NCLEX Mastery

When determining the effectiveness of teaching a child's mother about sickle cell disease, which statement by the mother indicates the need for additional teaching?

"He is going to be playing on a soccer team when he is feeling better." Rationale- Physical and emotional stress can precipitate a sickle cell crisis. Physical exercise such as running involved in soccer would increase the child's risk for a crisis. Thus, the mother needs additional instruction about this area.

Which statements by a female client would indicate that she is at high risk for a recurrence of cystitis?

"I can usually go 8 to 10 hours without needing to empty my bladder." Rationale- Stasis of urine in the bladder is one of the chief causes of bladder infection, and a client who voids infrequently is at greater risk for reinfection.

Which statement indicates that the client with a peptic ulcer understands the dietary modifications to follow at home?

"I should avoid alcohol and caffeine." Rationale- Caffeinated beverages and alcohol should be avoided because they stimulate gastric acid production and irritate gastric mucosa.

Which statement by a client undergoing external radiation therapy indicates the need for further teaching?

"I'm worried I'll expose my family members to radiation." Rationale- The client undergoing external radiation therapy requires further teaching when he voices a concern that he might expose his family to radiation. Internal radiation, not external radiation, poses a risk to the client's family.

A client is about to undergo bone marrow aspiration of the sternum. What should the nurse tell the client?

"You will feel a pulling type of discomfort for a few seconds." Rationale- As the bone marrow is being aspirated, the client will feel a suction or pulling type of sensation or discomfort that lasts a few seconds. A systemic premedication may be given to decrease this discomfort. A small area over the sternum is cleaned with an antiseptic. It is unnecessary to paint the entire anterior chest. The local anesthetic is injected through the subcutaneous tissue to numb the tissue for the larger-bore needle that is used for aspiration and biopsy. After the needle is removed, pressure is held over the aspiration site for 5 to 10 minutes to achieve hemostasis. A small dressing is applied; a large pressure dressing, such as an Ace bandage, would restrict the expansion of the lungs and is not used.

A client has been diagnosed with cirrhosis. When obtaining a health history, the nurse should specifically determine if the client takes?

Acetaminophen Rationale- The client with cirrhosis should be cautioned against taking any over-the-counter medications that may be hepatotoxic, because the liver will not be able to metabolize these drugs. Acetaminophen is an example of such a drug.

The nurse is preparing to defibrillate a client on a cardiac monitor who is in ventricular fibrillation (see photo). What should the nurse do?

After pressing the charge button and "calling all clear," push the shock button

During a panic attack, a client runs to the nurse and reports experiencing difficulty breathing, chest pain, and palpitations. The client is pale, with his mouth wide open and his eyebrows raised. What should the nurse do first?

Assist the client to breathe deeply into a paper bag. Rationale- Physiologic needs, particularly breathing, are the first priorities during a panic attack. Having the client breathe deeply into a paper bag corrects hyperventilation; restoring a normal breathing pattern should relieve the client's other symptoms.

Which does a nurse thoroughly evaluate before a hematopoietic stem cell transplant (HSCT) procedure?

Blood studies Rationale- Before the HSCT procedure, the nurse thoroughly evaluates the client's physical condition; organ function; nutritional status; complete blood studies, including assessment for past exposure to antigens such as HIV, hepatitis, or cytomegalovirus; and psychosocial status.

A client with renal insufficiency is admitted to the hospital with pneumonia. He's being treated with gentamicin. Which laboratory value should be closely monitored?

Blood urea nitrogen (BUN) Rationale- BUN and creatinine levels should be closely monitored to detect elevations caused by nephrotoxicity.

A patient complains of tingling in the fingers as well as feeling depressed. The nurse assesses positive Trousseau's and Chvostek's signs. Which decreased laboratory results does the nurse observe when the patient's laboratory work has returned?

Calcium Rationale- Calcium deficit is associated with the following symptoms: numbness and tingling of the fingers, toes, and circumoral region; positive Trousseau's sign and Chvostek's sign; seizures, carpopedal spasms, hyperactive deep tendon reflexes, irritability, bronchospasm, anxiety, impaired clotting time, decreased prothrombin, diarrhea, and hypotension. Electrocardiogram findings associated with hypocalcemia include prolonged QT interval and lengthened ST.

