NCLEX Practice

When a client files a lawsuit against a nurse for malpractice, the client must prove that there is a link between the harm suffered and actions performed by the nurse that were negligent. This is known as: a. evidence b. tort discovery c. proximate cause d. common cause

proximate cause evidence= data presented in proof of the facts tort= wrongful act common cause= to unite one's interest with another's

A client is admitted to the acute medical unit for severe amphetamine intoxication. Which medications should a nurse anticipate will be prescribed to counteract the effects of stimulant intoxication? Select all that apply. a. diazepam b. propranolol c. benzotropine d. bupropion e. amitriptyline

a and b stimulants increase both dopamine and adrenaline, causing seizures to occur--> Diazepam (valium) can reduce the chance of seizures- suppresses seizures through enhancement of gamma-aminobutyric acid, the major inhibitory neurotransmitter in the CNS amphetamines increase adrenaline which stimulates the heart --> propranolol (inderal) is a beta blocker that will help decrease adrenergic stimulation benzotropine (cogentin) i a cholinergic blocker and is not indicated bupropion (wellbutrin) and amitriptyline are contraindicated because it increases dopamine and adrenaline- would exacerbate a stimulant intoxication

An intravenous piggyback (IVPB) of cefazolin (Kefzol) 500 mg in 50 mL of 5% dextrose in water is to be administered over a 20-minute period. The tubing has a drop factor of 15 drops/mL. At what rate per minute should the nurse regulate the infusion to run? Record the answer using a whole number. ______ gtts/min

38 gtts/min

Four days after abdominal surgery a client has not passed flatus and there are no bowel sounds. Paralytic ileus is suspected. What does the nurse conclude is the most likely cause of the ileus? a. decreased blood supply b. impaired neural functioning c. perforation of the bowel wall d. obstruction of the bowel lumen

b. impaired neural functioning paralytic ileus occurs when neurologic impulses are diminished as a result of anesthesia, infection, or surgery. interference in blood supply will result in necrosis of the bowel perforation of the bowel will result in pain and peritonitis obstruction of the bowel will initially cause increased peristalsis and bowel sounds

To ensure the safety of a client who is receiving a continuous intravenous normal saline infusion, the nurse should change the administration set every: a. 4-8 hrs b. 12-24 hrs c. 24-48 hrs d. 72-96 hrs

72-96 hrs after initiation of use in pts not receiving blood, blood product, or fat emulsions. evidence-based and cost effective practice

The pt usually weighs 150lbs, but when she was weighed today she weighed 143lbs. The nurse explains that the pt's weight loss represents approximately how many liters of fluid loss?

7lbs lost 7/2.2= 3.2 kg each kilogram of body weight lost or gained is equivalent to approximately 1 liter of fluid Answer- 3 liters

How can a nurse best evaluate the effectiveness of communication with a client? a. client feedback b. medical assessments c. health care team conferences d. client's physiologic responses

Client feedback- permits client to ask questions and epress feelings

Based on the client's reported pain level, the nurse administers 8 mg of the prescribed morphine. The medication is available in a 10 mg syringe. Wasting of the remaining 2 mg of morphine should be done by the nurse and a witness. It is most appropriate for the nurse to ask which member of the health care team to be the witness? a. nursing supervisor b. LPN c. client's health care provider d. designated nursing assistant

LPN wasting should be witnessed by 2 licensed personnel, can be done by RN or LPN. not efficient to use supervisor

After gastric surgery a client has a nasogastric tube in place. What should the nurse do when caring for this client? a. Monitor for signs of electrolyte imbalance. b. Change the tube at least once every 48 hours. c. Connect the nasogastric tube to high continuous suction. d. Assess placement by injecting 10 mL of water into the tube.

Monitor for signs of electrolyte imbalance. gastric secretions are electrolyte rich and are lost through the nasogastric tube and the imbalances can be life threatening.

A client has been placing used insulin needles in a container sealed with heavy-duty tape. The client asks where the container can be disposed. How should the nurse respond? a. take it to the local hazardous waste collection site b. place it in the regular household trash c. take it to the local health department for disposal d. mail it to the EPA

a. take it to the local hazardous waste collection site Each state has their own waste management guidelines for proper disposal of sharps containers as well as hazardous waste collection sites. The local health department does not collect sharps containers. Patients cannot place needles in a recycling bin, as sharps are considered medical waste. Sharps containers are not mailed directly to the EPA.

