NCLEX-Foundations of Nursing (week 1)

The nurse is reinforcing discharge instructions to the parents of a 2-year-old child who sustained accidental burns from a hot cup of coffee. The nurse determines that the parents have correctly understood the teaching when they make which statement?

"We will be sure not to leave hot liquids unattended."

A client with acute muscle spasms has been taking baclofen. The client calls the clinic nurse because of continuous feelings of weakness and fatigue and asks the nurse about discontinuing the medication. The nurse would make which appropriate response to the client?

"Weakness and fatigue commonly occur and will diminish with continued medication use."

The nurse is reading a primary health care provider's prescription and notes that a client is to receive a medication at 1:00 p.m. Using the military time clock, the nurse administers the medication at which time? Refer to figure.

1

A client diagnosed with schizophrenia who is being prepared for discharge has been prescribed oral risperidone 6 mg daily. The medication label reads 2 mg/tablet. To ensure the correct dose, the nurse instructs the client to take how many tablets once daily? Fill in the blank.

3 tablets

The nurse is caring for a group of clients. Which client is most likely to have a serum phosphorus level of 2.0 mg/dL (0.64 mmol/L)?

A client with a history of alcoholism

The nurse, employed in a long-term care facility, is planning the clinical assignments for the day. The nurse knows not to assign which staff member to the client with a diagnosis of herpes zoster?

An assistive personnel who has never had chickenpox

A preliminary diagnosis is made for a child with acute lymphoblastic leukemia (ALL). In reviewing the complete blood cell count (CBC) of the child, the nurse would expect to find which?

An erythrocyte (red blood cell) count of 2 cells in 1 mL of peripheral blood

The nurse is assigned to care for a group of clients on the clinical nursing unit. Which client is least likely to develop third spacing of fluids?

Hypertension

The nurse is assisting in caring for a client immediately following an abdominal surgical procedure who lost a significant amount of blood during surgery. Which findings would indicate a sign of a potential complication? Select all that apply.

Increasing restlessness--A pulse rate of 108 beats per minute--A blood pressure (BP) of 88/58 mm Hg--Increasing pain unrelieved by analgesics

A client wishes to donate blood for a family member and asks the nurse about the procedure for identifying compatibility. The nurse tells the client that which test will be done to test compatibility?

Indirect Coombs

Carbamazepine is prescribed for a client with a diagnosis of psychomotor seizures. The nurse reviews the client's health history knowing that this medication is contraindicated if which disorder is present?

Liver disease

The nurse is preparing for the admission of a client with a prescription for seizure precautions. Which supplies will the nurse make available to this client? Select all that apply.

Oxygen--Suction machine--Prescribed diazepam--Padding for the side rails

The nurse is caring for a client following a total abdominal hysterectomy. The nurse anticipates that which postoperative outcome will be the priority in the first 24 hours following surgery?

Pain

A 4-year-old child is hospitalized with a suspected diagnosis of Wilms' tumor. The nurse reviews the plan of care and would question which intervention that is written in the plan?

Palpate the abdomen for a mass.

A client is at risk for developing hypocalcemia. The nurse determines which signs are associated with this electrolyte disturbance? Select all that apply.

Positive Trousseau's sign--Fine tremors noted in hands

A client is scheduled for a digital subtraction angiography (DSA). The nurse tells the client that the test is directed toward which outcome?

Providing information about the blood vessels

The nurse reinforces dietary instructions to a client at risk for hypokalemia about the foods high in potassium that should be included in the daily diet. The nurse determines the client has understood if the client plans to include which foods in the diet? Select all that apply.

Raisins--Kiwifruit--Bananas

The nurse is collecting data on a 12-month-old child with iron deficiency anemia. Which finding would the nurse expect to note in this child?

Tachycardia

A client who has undergone a barium enema is being readied for discharge from the ambulatory care unit. Which instruction would the nurse include in instructions to the client?

The barium will cause the stools to be clay colored, but then the stool becomes normal colored.

The nurse is told that an assigned client is suspected of having methicillin-resistant Staphylococcus aureus (MRSA). Which precautions would the nurse institute during the care of the client?

Wear a gown and gloves.