NCLEX again

A nurse on a rehabilitation unit is providing teaching to the partner of a client who is experiencing stimulant withdrawal. Which of the following statements by the partner indicates an understanding of the teaching?

"Depression is a manifestation of withdrawal."

A nurse is teaching the guardian of a preschooler. The guardian states that the preschooler has had an imaginary friend for about three months. What information should the nurse give the guardian?

"Have your child take responsibility for actions if he tries to blame the imaginary friend."

A nurse is providing discharge teaching to a client who had a kidney transplant and has a prescription for oral cyclosporine. What statement indicates an understanding of the teaching?

"I am likely to develop a higher blood pressure while taking this medication."

A nurse is evaluating teaching for a client who has bipolar disorder and a new prescription for lithium. Which of the following statements by the client indicates an understanding of the teaching?

"I am likely to gain weight while taking lithium."

A nurse is providing preoperative teaching for a client with colorectal cancer who is scheduled to undergo colostomy placement with a perineal wound. What statement by the client indicates an understanding of the teaching?

"I can have only liquids for two days before the surgery."

A nurse is providing teaching to a client who has cervical cancer and is scheduled to receive brachytherapy in an ambulatory care clinic. What statement by the client indicates understanding of the treatment?

"I need to lie still in bed during my brachytherapy treatment."

A nurse is teaching a client who will be taking dexamethasone daily for pain due to spinal edema. The nurse should identify which of the following client statements as an indication that teaching has been effective?

"I should stay away from people who are ill." This is a glucocorticoid treatment

A nurse is providing teaching to a client with chronic bronchitis about administering acytelcystine using a hand-held nebulizer. What statement made by the client indicates an understanding of the teaching?

"I should try and cough productively before I begin the treatment."

A nurse is providing teaching to the parent of an infant who has developmental hip dysplasia and a new prescription for a Pavlik harness. Which of the following parent statements indicates an understanding of the teaching?

"I will apply the harness over a t-shirt and knee socks." This prevents rubbing/irritation with the baby's skin

A nurse is providing teaching to a client who has COPD about maintaining proper nutrition. What statement would indicate an understanding of the teaching?

"I will eat more cold foods at meals." These foods provide a decreased feeling of fullness compared to hot meals

A nurse is teaching a client who had an amputation of the left lower leg three days ago. Which of the following statements indicates that the client understands how to care for the incision and his left upper leg?

"I will lie on my stomach (prone) for 30 minutes a few times a day." This position helps reduce the risk of developing hip flexion contractures

A nurse is teaching a client who has osteoporosis about a new prescription for risedronate. Which of the following statements indicates an understanding of the teaching?

"I will take this medication with a full cup of water." "I will not take this medication with food." "I will sit upright 30 minutes after taking this medication."

A nurse is providing teaching about immunization schedules to the parents of a newborn who is one week old. Which of the following pieces of information should the nurse include in the teaching?

"Initial vaccines should be administered between birth and two weeks of age."

A nurse is providing discharge teaching for a client who has a newly inserted permanent pacemaker. What instruction should the nurse include in the teaching?

"Keep your cell phone 6 inches away from your pacemaker when making a call."

A nurse is caring for a client who has ulcerative colitis. The provider prescribes bed rest with bathroom privileges. When the client asks the nurse why he has to stay in bed, what should the nurse say?

"Lying quietly in bed helps slow down the activity in your intestines."

A nurse is providing discharge instructions to a client who is breastfeeding her newborn. Which of the following statements should the nurse include?

"Notify your provider if you notice cracking on your nipples."

A postpartum nurse is caring for a client who reports excessive sweating during the first night after delivery. Which of the following statements should the nurse make?

"This is a source of your fluid loss after delivery."

A postpartum nurse is caring for a client who reports excessive sweating the first night after delivery. What should the nurse inform the patient about this?

"This is a source of your fluid loss after delivery."