A nurse is reviewing the laboratory report of a client with kidney problems. When ammonia is excreted by healthy kidneys, what mechanism usually is maintained? a. osmotic pressure of the body b. acid-base balance of the body c. low bacterial levels in the urine d. normal red blood cell production

acid-base balance of the body excreted ammonia combines with hydrogen ions in the glomerular filtrate to form ammonium ions, which are excreted from the body. mechanism helps rid the body of excess hydrogen, maintaining the a-b balance

A nurse manager is evaluating the effectiveness of a disaster drill during which nurses were sent from their usual assignments to the emergency department. Which criterion should be used for the nurse manager to evaluate care during the disaster drill? a. number of fatalities b. cost of nurse overtime c. nurse-to-client ratio on units d. completion of critical pathways

c. nurse-to-client ratio on units During a disaster, nursing coverage on all units should remain appropriate for client safety. Disaster nursing is concerned with providing care for clients in imminent danger and requires mobilization of people and resources from other areas. Number of fatalities is not the basis for evaluating the effectiveness of care b/c during a disaster many clients may be dead on arrival. Cost is not the concern during a disaster. Completion of critical pathways is not the basis for evaluation of care during a disaster

what should a nurse recommend to best help a client during the period immediately after a spouse's death? a. crisis counseling b. family counseling c. marital counseling d. bereavement counseling

d. bereavement counseling- involves being a part of a group of people who also have sustained a loss. The members provide support to each other

The nurse is caring for a client with a temperature of 104.5 degrees Fahrenheit. The nurse applies a cooling blanket and administers an antipyretic medication. The nurse explains that the rationale for these interventions is to: a. promote equalization of osmotic pressures b. prevent hypoxia associated with diaphoresis c. promote integrity of intracerebral neurons d. reduce brain metabolism and limit hypoxia

reduce brain metabolism and limit hypoxia cooling blankets and antipyretic medications can induce hypothermia which then decreases brain metabolism. this makes the brain less vulnerable by decreasing the need for oxygen

A nurse is caring for an older adult who is taking acetaminophen (Tylenol) for the relief of chronic pain. Which substance is most important for the nurse to determine if the client is taking because it intensifies the most serious adverse effect of acetaminophen? a. alcohol b. caffeine c. saw palmetto d. St. John's wort

too much ingestion of alcohol can cause scarring and fibrosis of the liver. 85-95% of acetaminophen is metabolized by the liver. acetaminophen and alcohol are both hepatotoxic substances.

A pain scale of 1 to 10 is used by a nurse to assess a client's degree of pain. The client rates the pain as an 8 before receiving an analgesic and a 7 after being medicated. What conclusion should the nurse make regarding the client's response to pain medication? a. client has a low pain tolerance b. medication is not adequately effective c. medication has sufficiently decreased the pain level d. client needs more education about the use of the pain scale

b. medication is not adequately effective the expected effect should be more than a 1-point decrease in the patient's pain level. Pain is generally considered to be tolerable if it is a 4 or below on a scale of 1-10

During the initial physical assessment of a newly admitted client with a pressure ulcer, a nurse observes that the client's skin is dry and scaly. The nurse applies emollients and reinforces the dressing on the pressure ulcer. Legally, were the nurse's actions adequate? a. the nurse also should have instituted a plan to increase activity b. the nurse provided supportive nursing care for the well-being of the client c. debridement of the pressure ulcer should have been done before the dressing as applied d. treatment should not have been instituted until the healthcare provider's prescriptions were received

b. the nurse provided supportive nursing care for the well-being of the client According to the Nurse Practice Act, a nurse may independently treat human responses to actual or potential health problems. An activity level is prescribed by a healthcare provider: this is a dependent function of the nurse. There is not enough information to come to the conclusion that debridement should have been done before the dressing was applied. Application of an emollient and reinforcing a dressing are independent nursing functions

