Have an organized, efficient team approach after the decision is made to restrain the client." Explanation: Emergency department personnel should use an organized, team approach when restraining violent clients so that no one is injured in the process. The leader, located at the client's head, should take charge; four staff members are required to hold and restrain the limbs.
A nurse is collecting data on a child with growth hormone deficiency. Which characteristic would the nurse most commonly observe? You Selected:
Height may be retarded more than weight because, with good nutrition, children with growth hormone deficiency can become overweight or even obese. Their well-nourished appearance is an important diagnostic clue to differentiation from other disorders, such as failure to thrive. Remediation: Add a Note
The health care provider has prescribed olanzapine for a client. Which statement from the client would indicate the medication is having the desired effect?
I am feeling more comfortable talking with others." Explanation: Olanzapine is used in the treatment of paranoid personality disorders.
A client is given triazolam for a sleep disorder. The nurse is reinforcing some teaching precautions concerning the medication. Which statements by the client indicate an understanding of the information provided?
I shouldn't confuse this medication with Haldol." Explanation: Haldol is an antipsychotic that has a spelling similar to Halcion and is used for clients with psychoses, Tourette's syndrome, severe behavioral problems in children, and emergency sedation of severely agitated psychotic clients. Halcion is one of a group of sedative-hypnotic medications that can be used only for a limited time because of the risk of dependency. Grapefruit and grapefruit juices can alter the absorption of Halcion
A nurse is caring for a client post-transurethral transection of the prostate (TURP). The client tells the nurse that he has to void. What is the appropriate nursing action?
Irrigate the catheter. Explanation: Blood clotting the catheter will produce the sensation of needing to void. Irrigation of the catheter will remove blood clots allowing urine to flow freely.
A nurse is reinforcing education for the parents of a child with Kawasaki disease. Which statement should the nurse include in the education about this disorder?
It's an acute systemic vasculitis of unknown cause." Explanation: Kawasaki disease can best be described as an acute systemic vasculitis of unknown cause. Most cases are geographic and seasonal, occurring in the late winter and early spring.
In a client who has been burned, which medication should the nurse expect to use to prevent infection?
Mafenide acetate
The nurse cares for a client who has been performing respiratory exercises. Which action should the nurse take to determine the effectiveness of the exercises?
Obtain a pulse oximetry reading. Explanation: Pulse oximetry is a noninvasive procedure in which a small sensor is positioned over a pulsating vascular bed to measure SaO2. An incentive spirometer is used to assist the client with deep breathing after surgery but does not determine the effectiveness of respiratory exercises.
What is the most important postoperative instruction the nurse must give a client who has just returned from the operating room after receiving a subarachnoid block?
Remain supine for the time specified by the physician."
To reduce occurrence of dumping syndrome, which action should the nurse instruct a client to take?
Rest for 20-30 minutES after eating
A client with anemia is admitted with pallor, fatigue, dry lips, and smooth, bright red tongue. Which diagnostic test should the nurse anticipate to confirm the client's specific type of anemia? You Selected:
Schilling test Explanation: Smooth, bright red tongue is a sign of vitamin B12 deficiency. Schilling test is performed to evaluate vitamin B12 absorption. It is used to diagnose pernicious anemia. Pernicious anemia is caused by lack of intrinsic factor produced by gastric mucosa, which is necessary for vitamin B12 absorption. Bone marrow examination is used for aplastic anemia. Ventilation-perfusion scan is used to help diagnose a client with pulmonary embolism. Tensilon test is a test for myasthenia gravis.
Flumazenil has been ordered for a client who has overdosed on oxazepam. Before administering the medication, the nurse should be prepared for which common adverse effect?
Seizures Explanation: Seizures are the most common serious adverse effect of using flumazenil to reverse benzodiazepine overdose.
A client with a tentative diagnosis of hyperosmolar hyperglycemic nonketotic syndrome (HHNS) has a history of type 2 diabetes, which is controlled by tolazamide. The nurse reviews which important laboratory test for confirming HHNS?
Serum osmolarity is the most important test for confirming HHNS;
When assessing a male neonate, the nurse notices that the urinary meatus is located on the ventral surface of the penis. How should the nurse report this finding?
She should report the finding as hypospadias. Explanation: Hypospadias is an abnormal finding that's characterized by the location of the urinary meatus on the ventral surface of the penis.
The nurse is reinforcing education about the staging of a cancer tumor to a client who is newly diagnosed with cancer. Which statement made by the client would indicate to the nurse a need for further teaching?
Surgical biopsy with cytologic cell examination is the only data collection method used to perform staging."
A client is prescribed transcutaneous electrical nerve stimulation (TENS) for pain relief. Which finding indicates that the client is responding appropriately to TENS therapy?
The client reports an improvement in discomfort over the painful area. Explanation: The rationale for using TENS for pain relief is to block painful stimuli traveling over small nerve fibers. The client should experience relief of the pain in the area involved.
The nurse is monitoring a client for adverse reactions to dantrolene. Which most common adverse reaction related to dantrolene is the nurse observing for in this client?
The most common adverse reaction to dantrolene is muscle weakness.
The parents of a 14-year-old child who underwent an atrial septal repair 5 days ago have asked if a few family members can visit. Which response by the nurse is appropriate?
While controlling infection and promoting rest are important, a few visitors would not be a problem at this stage of recovery." Explanation: Prevention of infection after any surgical procedure is important. After a week, the child's risk for infection, while still present, is lessened. If all visitors are free of infection, a visit would be fine.
The nurse is scheduled by the home health supervisor to change an abdominal wound dressing at an older adult client's home. Upon arrival, the nurse observes a bed-confined client, laying in dried feces and wet with urine. The client has ecchymosis in the periorbital area. What intervention should the nurse initially provide?