A nurse is teaching a client with a new diagnosis of peptic ulcer disease (PUD) who has a prescription for bismuth subsalicylate. The client asks the nurse, "How will this medication help my ulcer?" Which of the following statements should the nurse make?

"This medication can decrease bacteria in the gastrointestinal tract." (Specifically Helicobacter pylori)

A nurse is performing a nonstress test (NST) on a client who is at 41 weeks of gestation. The client asks what the purpose of the test is. Which of the following responses should the nurse provide?

"This test will help determine if your baby is healthy."

A nurse is assessing a 2-day old newborn and notes an egg-shaped, edematous, bluish discoloration that does not cross the suture line. What should the nurse tell the mother if she asks about this finding?

"This will resolve in 3-6 weeks without treatment."

A middle-aged adult client is discussing future plans with the nurse. Which of the following statements should the nurse identify as an indication that the client is having difficulty achieving Erikson's developmental task for this age group?

"We miss our daughter so much that we are going to move closer to her."

A nurse is teaching breathing techniques to a client who has emphysema. Which of the following statements indicates that the client understands the mechanics of pursed-lip breathing?

"When I breathe out through pursed lips, my airways don't collapse between breaths."

A nurse in a clinic is providing teaching to a client who is at 37 weeks of gestation and is scheduled for an external cephalic version. What statement should the nurse make?

"You will receive a medication to relax your uterus prior to the procedure."

What is the standard serum creatinine level?

0.6-1.3

A nurse is caring for a client who had a vaginal delivery 24 hours ago. What finding should the nurse report to the provider?

3+ Deep tendon reflexes This can indicate preeclampsia

How many mLs are in one ounce?

30

How many mLs are in one pint?

480

A charge nurse is teaching a newly licensed nurse about the purpose of a client being prescribed transdermal fentanyl patches. Which of the following clients should the charge nurse include in the teaching who requires this medication?

A client who is opioid-tolerant

A charge nurse is observing a newly licensed nurse administer an IV medication to a client who has an implanted venous access port. Which of the following observations requires intervention by the charge nurse?

A solution of 5 mL of heparin 1,000 units/mL has been prepared. It should be 100 mLs.

A nurse is preparing a client for a bone scan. Which of the following statements indicates that the client understands the pre-procedure teaching?

A special camera will can the bones in my entire body I'll have to drink a lot of water to help get the radiation out of my body I understand the radiation is harmless, and I don't have to worry about it

A nurse is caring for a client who is postoperative following a total knee anthroplasty and has been prescribed a continuous passive motion (CPM) machine and PCA. The client tells the nurse, "I am in so much pain." What should the nurse do first?

Ask the client to describe the characteristics of the pain

A nurse is conducting a health assessment for a 24-month old toddler at the local health department. The nurse should expect which of the following findings?

Ability to build a tower of 8 blocks Slightly bowed or curved leg appearance

A nurse is rewarming a client following coronary artery bypass graft surgery. For which of the following complications of the rewarming process should the nurse monitor the client?

Acidosis

A nurse is caring for a client who is undergoing electroconvulsive therapy to treat major depression. Following the procedure, what action should the nurse take?

Administer oxygen

A nurse is teaching a group of nurses about the manifestations of progestin deficiency for clients who take a combination oral contraceptive. What finding should the nurse note as an indication of progestin deficiency?

Amenorrhea

A nurse is caring for a preschooler who was brought to an outpatient clinic with a 2-day history of a vesicular, honey-colored crusty region around the nose and mouth. If the provider determines the lesions to be impetigo contagiosa, what should the nurse anticipate teaching the child's parent about the illness?

Apply a topical antibacterial ointment to the lesions Wash the child's bed linens daily with hot water Wash hands before and after contact with the affected area

A nurse in an emergency department is caring for a client who reports developing severe right eye pain with gritty sensation while sawing wood. Which of the following actions should the nurse take first?

