NCLEX 200 SATA

sun setting eyes

Which finding would be most indicative of hydrocephalus in an infant?

sunset eyes

Which finding would be most indicative of hydrocephalus in an infant?

chocolate smoked meats yogurt

Which foods should the nurse teach the client not to consume when taking phenelzine? Select all that apply.

excessive climbing and running excessive fidgeting cannot wait to take turns easily distracted

A child is being seen at the clinic for an attention deficit hyperactivity disorder (ADHD) assessment. What symptoms the nurse would expect to find? Select all that apply.

severe lower back pain

A client has a herniated disk in the region of the third and fourth lumbar vertebrae. Which nursing assessment finding most supports this diagnosis?

performing lumbar puncture

After striking their head on a tree while falling from a ladder, a client is admitted to the emergency department. The client is unconscious and their pupils are nonreactive. Which intervention should the nurse question?

involvement of facial and cranial nerves

The nurse asks a school-age child with Guillain-Barré syndrome to cough and also assesses the child's speech for decreased volume and clarity. The underlying rationale for these assessments is to determine which finding?

Pulse oximetry readings

A 30-year-old client is admitted to the progressive care unit with a C5 fracture from a motorcycle accident. What would be the nurse's priority assessment?

Observe the client closely for signs and symptoms of bowel perforation. Monitor vital signs frequently until they are stable. Inform the client that there may be blood in the stool and to report excessive blood

A 53-year-old client undergoes colonoscopy for colorectal cancer screening. A polyp was removed during the procedure. Which nursing interventions are necessary when caring for the client immediately after colonoscopy? Select all that apply.

starting an I.V. infusion of lactated Ringer's solution administering 6 mg of morphine I.V. administering tetanus prophylaxis as ordered

A client arrives at the emergency department with deep partial-thickness and full-thickness burns over 15% of his body. At admission, the client's vital signs are: blood pressure 100/50 mm Hg, heart rate 130 beats/minute, and respiratory rate 26 breaths/minute. Which nursing interventions are appropriate for this client? Select all that apply.

constricts cerebral blood vessels

A client asks a nurse, "How does sumatriptan relieve migraine headaches?" The nurse should respond that it:

constricts cerebral blood vessels.

A client asks a nurse, "How does sumatriptan relieve migraine headaches?" The nurse should respond that it:

Assist the client to lie down. Administer the prescribed celecoxib. Apply a warm compress to the client's back. Notify the health care provider (HCP).

A client attempting to get out of bed stops midway because of low back pain radiating down to the right heel and lateral foot. What should the nurse do in order of priority from first to last? All options must be used.

infection in the peritoneal cavity."

A client has a Jackson-Pratt drainage tube in place the first day after surgical repair of a ruptured diverticulum. The client asks the nurse the purpose of the drain. What should the nurse tell the client? "The drainage tube is used to prevent:

semen analysis hysterosalpingogram basal body temperature graph hypothalamic pituitary level

A client has been trying to achieve a pregnancy for 3 years and has just recently sought the assistance of an infertility specialist. Which tests may be conducted to analyze the causes of this client's infertility? Select all that apply.

muscle contraction is palpable and visible

A client is admitted to an acute care facility for treatment of a brain tumor. When reviewing the chart, the nurse notes that the client's extremity muscle strength is rated 1/5. Which assessment finding should the nurse anticipate?

Identify one nurse to interact with the client. Direct other clients away from the area. Discretely notify security to assist. Identify with the client's perspective and reason for agitation.

A client on a mental health unit becomes increasing agitated and barricades themself in a corner room holding another client hostage. Verbal exchanges indicate an escalation in client desperation. Which nursing actions would be taken at this time? Select all that apply.

1.Assess the client's airway. 2.Start an intravenous line. 3.Administer an antihistamine. 4.Document the food allergy. 5.Teach the client how to use an EpiPen autoinjector.

A client presents to the emergency department with symptoms of wheezing, coughing, edema of the lips, tongue, and palate. The client's significant other states they decided to try lobster for the first time. The health care provider suspects an immunoglobulin E (IgE) mediated food allergy. Place the steps that the nurse should do in the correct order. All options must be used.

administration of 100% humidified oxygen blood drawn for carboxyhemoglobin levels

A client rescued from a burning building is brought to the emergency department. The client does not have any visible burn injury and is conscious. Which interventions will the nurse anticipate? Select all that apply.

Align self to prevent personal injury. Prepare the client to be in normal anatomical alignment. Keep the client in anatomical alignment during the move. Use large muscle groups to prevent sore muscles and joints.

