nclex pass point set 5 study
A client with diabetes and peripheral neuropathy is being discharged from the hospital. What instruction should the nurse provide to decrease the risk for skin breakdown? Select all that apply. It is acceptable to use a hot water bottle to keep feet warm. Always wear socks, and preferably, shoes to protect the feet. Check the feet daily to look for any injuries to the feet. Nail clippers can be used with toenails to prevent injury. Use lotion on feet to keep skin from becoming dry and cracked.
Correct response: Always wear socks, and preferably, shoes to protect the feet. Check the feet daily to look for any injuries to the feet. Use lotion on feet to keep skin from becoming dry and cracked. Explanation: The client with peripheral neuropathy has a risk for skin breakdown due to decreased sensation in lower legs and, particularly, the feet. The client should wear socks and shoes, check the feet daily, and apply lotion to moisten the dry skin, but lotion should not be applied between the toes because lotion can cause skin maceration. The client should use a nail file instead of clippers to prevent injury and should not use a hot water bottle, as this can cause burns due to the client's decreased sensation.
The parents of a neonate with hypospadias and chordee wish to have him circumcised. Which explanation should the nurse incorporate into the discussion with the parents concerning the recommendation to delay circumcision? The associated chordee is difficult to remove during circumcision. The foreskin is used to repair the deformity surgically. The meatus can become stenosed, leading to urinary obstruction. The infant is too small to have a circumcision.
The foreskin is used to repair the deformity surgically. Explanation: The condition in which the urethral opening is on the ventral side of the penis or below the glans penis is referred to as hypospadias. Chordee refers to a ventral curvature of the penis that results from a fibrous band of tissue that has replaced normal tissue. Circumcision is delayed because the foreskin, which is removed with a circumcision, often is used to reconstruct the urethra. The chordee is corrected when the hypospadias is repaired. Circumcision is performed at the same time. Urethral meatal stenosis, which can occur in circumcised infants, results from meatal ulceration, possibly leading to urinary obstruction. It is not associated with hypospadias or circumcision. The infant is not too small to have a circumcision, which is commonly performed on the first or the second day of life.
A client had abdominal surgery 2 days ago and has copious drainage. The nurse uses Montgomery straps when changing the dressing. Which is the expected outcome of using these straps? Maintain pressure on the suture line. Prevent dehiscence. Avoid skin breakdown. Keep the client from touching the incision.
Avoid skin breakdown. Explanation: While the client has copious drainage and requires frequent dressing changes, the nurse uses Montgomery straps to avoid removing the tape that is holding the dressing in place and thus preventing skin breakdown. The straps are not used to provide pressure on the incision and will not help prevent dehiscence. The straps are secured on the abdomen and would not prevent the client from touching the incision.
A nurse assesses the neuromuscular function of a neonate. Which finding should the nurse consider normal?
Flexor tone tends to develop first in the lower extremities, and proceed toward the head and neck. A 28-week neonate will lie with minimally flexed limbs, and have minimal resistance to passive movement of all extremities. By 32 weeks, the neonate will develop flexor tone at the hips and knees, and be able to resist manipulation of the lower extremities. This progression correlates with increasing myelination of the subcortical motor pathways originating in the brainstem. By 36 weeks, the neonate will develop flexion at the elbows, and by term, the neonate will be able to flex all extremities.
When a client cannot read or write but is of sound mind, the nurse should read the informed consent to the client in the presence of two witnesses and do what next? Have the client's next-of-kin sign the informed consent. Have the client put an "X" on the signature line. Have a court appoint a guardian for the client. Have a hospital quality management coordinator sign for the client.
Have the client put an "X" on the signature line. Explanation: The surgeon is responsible for explaining the surgical procedure to be performed and the risks of the procedure, as well as for obtaining the informed consent from the client. A nurse may be responsible for obtaining and witnessing a client's signature on the consent form. The nurse is the client's advocate, verifying that a client (or family member) understands the consent form and its implications, and that consent for the surgery is truly voluntary.
A client with Meniere's disease is having an attack of vertigo. Which nursing intervention is the priority? Instruct the client to remain in bed. Use pillows to support the client's head. Remind the client to ask for assistance when turning. Assist the client to the restroom every hour.
Instruct the client to remain in bed. Explanation: The priority intervention is to have the client remain in bed to prevent falls. The other options are correct; however, client safety is the priority.