Ask the client about first aid performed at the scene

A nurse is preparing to massage the fundus of a client who is postpartum and experiencing uterine atony. In what order should the nurse take actions when performing a fundal massage?

Ask the client to lie on her back with her knees flexed Place a hand just above the client's symphysis pubis Position a hand around the top of the client's fundus Rotate the upper hand to massage the client's uterus Use slight downward pressure to compress the client's fundus

A charge nurse receives notification of the admission of a client who is coughing frequently and whose sputum is pink, frothy, and copious. The client has a history of night sweats, anorexia, and weight loss. Which of the following actions should the nurse take?

Assign the client to a private room with negative pressure airflow Wear an N95 respirator when entering the client's room

A charge nurse is providing teaching for a newly hired nurse about the potential side effects of an epidural anesthetic for a laboring client. Which of the following effects should the nurse include?

Impaired placental perfusion

A nurse is caring for a client who has a fractured right hip. Which of the following types of traction should the nurse expect the client to have prior to hip arthroplasty surgery?

Buck's traction

A nurse is caring for a group of clients on a medical-surgical unit. Which of the following disorders should the nurse identify as increasing the client's metabolic needs?

COPD Cancer Parkinson's Disease Major burns

A nurse is caring fora client who is receiving total parenteral nutrition (TPN). Which of the following actions should the nurse take?

Check the client's capillary blood glucose every four hours

A nurse is planning care for a client who has Cushing's syndrome due to chronic corticosteroid use. Which of the following actions should the nurse include in the plan of care?

Check the client's urine specific gravity

A nurse is planning care for a client with Cushing's syndrome due to chronic corticosteriod use. Which of the following actions should the nurse include in the plan of care?

Check the client's urine specific gravity (assess for fluid volume overload)

A nurse is caring for a client with Alzheimer's disease who has a new prescription for mematine. What laboratory result should the nurse identify as increasing the client's risk for decreased clearance of the medication?

Creatinine clearance below 88/minute

A nurse is caring for a client who is 2 hours postpartum and exhibiting signs of hypovolemic shock. What action should the nurse tack?

Elevate the client's legs to a 30 degree angle This improves blood flow and decreases manifestations of hypotension

What is a common/expected finding in patients with heart failure?

Elevated BNP (over 100)

A nurse is assessing a toddler who has gastroenteritis. What finding indicates the toddler is experiencing severe dehydration?

Deep, rapid respirations

A nurse is providing discharge teaching for a client who has a new prescription for doxepin. Which of the following adverse effects are associated with this medication?

Drowsiness, constipation and tachycardia

A nurse is caring for a client who has asthma and advanced rheumatoid arthritis and deformity of the hands. The nurse should anticipate that the client will receive which of the following medication-delivery devices for the treatment of asthma?

Dry-powder inhaler (This does not require hand-breath coordination)

A nurse is working with the facility's language interpreter to explain a wound-care procedure to a client who does not speak the same language as the nurse. Which of the following actions should the nurse take when describing the procedure to the client?

Ensure the interpreter and the client speak the same dialect

A nurse is caring for a newborn who has neonatal abstinence syndrome. What clinical finding should the nurse expect?

Exaggerated reflexes (Due to hyperactive central nervous system)

A nurse is assessing a four-year-old child. The nurse should expect the child to be able to preform which of the following activities?

Fastening buttons on a shirt

A nurse is providing care to a client who is in labor and experienced a spontaneous rupture of membranes. Which of the following findings requires intervention by the nurse?

Fetal heart rate decreased by 15/min

A nurse in labor and delivery is teaching a newly licensed nurse about performing McRoberts manuever to relieve shoulder dystocia. What information should the nurse include?

Flex the client's legs apart and raise her knees to her abdomen

A nurse is caring for a client who has a peripherally inserted central catheter (PICC) in place. Which of the following actions should the nurse take when handling this access device?