A client who received general anesthesia returns from surgery. Postoperatively, which nursing diagnosis takes highest priority for this client?

Ineffective airway clearance related to anesthesia Rationale- Ineffective airway clearance related to anaesthesia takes priority for this client because general anaesthesia may impair a client's ability to clear secretions from his airway.

A client is scheduled for a creatinine clearance test. What should the nurse do?

Instruct the client about the need to collect urine for 24 hours. Rationale- A creatinine clearance test is a 24-hour urine test that measures the degree of protein breakdown in the body.

The client tells the nurse that he is allergic to shellfish. The nurse should ask the client if he is also allergic to:

Iodine skin preparations. Rationale- Clients who are allergic to shellfish are allergic to iodine skin preparations (Iodophor and Betadine) or any other products containing iodine, such as dyes.

A nurse is working with a student nurse who is caring for a client with an acute bleeding cerebral aneurysm. Which action by the student nurse requires further intervention?

Keeping the client in one position to decrease bleeding Rationale- The student nurse shouldn't keep the client in one position. She should carefully reposition the client often (at least every hour). The client needs to be positioned so that a patent airway can be maintained. Fluid administration must be closely monitored to prevent complications such as increased intracranial pressure. The client must be maintained in a quiet environment to decrease the risk of rebleeding.

A client has just undergone bronchoscopy. Which nursing assessment is most important at this time?

Level of consciousness (LOC) Rationale- Following bronchoscopy, LOC is the most important assessment because changes in the client's LOC may alert the nurse to serious neurologic problems.

The nurse observes that the right eye of an unconscious client does not close completely. Which nursing intervention is most appropriate?

Lightly tape the eyelid shut. Rationale- When the blink reflex is absent or the eyes do not close completely, the cornea may become dry and irritated. Corneal abrasion can occur. Taping the eye closed will prevent injury.

Which assessment is most supportive of the nursing diagnosis, impaired skin integrity related to purulent inflammation of dermal layers as evidenced by purulent drainage and erythema?

Oral temperature of 101° F (38.3° C) Rationale- The nursing diagnosis indicates that the client's wound, which has purulent drainage, is infected. In response to the infection, the client's temperature would be elevated.

A client has been diagnosed with hypothyroidism and started on synthetic levothyroxine for thyroid replacement therapy. Which of the following is the most important effect to report to the physician?

Palpitations and chest pain on exertion Rationale- Assessment of the effects of severe hypothyroidism on the circulatory system is important. Serum cholesterol levels are also elevated in clients with hypothyroidism. As the metabolic rate increases with the thyroid replacement therapy, there is more demand on the heart, and angina and palpitations may occur.

Older adults, who are more subject to falls, may fracture one or more ribs and be more susceptible to which condition after a rib fracture?

Pneumonia Rationale- Older adults, who are more subject to falls, may fracture one or more ribs and be more susceptible to pneumonia after a rib fracture.

The nurse is completing a health history and physical assessment on a client admitted with esophageal varices and cirrhosis. What signs and symptoms alert the nurse to a potential internal hemorrhage?

Pulse 108 bpm, temperature 97.7°F (36.5°C), distended abdomen, and nausea

The nurse is participating in the care of a client who had a peripherally inserted central catheter (PICC) placed in the right arm. After catheter placement, the nurse should complete which action?

Send the client for a chest x-ray. Rationale- A chest x-ray is needed to confirm the placement of catheter tip before initiating ordered infusions.

A nurse is caring for a client who has experienced an acute exacerbation of Crohn's disease. Which assessment best indicates that the disease is under control?

The client exhibits signs of adequate GI perfusion with normal bowel sounds.

A child who was hospitalized for sickle cell crisis is being discharged. Which parent outcome demonstrates effective teaching regarding prevention of future crises?

The parent verbalizes the need to stay away from persons with known infections. Rationale- Preventing infections through proper hand washing and staying away from persons with known infections is an important measure in preventing sickle cell crises

When developing a plan of care for a patient with impaired physical mobility who must remain on complete bedrest, which of the following would the nurse most likely include to prevent external rotation of the hip?