Two weeks after being diagnosed with a streptococcal infection, a client develops fatigue, a low-grade fever, and shortness of breath. The nurse auscultates bilateral crackles and observes jugular vein distention. Urinalysis reveals red and white blood cells and protein. After the physician diagnoses poststreptococcal glomerulonephritis, the client is admitted to the medical-surgical unit. Which immediate action should the nurse take? Encourage activity as tolerated. Provide a high-protein, fluid-monitored diet. Monitor patient blood pressure. Place the client on a sheepskin, and monitor for increasing edema.
Monitor patient blood pressure. Explanation: Blood pressure control is a priority assessment in clients with poststreptococcal glomerulonephritis. The blood pressure can be increased for up to 6 weeks after treatment. The nurse must provide a low-protein diet during the acute phase. The nurse must also closely monitor the client's fluid intake and output. Clients should be placed on bed rest to control hypertension and workload on the kidney. Although providing comfort measures (such as placing the client on a sheepskin) are important, this action isn't a priority.
The nurse is planning care for a client who has an allergy to latex. What intervention would be the priority for the nurse to include in the plan of care? Avoid using oil-based lotions on the client's skin. Ensure client's roommate does not have an indwelling latex urinary catheter. Place latex-free, powder-free gloves at client's bedside. Place client in private room with clear signage about allergy.
Place latex-free, powder-free gloves at client's bedside. Explanation: Latex-free, powder-free gloves reduce the risk of respiratory exposure to latex. Having them conveniently located will enhance staff adherence, so this is the most important intervention. Using oil-based hand lotion should be avoided when wearing latex gloves because this increases risk of latex breakdown and can increase latex exposure for the person wearing the gloves. However, the client can have oil-based lotions applied to the skin as this is not contraindicated. Obviously, the nurse would wear latex-free gloves for application, or no gloves at all if no contact with body fluids is expected. Having a roommate with a latex catheter does not pose a risk of direct exposure for the client. Clients with latex allergies should have clear signage but do not require a private room.
A middle-aged female with a history of breast-conserving surgery, axillary node dissection, and radiation therapy reports that her arm is red, warm to touch, and slightly swollen. Which action should the nurse suggest? Apply warm compresses to the affected arm. Elevate the arm on two pillows. See the health care provider immediately. Apply a compression sleeve.
See the health care provider immediately. Explanation: Redness, warmth, and swelling are all signs of infection. Treatment with antibiotics is usually indicated. Infection usually increases fluid accumulation and could worsen the lymphedema. Warm compresses could also increase fluid accumulation. Elevating the arm will not treat the infection, nor does wearing a compression sleeve. It is critical that the client not delay treatment.
The nurse is reviewing the content of a prescription before giving it to a client. The nurse determines that the prescription is accurately written when which information is included on the prescription? Select all that apply. healthcare provider signature frequency pharmacy name dose telephone number of client
Correct response: healthcare provider signature frequency dose Explanation: Information needed on the prescription includes: the date, client name, medication (trade and generic name), dose, route, frequency, quantity, and signature of prescriber. The pharmacy name and telephone number of the client are not required.
A 5-year-old child who weighs 44 lb (20 kg) is given penicillin V suspension for a throat culture positive for streptococcus. The dose is 40 mg/kg/day, divided into two doses. The pharmacy supplies penicillin V in a concentration of 250 mg/5 mL. The nurse should administer how many milliliters for each dose? Record your answer using a whole number.
Correct response: 8 Explanation: Determine the dosage for 1 day:40 mg/kg/day x 20 kg = 800 mg/day or 400 mg/dose.Determine the volume for the dose:250 mg/5 mL = 400 mg/x.Cross multiply and solve for x:250x = 2000 mL.x = 8 mL.
A nurse applies standard precautions when caring for a client with human immunodeficiency virus (HIV). The nurse takes what action when applying standard precautions? wearing gloves when helping client dress providing a dedicated commode at bedside wearing gloves for providing mouth care gowning and gloving for intravenous insertion
wearing gloves for providing mouth care Explanation: The client's HIV status is irrelevant to the application of standard precautions, and the client should not be treated differently because of this diagnosis. A healthcare worker wears gloves when contact with any client's blood or body fluids is anticipated, such as when providing mouth care. Such barrier protection helps prevent viruses from entering the bloodstream. When assisting a client to get dressed, gloves are not required unless contact with blood is anticipated. Gowns are not required for intravenous insertion, and a dedicated commode is not part of standard precautions.
Which information should the nurse include in the discharge plan for a client with multiple sclerosis who has an impaired peripheral sensation? Select all that apply. Carefully test the temperature of bath water. Avoid kitchen activities because of the risk of injury. Avoid hot water bottles and heating pads. Inspect the skin daily for injury or pressure points. Wear warm clothing when outside in cold temperatures.