Flush the line with sterile 0.9% sodium chloride before and after medication administration Access the PICC for blood sampling Perform a heparin flush of the line at least daily when not in use

A nurse is teaching a client who has severe generalized rheumatoid arthritis and is scheduled to start taking prednisone for long-term therapy. The nurse should instruct the client to report what as an adverse effect of prednisone?

Gastric ulceration

A nurse is monitoring a client who has diabetes insipidus and was administered desmopressin. Which of the following findings should indicate to the nurse that the client is experiencing an adverse effect of this medication?

Headache

A nurse in an emergency department is assessing a client who reports recent cocaine use. Which manifestations should the nurse expect?

Hypertension, tachycardia, dilated pupils

A nurse in the emergency department is caring for an inmate who has a laceration and is bleeding. The client was brought to the facility by a guard who asks the nurse about the client's HIV infection status. What should the nurse say?

Instruct the guard to ask the inmate

A charge nurse is teaching a newly licensed nurse about a client who has severe allergy-related asthma and a new prescription for omalizumab. Which of the following pieces of information should the charge nurse include to describe the medication's mechanism of action?

It reduces the number of immunoglobulin E molecules on mast cells

A nurse is determining the total score for a client's Alcohol Use Disorders Identification Test by assigning a score of 0 to 4 for each answer. For which of the following self-reported findings should the nurse assign the client a score of 4?

Last month, the provider suggested the client should reduce alcohol intake

A nurse is caring for a client who has a prescription for silver sulfadiazine cream to be applied to her burn wounds. The nurse should evaluate the client for which of the laboratory findings?

Leukopenia (Adverse effect of silver sulfadiazine)

A nurse is planning care for a client who has anorexia and nausea due to cancer treatment. What interventions should the nurse include?

Limit drinking liquids with food (to promote maximum calorie consumption)

A nurse is admitting a child who has acute lymphocytic leukemia. Which of the following laboratory values should the nurse expect?

Low red blood cells (below 4.2 to 6.1 million)

A nurse working in a retirement community is assessing an older adult client. What manifestation is an expected age-related change?

Making occasional errors when balancing a checkbook

A nurse is monitoring a client who is receiving terbutaline to suppress preterm labor. Which of the following findings should indicate to the nurse that the client is experiencing an adverse effect of the medication?

Maternal heart rate is greater than 120/minute (This medication can cause tachycardia)

A nurse is caring for a client who requests an intrauterine device (IUD) for contraception. What is a contraindication for this device?

Menorrhagia or ectopic pregnancies

A nurse is caring for a client who is wearing a halo fixator. Which of the following interventions should the nurse implement?

Monitor the client's vital signs every four hours Monitor the client's pin sites for loosening Check the client's skin to ensure the jacket is not applying pressure

A nurse is caring for a client who has encephalitis due to West Nile virus. What actions should the nurse take?

Monitor vital signs every two hours Assess neurological status every four hours Keep the client's room darkened

A nurse is providing teaching to the parent of a 2-year-old toddler about nutrition. What statement by the parent indicates an understanding of the teaching?

My child should consume 1,000 calories a day and 2 oz of protein a day

A nurse is caring for a client who is experiencing an acute gout attack. The nurse should expect a prescription form the provider for which of the following medications?

Naproxen

A nurse is making a client's bed and finds a capsule of medication in the sheets. What should the nurse do to practice safe nursing?

Notify the provider Complete a variance report

A nurse on a medical-surgical unit is caring for a client. Which of the following actions should the nurse prioritize when using the nursing process?

Obtain client information (Assessment)

A nurse is admitting a client who has cirrhosis. What should the nurse anticipate doing?

Obtain the client's PT and INR measurements Administer lactulose 30 mL PO 4 times daily Obtain daily weight and abdominal girth Administer a daily multivitamin

A nurse is caring for a client who has a percutaneous endoscopic gastrostomy tube and is receiving intermittent feedings. Prior to initiating the feeding, what should the nurse do?

