NCLEX

A perforated eardrum is suspected in a client who was hit in the ear with a basketball. A tympanoplasty was performed. The nurse is giving the client discharge instructions. Which client statement indicates a need for further teaching?

"I will drink from the plastic bottle mouth since I can't use drinking straws."

A comatose client received therapeutic hypothermia after a cardiac arrest. The nurse anticipates which primary complications associated with this treatment? Select all that apply.

Infection Bleeding Metabolic and electrolyte disturbances

The nurse working in a prenatal clinic reviews a client's chart and notes that the primary health care provider documents that the client has a gynecoid pelvis. The nurse plans care understanding that which findings are characteristic of this type of pelvis? Select all that apply.

Round shape Diagonal conjugate measures 12.5 cm to 13 cm Blunt, somewhat widely separated ischial spines

The nurse is assisting in caring for a client in the telemetry unit and is monitoring the client for cardiac changes indicative of hypokalemia. Which occurrence noted on the cardiac monitor indicates the presence of hypokalemia?

ST-segment depression

The nurse is caring for a client who has been admitted to the hospital with a diagnosis of angina pectoris. What are included in the discharge plan? Select all that apply.

Smoking cessation Get a flue vaccination Limit activity in cold weather Check blood pressure and pulse

The nurse is caring for a 8-month-old infant. The nurse determines the child is at the expected developmental level if the child displays which behavior?

Waves bye-bye

The nurse is caring for a client with a diagnosis of aplastic anemia. Which are the most likely signs/symptoms associated with aplastic anemia? Select all that apply.

Fatigue Infection Petechiae Shortness of breath

The nurse is preparing to administer a medication through a nasogastric (NG) tube that is connected to suction. Which interventions should be included to accurately administer the medication? Select all that apply.

-Clamp the NG tube for 30 minutes after medication administration. -Before medication administration, verify correct placement of tube. -Flush the NG tube with saline before and after medication administration. -Discontinue the suction from the tube during administration of medication.

Which actions are included in the nursing care of the client undergoing peritoneal dialysis? Select all that apply.

Monitor vital signs including temperature. Weigh the client before and after dialysis. Check color and volume of dialysate solution. Maintain aseptic technique when accessing the peritoneal catheter.

A CD4+ count has been prescribed for a child with human immunodeficiency virus (HIV) infection. The mother asks the nurse about the purpose of the test and why the test needs to be done if it is already known that the child has HIV. The nurse should reinforce which information to the mother? Select all that apply.

-The CD4+ count is used to determine the child's immune status. -The CD4+ count is used to identify the risk for disease progression. -The CD4+ count identifies the need for Pneumocystis jiroveci pneumonia prophylaxis after 1 year of age. -The CD4+ count is measured at ages 1 and 3 months, every 3 months until the age of 2 years, and at least every 6 months thereafter. -More frequent monitoring of CD4+ counts is indicated when pneumonia prophylaxis and antiretroviral therapy are administered.

The nurse is caring for a client who was just admitted with a diagnosis of fractured right femur. What are some of the acute complications the nurse needs to assess for? Select all that apply.

Crush syndrome Fat embolism syndrome Acute compartment syndrome (ACS) Hemorrhage and hypovolemic shock

A postoperative client has been receiving morphine sulfate every 3 to 4 hours for pain. The nurse should be sure to implement which measures to reduce the risk of adverse effects from this medication? Select all that apply.

Encourage fluids when not NPO. Encourage coughing and deep breathing. Monitor the number of bowel movements

The nurse is obtaining the report for a group of assigned clients. The nurse plans to monitor the serum potassium levels in which clients at risk for hyperkalemia? Select all that apply.

A client with a new burn injury A client diagnosed with acute kidney injury (AKI)