Correct response: Carefully test the temperature of bath water. Avoid hot water bottles and heating pads. Inspect the skin daily for injury or pressure points. Wear warm clothing when outside in cold temperatures. Explanation: A client with impaired peripheral sensation does not feel pain as readily as someone whose sensation is unimpaired; therefore, water temperatures should be tested carefully. The client should be advised to avoid using hot water bottles or heating pads and to protect against cold temperatures. Because the client cannot rely on minor pain as an indicator of damaged skin or sore spots, the client should carefully inspect the skin daily to visualize any injuries that he cannot feel. The client should not be instructed to avoid kitchen activities out of fear of injury; independence and self-care are also important. However, the client should meet with an occupational therapist to learn about assistive devices and techniques that can reduce injuries, such as burns and cuts that are common in kitchen activities.
A nurse notes the following laboratory values for a client receiving chemotherapy: white blood cell count 6000/µL, red blood cell count (RBC) 3.7 million cells/cm3, hematocrit 35%, platelet count 80,000 mm3. Which order would the nurse question? semiprivate room regular diet activity as tolerated rectal temperatures every 4 hours
rectal temperatures every 4 hours Explanation: The platelet count indicated that the client is a risk for bleeding. The low RBC can cause fatigue, so the activity order is appropriate. The hematocrit is reflective of the low RBC count. The white blood cell count is normal, so a semiprivate room or regular diet is acceptable.
What would the nurse expect to find during the physical examination of a preterm male neonate born at 28 weeks' gestation? abundance of scalp hair thin, wasted appearance descended testicles numerous scrotal rugae
thin, wasted appearance Explanation: The premature neonate characteristically exhibits a thin, wasted appearance.The premature neonate commonly exhibits a scarcity of scalp hair.In the premature male neonate, testicles are typically high in the inguinal canal and absence of rugae on the scrotum is typical.
A 36-month-old child weighing 20 kg (44 lb) is to receive ceftriaxone 2 g IV every 12 hours. The recommended dose of ceftriaxone is 50 to 75 mg/kg per day in divided doses. How should the nurse proceed? Administer the medication as prescribed. Administer half the prescribed dose. Call the laboratory to check the therapeutic serum level of ceftriaxone. Withhold administering the ceftriaxone, and notify the child's health care provider (HCP).
Withhold administering the ceftriaxone, and notify the child's health care provider (HCP). Explanation: The child's HCP should be notified because the maximum daily recommended dosage for ceftriaxone for this child's weight would be 1,500 g/day, and giving this dose would administer 4 g/day. The nurse cannot administer a different dose than that prescribed. There is no therapeutic serum level of ceftriaxone.
While making rounds, the nurse enters a client's room and finds the client on the floor between the bed and the bathroom. In which order of priority from first to last should the nurse take the following actions? All options must be used. Click an option, hold and drag it to the desired position, or click an option to highlight it and move it up or down in the order using the arrows to the left. 1Assess the client's current condition and vital signs. 2If no acute injury, get help, and carefully assist the client back to bed. 3Notify the client's health care provider (HCP) and family. 4Document as required by the facility.
Correct response: Assess the client's current condition and vital signs. If no acute injury, get help, and carefully assist the client back to bed. Notify the client's health care provider (HCP) and family. Document as required by the facility. Explanation: The nurse should first assess the client and then, if there is no acute injury, help the client get back into bed. The nurse must notify the HCP and the family of the client who fell and, finally, document the event on the client's health record.
After a tonsillectomy and adenoidectomy, which finding should alert the nurse to suspect early hemorrhage in a 5-year-old child? drooling of bright red secretions pulse rate of 95 bpm vomiting of 25 ml of dark brown emesis blood pressure of 95/56 mm Hg
drooling of bright red secretions Explanation: After a tonsillectomy and adenoidectomy, drooling bright red blood is considered an early sign of hemorrhage. Often, because of discomfort in the throat, children tend to avoid swallowing; instead, they drool. Frequent swallowing would also be an indication of hemorrhage because the child attempts to clear the airway of blood by swallowing. Secretions may be slightly blood-tinged because of a small amount of oozing after surgery. However, bright red secretions indicate bleeding. A pulse rate of 95 bpm is within the normal range for a 5-year-old child, as is a blood pressure of 95/56 mm Hg. A small amount of blood that is partially digested, and therefore dark brown, is often present in postoperative emesis.