Trochanter roll Rationale- A trochanter roll extending from the crest of the ilium to the mid-thigh prevents external rotation of the hip. Range-of-motion exercises are used to maintain muscle strength and joint mobility. Protective boots are used to prevent footdrop. Using a pillow between the legs would help support the body in the correct alignment.

Which abnormal blood value would not be improved by dialysis treatment?

decreased hemoglobin concentration Rationale- Dialysis has no effect on hemoglobin levels because some red blood cells are injured during the procedure; dialysis aggravates a low hemoglobin concentration and may contribute to anemia. Dialysis will clear metabolic waste products from the body and correct electrolyte imbalances.

A client is using an herbal therapy while receiving chemotherapy. The nurse should:

determine what substances the client is using, and make sure that the health care provider (HCP) is aware of all therapies the client is using.

An antenatal primigravid client has just been informed that she is carrying twins. The plan of care includes educating the client concerning factors that put her at risk for problems during the pregnancy. The nurse realizes the client needs further instruction when she indicates carrying twins puts her at risk for which complication?

group B streptococcus Rationale- Group B Streptococcus is a risk factor for all pregnant women and is not limited to those carrying twins.

A client is admitted with a myocardial infarction and atrial fibrillation. While auscultating the heart, the nurse notes an irregular heart rate and hears an extra heart sound at the apex after the S2 that remains constant throughout the respiratory cycle. The nurse should document these findings as:

heart rate irregular with S3 Rationale- An S3 heart sound occurs early in diastole as the mitral and tricuspid valves open and blood rushes into the ventricles.

College freshmen are participating in a study abroad program. When teaching them about hepatitis B, the nurse should instruct the students on the need for:

safe sexual practices.

The nurse is caring for a newborn of a primiparous woman with insulin-dependent diabetes. When the mother visits the neonate at 1 hour after birth, the nurse explains to the mother that the neonate is being closely monitored for symptoms of hypoglycemia because of which reason?

interrupted supply of maternal glucose and continued high neonatal insulin production Rationale- Glucose crosses the placenta, but insulin does not. Hence, a high maternal blood glucose level causes a high fetal blood glucose level. This causes the fetal pancreas to secrete more insulin. At birth, the neonate loses the maternal glucose source but continues to produce much insulin, which commonly causes a drop in blood glucose levels (hypoglycemia), usually at 30 to 60 minutes postpartum. Most neonates do not develop hypoglycemia if their mothers are not insulin dependent unless they are preterm. Therefore, hypoglycemia is not a normal response as the neonate transitions to extrauterine life.

Following a gastrectomy, the nurse should postion the client in which position?

low Fowler's Rationale- A client who has had abdominal surgery is best placed in a low Fowler's position postoperatively. This positioning relaxes abdominal muscles and provides for maximum respiratory and cardiovascular function.

The nurse is evaluating the client's risk for having a pressure sore. Which is the best indicator of risk for the client's developing a pressure sore?

mobility status

A priority for nursing care for an older adult who has pruritus, is continuously scratching the affected areas, and demonstrates agitation and anxiety regarding the itching is:

preventing infection Rationale- The client is at risk for infection because of the pruritus, and the nurse should institute measures to help the client control the scratching such as cutting fingernails, using protective gloves or mitts, and, if necessary, using antianxiety medications.

The nurse is caring for an adult with a grade III compound fracture of the right femur; the client has been placed in skeletal traction. The intended outcome of the traction is to:

reduce and immobilize the fracture Rationale- Skeletal traction is often used to regain normal length of the bone, but in this situation the main purpose of the traction is to reduce and immobilize the fracture. This type of traction allows the client to move in bed without dislocating the fracture. This client has an open fracture, but skeletal traction will not prevent further skin breakdown.

Which activities should the nurse teach the client to do to strengthen the hand muscles in preparation for using crutches?

squeezing a rubber ball Rationale- A client being prepared for crutch walking should be taught to support weight with the hands when crutch walking. Supporting weight in the axillae is contraindicated owing to the risk of possible nerve damage and circulatory obstruction. The client should be taught to squeeze a ball vigorously to help strengthen the hands in preparation for weight bearing with the hands.

The nurse is assessing a hospitalized older client for the presence of pressure ulcers. The nurse notes that the client has a 1 inch × 1 inch (3 cm x 3 cm) area on the sacrum in which there is skin breakdown as far as the dermis. What should the nurse note on the medical record?

stage II pressure ulcer Rationale- Stage II ulcers have breakdown of the dermis. The nurse should immediately initiate plans to relieve the pressure, ensure good nutrition, and protect the area from abrasion.