The nurse should first ensure the immediate safety of the client as well as his or her immediate hygiene needs to prevent skin breakdown. After meeting the client's immediate needs, the nurse should call the supervisor and report the condition so further steps can be made to ensure the safety of the client. A referral may be made to Adult Protective Services depending upon the nursing assessment.
Which action should the nurse take when a client diagnosed with human immunodeficiency virus (HIV) infection refuses treatment?
The nurse should recognize that individuals may not be ready to make treatment decisions immediately after diagnosis. The nurse should make sure the client understands his treatment options but shouldn't make recommendations. The decision lies with the client. An Against Medical Advice form should be signed if the client insists on leaving the hospital against the advice of his physician. Requesting that a family member speak with the client breeches client confidentiality. Moreover, treatment decisions are for the client to make, not family members.
During a client-teaching session, the nurse includes which instruction to a client receiving kaolin and pectin for treatment of diarrhea?
The nurse should tell the client to drink 8 to 13 8-oz glasses of fluid daily to replace fluids lost through diarrhea. Kaolin and pectin mixtures should be taken after each loose bowel movement for up to eight doses daily. The client should avoid self-medication for longer than 48 hours. The client should consult a physician if diarrhea persists longer than 48 hours despite treatment. Add a Note
A client with asthma is receiving a theophylline preparation to promote bronchodilation. Because of the risk of drug toxicity, the nurse must monitor the client's serum theophylline level closely. When reviewing this client's chart, which range will the nurse identify as the therapeutic theophylline concentration?
The therapeutic serum theophylline concentration ranges from 10 to 20 mcg/ml. Values below 10 mcg/ml aren't therapeutic.
A client with metastatic cancer is experiencing neuropathic pain. Which alternative therapy is most beneficial in treating this type of pain?
Transcutaneous electrical nerve stimulation (TENS) Explanation: TENS alters the client's perception of pain by blocking painful stimuli traveling over nerve fibers. This treatment is believed to help treat cancer pain because it reduces muscle spasm, decreases edema, and raises the pain threshold. This therapy appears to be the most effective in treating neuropathic pain. Cryotherapy is used for acute injuries, such as an ankle sprain, because it reduces inflammation.
A client who has just been diagnosed with mixed muscular dystrophy asks the nurse about the usual course of this disease. How should the nurse respond?
You may experience progressive deterioration in all voluntary muscles." Explanation: Muscular dystrophy causes progressive, symmetrical wasting of skeletal muscles, without neural or sensory defects. The mixed form of the disease typically strikes between ages 30 and 50 and progresses rapidly, causing deterioration of all voluntary muscles. Because the client asked the nurse this question directly, the nurse should answer and not simply refer the client to the physician.
The nurse cares for an older adult client with a history of left-sided heart failure. Which finding indicates to the nurse that the client is experiencing an exacerbation of heart failure?
bibasilar fine crackles Explanation: Bibasilar fine crackles are a sign of alveolar fluid, a sequelae of left ventricular fluid, or pressure overload.
The nurse is monitoring laboratory studies for a client who had a myocardial infarction. Which test will the nurse monitor that is most indicative of cardiac damage?
creatine kinase isoenzymes (CK-MB) Explanation: CK-MB isoenzymes are present in the blood after a myocardial infarction. These enzymes spill into the plasma when cardiac tissue is damaged. ABG levels are obtained to review respiratory function, a CBC is obtained to review blood counts, and a complete chemistry is obtained to review electrolytes.
After undergoing a left thoracotomy, a client has a chest tube in place. When caring for this client, the nurse should:
encourage coughing and deep breathing. Explanation: When caring for a client who's recovering from a thoracotomy, the nurse should encourage coughing and deep breathing to prevent pneumonia.
The nurse is caring for an infant following surgical repair for hypospadias. What is a priority nursing action?
frequent inspection of the tip of the penis Explanation: Following hypospadias repair, a pressure dressing is applied to the penis to reduce bleeding and tissue swelling. The penile tip should then be assessed frequently for signs of circulatory impairment.
A client has a spinal cord transection at the T4 level. The nurse can expect the client to have which symptom?
paraplegia Explanation: Spinal cord injuries at the T4 level affect all motor and sensory nerves below the level of injury and result in dysfunction of legs, bowel, and bladder. Paraplegic injuries involve the thoracic, lumbar, or sacral region of the spinal cord.
A client is taking salicylates for osteoarthritis. What should the nurse carefully monitor the client for?
hearing loss Explanation: Many older adults already have diminished hearing, and salicylate use can lead to further or total hearing loss
After checking the client's chart for possible contraindications, the nurse is administering meperidine, 50 mg I.M., to a client with pain after an appendectomy. The nurse would question which medication if noted on the physician's orders for this client?
monoamine oxidase (MAO) inhibitor Explanation: MAO inhibitors increase the effects of meperidine and can cause rigidity, hypotension, and excitation. The client shouldn't receive meperidine within 14 days after administration of an MAO inhibitor.
A health care provider and nurse are discussing treatment options with a client diagnosed with severe ulcerative colitis symptoms. Which potential complication requires frequent assessment?
orrect response: bowel perforation Explanation: Bowel perforation, obstruction, or hemorrhage and toxic megacolon are common complications of ulcerative colitis that may require surgery. Gastritis and herniation are not associated with irritable bowel diseases, and outpouching of the bowel wall is diverticulosis.
A client is receiving a tocolytic agent to help stop preterm labor contractions. The nurse would be alert for signs and symptoms of which potentially life-threatening complication?
pulmonary edema Explanation: Tocolytics are used to stop labor contractions. The most common adverse effect associated with the use of these drugs is pulmonary edema. Only clients who have diabetes need to be observed for diabetic ketoacidosis.