A nurse discusses the philosophy of Alcoholics Anonymous (AA) with the client who has a history of alcoholism. What need must self-help groups such as AA meet to be successful? a. trust b. growth c. belonging d. independence

belonging

A client is admitted with a diagnosis of premature labor. The nurse discovers that the client has been using heroin throughout her pregnancy. What is the most appropriate action for the nurse to take? a. notify the nurse manager of the unit b. inform no one because all client information is confidential c. inform the client's healthcare provider d. alert the hospital security department because heroin is an illegal substance

c. inform the client's healthcare provider The fetus of a heroin-addicted mother is at risk for serious complications such as hypoxia and meconium aspiration. It is important to notify the healthcare provider of the client's heroine use, because this information will influence the care of the client and newborn. This information is used only in relation to the client's care. with the client's consent, it may be shared with other social services or health agencies that become involved with the client's long-term care. The nurse manager of the unit may be notified as it relates to the care of the client and her newborn. Client information is confidential and only necessary staff should be privileged to such information. Hospital security would only be notified if actual illicit substances were discovered on hospital premises.

A nurse provides teaching for a client that is scheduled for a cholecystectomy. In the initial postoperative period, the nurse explains that the most important part of the treatment plan is: a. early ambulation b. coughing and deep breathing c. wearing anti-embolic elastic stockings d. maintenance of a nasogastric tube

coughing and deep breathing b/c pt with cholecystectomy will have difficulty taking deep breaths and coughing because of the location of the surgical incision. important to teach pre and post op. cholecystectomy= removal of gallbladder

A nurse assesses the lungs of a client and auscultates soft, crackling, bubbling breath sounds that are more obvious on inspiration. This assessment should be documented as: a. vesicular b. bronchial c. crackles d. rhonchi

crackles= abnormal vesicular= normal, heard over periphery lung(quiet on inspiration and silent on expiration) bronchial= normal, heard over trachea and large bronchi (full inspiration and expiration being louder) rhonchi= abnormal, heard over large airways of the lung (low pitch sound caused by secretions, usually clear with coughing)

A health care provider has prescribed isoniazid (Laniazid) for a client. Which instruction should the nurse give the client about this medication? a. Prolonged use can cause dark concentrated urine. b. The medication is best absorbed when taken on an empty stomach. c. Take the medication with aluminum hydroxide to minimize GI upset. d. Drinking alcohol daily can cause drug-induced hepatitis.

d. Drinking alcohol daily can cause drug-induced hepatitis. should take with meals to avoid GI upset; avoid taking aluminum antacids at the same time because it impairs absorption. Isoniazid- can treat and prevent TB

After abdominal surgery a client reports pain. What action should the nurse take first? a. reposition the client b. obtain the client's vital signs c. administer the prescribed analgesic d. determine the characteristics of the pain

d. determine the characteristics of the pain The exact nature of the pain must be determined to distinguish whether or not it is a result of the surgery. The other actions should be done later, but the first action is to determine the cause of the pain.

A client who was exposed to hepatitis A asks why an injection of gamma globulin is needed. Before responding, what should the nurse consider about how gamma globulin provides passive immunity? a. it increases production of short-lived antibodies b. it accelerates antigen-antibody union at the hepatic sites c. the lymphatic system is stimulated to produce antibodies d. the antigen is neutralized by the antibodies that it supplies

d. the antigen is neutralized by the antibodies that it supplies Gamma globulin, which is an immune globulin, contains most of the antibodies circulating in the blood. When injected into an individual, it prevents a specific antigen from entering a host cell. Gamma globulin does not stimulate antibody production. it does not affect antigen-antibody function

A client is admitted with metabolic acidosis. The nurse considers that two body systems interact with the bicarbonate buffer system to preserve healthy body fluid pH. What two body systems should the nurse assess for compensatory changes? a. skeletal and nervous b. circulatory and urinary c. respiratory and urinary d. muscular and endocrine

respiratory and urinary increased respirations blow off CO2, which decreases the hydrogen ion concentration and the pH increases (less acidity). decreased respirations result in CO2 buildup, which increases hydrogen ion concentration and the pH falls (more acidity). kidneys either conserve or excrete bicarbonate and hydrogen ions, which helps to adjust the body's pH. the buffering capacity of the renal system is greater than that of the pulmonary system, but the pulmonary system is quicker to respond