The nurse interviews a 22-year-old female client who is scheduled for abdominal surgery the following week. The client is obese and uses estrogen-based oral contraceptives. This client is at high risk for development of:

thrombophlebitis Rationale- The data suggest an increased risk of thrombophlebitis. The risk factors in this situation include abdominal surgery, obesity, and use of estrogen-based oral contraceptives.

To prevent footdrop, the client is positioned

to keep the feet at right angles to the leg Rationale- When the patient is supine in bed, padded splints or protective boots are used. Semi-Fowler's positioning is used to decrease the pressure of abdominal contents on the diaphragm. In order to prevent footdrop, the feet must be supported.

A client, age 87, with major depression undergoes a sixth electroconvulsive therapy (ECT) treatment. When assessing the client immediately after ECT, the nurse expects to find:

transitory short- and long-term memory loss and confusion Rationale- ECT commonly causes transitory short- and long-term memory loss and confusion, especially in elderly clients.

The nurse is evaluating the effectiveness of fluid resuscitation during the emergency period of burn management. Which finding indicates that adequate fluid replacement has been achieved in the client?

urine output greater than 35 mL/hour Rationale- urine output of 30 to 50 mL/h indicates adequate fluid replacement in the client with burns.

Which nursing assessment finding in an elderly client with sepsis requires immediate intervention?

urine output of 90 mL over the past 6 hours Rationale- Indicators of deterioration due to sepsis include decreased urine output, tachypnea, tachycardia, and hypotension.

When caring for a client with a 3-cm stage I pressure ulcer on the coccyx, which action may the nurse institute independently?

Using normal saline solution to clean the ulcer and applying a protective dressing as necessary Rationale- Using normal saline solution to clean the ulcer and applying a protective dressing as necessary

Twelve hours after cardiac surgery, the nurse is assessing a 3-year-old who weighs 15 kg. The nurse should notify the surgeon about which clinical finding?

alterations in levels of consciousness Rationale- Clinical signs of low cardiac output and poor tissue perfusion include pale, cool extremities, cyanosis or mottled skin, delayed capillary refill, weak, thready pulses, oliguria, and alterations in level of consciousness.

A nurse is assessing a 15-year-old girl who has lost 30 lb (13.6 kg) over 3 months. What other finding is the nurse likely to assess

amenorrhea

A client with an indwelling urinary catheter is suspected of having a urinary tract infection. The nurse should collect a urine specimen for culture and sensitivity by:

wiping the self-sealing aspiration port with antiseptic solution and aspirating urine with a sterile needle Rationale- Most catheters have a self-sealing port for obtaining a urine specimen. Antiseptic solution is used to reduce the risk of introducing microorganisms into the catheter. Tubing shouldn't be disconnected from the urinary catheter. Any break in the closed urine drainage system may allow the entry of microorganisms. Urine in urine drainage bags may not be fresh and may contain bacteria, giving false test results. When there's no urine in the tubing, the catheter may be clamped for no more than 30 minutes to allow urine to collect.

After suction and evacuation of a complete hydatidiform mole, the 28-year-old multigravid client asks the nurse when she can become pregnant again. The nurse would advise the client not to become pregnant again for at least how long?

12 months Rationale- A client who has experienced a molar pregnancy is at risk for development of choriocarcinoma and requires close monitoring of human chorionic gonadotropin (hCG) levels. Pregnancy would interfere with monitoring these levels. High hCG titers are common for up to 7 weeks after the evacuation of the mole, but then these levels gradually begin to decline. Clients should have a pelvic examination and a blood test for hCG titers every month for 6 months and then every 2 months for 1 year. Gradually declining hCG levels suggest no complications. Increasing levels are indicative of a malignancy and should be treated with methotrexate. If after 1 year the hCG levels are negative, the client is theoretically free of the risk of a malignancy developing and could plan another pregnancy.

After lobectomy for lung cancer, a client receives a chest tube connected to a disposable chest drainage system. The nurse observes that the drainage system is functioning correctly when she notes tidal movements or fluctuations in which compartment of the system as the client breathes?