Place the client in semi-fowler's position

A nurse is planning care for a child who has hyperthermia. Which of the following actions should the nurse take?

Position the child on a cooling blanket and cover her with a sheet

A nurse is preparing to provide self-care teaching to a client who is four days postoperative after the creation of a colostomy who refuses to look at the stoma. What should the nurse do?

Postpone any teaching with the client at this time

A nurse is providing teaching to a female client with a new prescription for pravastatin to treat hyperlipidemia. Which of the following pieces of information should the nurse include in the teaching?

Pravastatin can be taken with grapefruit juice

A nurse is caring for a client who experienced a spontaneous rupture of membranes and has prolonged decelerations on the fetal monitor. Which of the following conditions should the nurse expect?

Prolapsed umbilical cord

An emergency room nurse is assessing a client who has a new traumatic brain injury. The nurse observes extension of the client's arms and legs, pronation of the arms, and plantar flexion of the feet. What action is the nurse's priority?

Provide supplemental oxygen

A nurse is planning care for a 4-year-old with nephrotic syndrome. Which of the following actions should the nurse take?

Provide thorough skin care (Increased risk of infection)

A nurse is caring for an adolescent client who has a prescription for opioids. What is an adverse effect of opioids?

Pruritus (itchy skin)

A nurse is assessing a client prior to administering lithium. The client began taking lithium one week ago for the treatment of mania. For which of the following findings should the nurse withhold the dose?

Reports of nausea with frequent episodes of emesis

A nurse is preparing a discharge teaching plan for a client who is scheduled to begin long-term oral prednisone for asthma. What should the nurse instruct the client to do?

Schedule the medication on alternate days to decrease adverse effects

A nurse is teaching a client who has depression and is scheduled for transcranial magnetic stimulation (TMS). The nurse should inform the client that TMS can cause which of the following adverse effects?

Seizures

A nurse is caring for a client with cystic fibrosis who has a prescription for high-dose ibuprofen daily. The nurse should identify that which of the following is an expected outcome for the client receiving this medication?

Slowed progression of pulmonary damage (NSAIDs suppress inflammatory responses)

A nurse is caring for a client who has schizophrenia and is experiencing negative symptoms. What manifestation should the nurse expect?

Social discomfort

A nurse is providing education about newborn skin care for a group of new parents. What instruction should the nurse include?

Sponge bathe the newborn every other day

A nurse is preparing to perform Leopold maneuvers on a client who is in labor. Which of the following actions should the nurse plant to take??

Stand at the client's right side if the nurse is right-handed

The nurse is providing teaching for a client who has received a liver transplant and has a prescription to transition from cyclosporine to tacrolimus. What should the nurse instruct the patient to do?

Stop taking the cyclosporine for 24 hours and then begin taking the tacrolimus

A nurse suspects that a client is having an allergic reaction to a medication. Which of the following factors should the nurse identify as increasing the likelihood of an allergic reaction to the medication?

The client has had previous exposure to the medication

A nurse is reviewing the medication history of a client who has asthma. What medication combination is incompatible?

Theophylline and zileuton

A nurse is creating a plan of care for an 18-month old toddler who has cerebral palsy. Which of the following interventions should the nurse include?

Use manual jaw control when feeding the toddler

A nurse is planning preoperative teaching for a school-aged child who is scheduled for cardiac surgery. What should the nurse do when teaching the child?

Use photographs to help explain the procedure

A nurse is assessing a client who has panic disorder and has been taking paroxetine. What assessment should the nurse identify as an adverse effect of this medication?

Weight gain

A nurse is assessing a 2-month old infant who has ventricular septal defect. What finding should the nurse report to the provider?

Weight gain of four pounds

A nurse is caring for a client with a hip fracture who has Buck's extension traction in place. Which of the following pieces of information should the nurse give the client about this type of traction?

You'll have considerably less pain with the traction in place The traction will help decrease muscle spasms The weights act as a pulling force to keep your leg and hip still