A client who is bedridden has slid down in the bed. Which principle of body mechanics should the nurse use when repositioning the client? Select all that apply.

Discontinue the infusion at the affected site. Apply warm soaks to the intravenous site. Document the assessment, nursing actions taken, and the client's response.

A client with an intravenous line in place states having pain at the insertion site. Assessment of the site reveals a vein that is red, warm, and hard. Which actions would the nurse take? Select all that apply.

Contact the HCP before administering the carbidopa-levodopa. Determine if the client is on antidepressants or monoamine oxidase (MAO) inhibitors. Determine if the client is at risk for suicide.

A health care provider (HCP) has prescribed carbidopa-levodopa four times per day for a client with Parkinson's disease. The client wants "to end it all now that the Parkinson's disease has progressed." What should the nurse do? Select all that apply.

Verify the infant's full name with the parent. Check the neonate's identification band against the medical record number. Verify the date of birth from the medical record with the date of birth on the client's identification band

A nurse administers indomethacin to a neonate. What should the nurse do to ensure that the nurse has identified the neonate correctly? Select all that apply.

nuchal rigidity positive Brudzinski's sign positive Kernig's sign photophobia

A nurse assesses a client with suspected bacterial meningitis. Which documented finding of meningeal irritation suggests this diagnosis? Select all that apply.

Teach diaphragmatic, pursed-lip breathing. Administer low-flow oxygen as needed. Encourage alternating client activity with rest periods. Teach the use of postural drainage and chest physiotherapy.

A nurse assigned to a client with emphysema is providing shift report. Which nursing interventions would be appropriate to include? Select all that apply.

to replace antidiuretic hormone (ADH)

A nurse is caring for a client following a hypophysectomy. Included in the postoperative orders is vasopressin intramuscularly. Which rationale is most correct for the administration of this medication?

increased heart rate dry mucous membranes muscle hyperreflexia

A nurse is completing a health assessment with an adult client in a health care provider's office. What assessment findings will the nurse report to the health care provider as indications of fluid volume deficit? Select all that apply.

advanced age urinary urgency benzodiazepine medication

A nurse is completing an admission fall assessment with an adult client. What are important nursing considerations to determine a high risk for falls? Select all that apply.

providing effective and timely "hand-off reports" between labor and birth staff and mother-baby staff ensuring that preprocedural verifications are completed by health care providers (HCP) for any invasive procedure involving clients in education to cord infections identifying safety risks specific to the unit, such as infant abduction

A nurse who works on an obstetrical inpatient unit has been assigned to the client safety committee. What client safety goals are most applicable to this setting? Select all that apply.

Diapers are discarded into covered receptacles. Disposable papers are used on the diaper-changing surfaces. Facilities for hand hygiene are located in every classroom.

A parent is planning to enroll the 9-month-old infant in a day care. The parent asks the nurse what indicators would ensure that the daycare facility is adhering to good infection control measures. How should the nurse reply? Select all that apply.

cranial nerves IX and X.

During recovery from a stroke, a client is given nothing by mouth to help prevent aspiration. To determine when the client is ready for a liquid diet, the nurse assesses the client's swallowing ability once per shift. This assessment evaluates

has had symptoms of the stroke less than 3 hours does not have active internal bleeding has a blood pressure within normal limits

Prior to administering plasminogen activator (t-PA) to a client admitted with a stroke, the nurse should verify which information about the client? Select all that apply.

has had symptoms of the stroke less than 3 hours has a blood pressure within normal limits does not have active internal bleeding

Prior to administering plasminogen activator (t-PA) to a client admitted with a stroke, the nurse should verify which information about the client? Select all that apply.

home health aide and Meals on Wheels physiotherapist and occupational therapist public health nurse and social worker

The discharge planner is facilitating an interdisciplinary team meeting about a client being discharged post cerebrovascular accident (CVA). Which health team members would be appropriate for follow-up care in the home? Select all that apply.

lifting causes the infant to cry reduction of movement in one of the infant's arms loss of sensation in one the infant's arms

The nurse assesses for complications in a newborn infant born with assistance of forceps. What findings would indicate a need for further assessment? Select all that apply.

Notify the physician. Notify the nursing supervisor. Send a copy of the report to the risk management department. Document the client's condition.

The nurse completes an incident report after discovering and assessing a client sitting on the floor beside the bed. Which actions should the nurse take after completing the incident report? Select all that apply.

blood pressure 86/50 mm Hg; pulse weak and thready at 120 bpm fever of 102 degrees F, no urine output for 2 hours

The nurse has reinforced a pressure dressing on a client who is postoperative mastectomy and notes there is considerable sanguineous drainage in the Hemovac. Which assessments should the nurse report to the physician? Select all that apply.