Water-seal chamber Rationale- Fluctuations in the water-seal compartment are called tidal movements and indicate normal function of the system as the pressure in the tubing changes with the client's respirations.

A preschooler goes into cardiac arrest. When performing cardiopulmonary resuscitation (CPR) on a child, how should the nurse deliver chest compressions?

With the heel of one hand Rationale- When performing CPR on a child between ages 1 and 8, the nurse should use the heel of one hand to compress the chest one-third to one-half the depth of the chest.

An adult male client has been unable to void for the past 12 hours. The best method for the nurse to use when assessing for bladder distention in a male client is to check for:

a rounded swelling above the pubis Rationale- The best way to assess for a distended bladder in either a male or female client is to check for a rounded swelling above the pubis. This swelling represents the distended bladder rising above the pubis into the abdominal cavity.

A client has monthly laboratory tests done. The nurse notes a decrease in the albumin level. What condition in the client's history could alter the albumin level?

Liver disease Rationale- Albumin levels are used as measures of protein in adults. Albumin systhesis depends on normal liver function. Decreased albumin levels may be caused by overhydration, liver or renal disease, or excessive protein loss.

The nurse discovers that a young client has been given a dose of morphine four times the ordered dose. Which of the following is the immediate priority action for the nurse to take?

Obtain an order for naloxone and administer it promptly Rationale- Naloxone is an opioid antagonist that is given as an antidote for morphine. An antidote is an agent that neutralizes a poison or counteracts its effects. This should be the immediate priority for the nurse.

A client treated with terbutaline (Brethine) for premature labor is ready for discharge. Which instruction should the nurse include in the discharge teaching plan?

Report a heart rate greater than 120 beats/minute to the physician. Rationale- Because terbutaline can cause tachycardia, the woman should be taught to monitor her radial pulse and call the physician for a heart rate greater than 120 beats/minute. Terbutaline must be taken every 4 to 6 hours around-the-clock to maintain an effective serum level that will suppress labor. A fetus normally moves 10 to 12 times per hour. The client doesn't need to contact the physician if such movement occurs. The client experiencing premature labor must maintain bed rest at home

A client is scheduled for amniocentesis. When preparing her for the procedure, the nurse should:

ask the client to void Rationale- To prepare a client for amniocentesis, the nurse should ask her to empty her bladder to reduce the risk of bladder perforation. Before transabdominal ultrasound, the nurse may instruct the client to drink 1 L of fluid to fill the bladder (unless ultrasound is done before amniocentesis to locate the placenta). I.V. anesthesia isn't given for amniocentesis. The client should be supine during the procedure; afterward, she should be placed on her left side to avoid supine hypotension, promote venous return, and ensure adequate cardiac output.

A barium enema is not prescribed as a diagnostic test for a client with diverticulitis, because a barium enema:

can perforate an intestinal abscess. Rationale- Barium enemas and colonoscopies are contraindicated in clients with acute diverticulitis because they can lead to perforation of the colon and peritonitis. A barium enema may be prescribed after the client has been treated with antibiotic therapy and the inflammation has subsided.

A patient who had a myocardial infarction is experiencing severe chest pain and alerts the nurse. The nurse begins the assessment but suddenly the patient becomes unresponsive, no pulse, with the monitor showing a rapid, disorganized ventricular rhythm. What does the nurse interpret this rhythm to be?

Ventricular fibrillation Rationale- The most common dysrhythmia in patients with cardiac arrest is ventricular fibrillation, which is a rapid, disorganized ventricular rhythm that causes ineffective quivering of the ventricles. No atrial activity is seen on the ECG. The most common cause of ventricular fibrillation is coronary artery disease and resulting acute myocardial infarction. Ventricular fibrillation is always characterized by the absence of an audible heartbeat, a palpable pulse, and respirations.

The nurse is assessing a child with ketoacidosis. The nurse should particularly observe if the client has:

deep, rapid respirations Rationale- The accumulation of ketones, organic acids that readily release free hydrogen ions causing blood pH to fall, leads to ketoacidosis. To compensate, the respiratory buffering system is activated, which results in the child taking deep, rapid breaths to rid the body of excess carbon dioxide. This characteristic breathing pattern is known as Kussmaul's respirations