1.q 14-year-old with a 2-inch (5.1-cm) laceration to the chin, history of asthma, respirations 26 breaths/min, audible wheezing 2.a 22-year-old with a 2-inch (5.1-cm) laceration to the left temple, slightly confused 3.a 22-year-old female, 36 weeks pregnant with contractions every 10 to 15 minutes 4.a 75-year-old with a 2-inch (5.1-cm) laceration to the left forearm

The nurse in the emergency department is triaging victims of an airplane crash. Prioritize the clients in the order in which they should be treated from first to last. All options must be used.

"I won't share any information with your family without your permission." "We'll be meeting every day at 10:00 a.m. for 15 minutes." "Tell me what brought you here today."

The nurse is admitting a client diagnosed with depression. Which statements by the nurse should be made in the orientation phase of the nurse-client relationship? Select all that apply.

confusion

The nurse is assessing a client who is in shock. Which neurologic change indicates that the client is in the progressive stage of shock?

intravascular to the interstitial compartment.

The nurse is caring for a client who has deep partial-thickness and full-thickness burns. During the emergent (resuscitative) phase of burn management, there will be a fluid shift from the:

arterial blood gases reporting a PaCO2 of 48 and a PaO2 of 84 nasal flaring with abdominal retractions lung sounds of stridor increased respiratory effort

The nurse is caring for a client who is demonstrating signs of increased respiratory distress related to laryngeal obstruction. The nurse is calling the physician to report on the client's condition. What will the nurse report? Select all that apply.

Maintain pressure over the femoral access site. Check the dressing and access site for bleeding. Keep the extremity straight.

The nurse is caring for a client who just underwent cardiac catheterization through a femoral access site. Which nursing interventions should the nurse include in the care plan for the next 8 hours? Select all that apply.

Offer a light snack. Assess pain level. Offer an 8 ounce (240 mL) glass of water.

The nurse is caring for a female client with dysmenorrhea that interferes with activities of daily living. The client is prescribed ibuprofen 400 mg three times daily. Which nursing action is completed with medication administration? Select all that apply.

Rest as needed. Avoid people with colds or flu. Contact the health care provider (HCP) if a fever develops.

The nurse is developing a discharge plan with a client who is receiving chemotherapy to treat lymphoma. What should the nurse include in the plan? Select all that apply.

nutrition and hydration needs capillary refill continued need for restraints skin integrity

The nurse is documenting care of a client who is restrained in bed with bilateral wrist restraints. Following assessment of the restraints, what should the nurse's documentation include? Select all that apply.

washing the hands immediately after removing the sterile gloves removing the dressing with nonsterile gloves donning sterile gloves for the irrigation wearing a face shield during the irrigation

The nurse is irrigating a draining wound prior to packing with gauze. Which nursing actions are appropriate? Select all that apply.

Walk daily. Engage in stretching. Avoid wearing high heeled shoes. Keep body weight within normal limits

The nurse is preparing a teaching tool to prevent back injuries for participants in a community health fair. Which information should the nurse include? Select all that apply.

Clarify the order with the healthcare provider. Hold the medication.

The nurse is providing care to a client with asthma. The healthcare provider orders albuterol sulfate INH 2 puffs q 6 hours for maintenance dosing. What should the nurse do Select all that apply.

Contractions become more intense and closer together. She notices vaginal bleeding. She thinks the membranes have ruptured. She notices an absence of fetal movement. She feels the urge to push.

The obstetrical triage nurse assesses a client with a term pregnancy. There has not been any change in the cervix for the past 2 hours despite irregular contractions. When discharging the client to her home, the nurse should tell the client to return to the hospital when which conditions occur? Select all that apply.

name of the medication purpose of the medication . possible adverse effects

When administering an intravenous medication, the nurse should explain which teaching points to the client? Select all that apply.

Support the cast with palms of hands. Wait until the cast dries before cleaning the surrounding skin. Rest the cast on the bed, supported by pillows.

nurse is caring for a client immediately following the application of a plaster cast for a fractured femur. What would the nurse do to care for the client with a cast? Select all that apply.

The client refrains from performing rituals during stress. The client verbalizes that he uses "thought stopping" when obsessive thoughts occur. The client verbalizes the relationship between stress and ritualistic behaviors.

nurse recognizes improvement in a client with the nursing diagnosis of Ineffective role performance related to the need to perform rituals. Which behaviors indicate improvement? Select all that apply.