NCLEX Practice Exam 1
Pitocin (oxytocin)
Inducing labor in women with Rh problems, diabetes, preeclampsia, or when it is in the best interest of the mother or fetus
the nurse is found to be found guilty of charting blood glucose results without actually performing the procedure. after talking to the nurse, the charge nurse should:
file a formal reprimand
in planning care for teh patient with ulcerative colitis, the nurse identifies which nursing diagnoses as a priority?
fluid volume deficit
a new nursing graduate indicates in charting entries that he is a licensed practical nurse, although he has not yet received the results of the licensing exam. the graduates actions can result in what type of charge?
fraud
a client with pneumonia
frequent coughing
a client with Crohns disease
frequent stools could spread infection
myxedema
hyperthyroidism
Montgomery straps
hypoallergenic adhesive straps used to facilitate frequent dressing changes without having to remove and reapply tape
a client with a femoral popliteal bypass graft is assigned to a semiprivate room. the most suitable roommate for this client is the client with:
hypothyroidism
during the change of shift, the oncoming nurse notes a discrepancy in the number of Percocet (Oxycodone) listed and the number present in the narcotic drawer. the nurse's first action should be to:
notify the nursing supervisor
TPN
nutrient solution directly into a vein
an important intervention in monitoring the dietary compliance of a client bulimia is:
observing her for 1-2 hours after meals
responsibility of the doctor
obtaining the permit, explaining the procedure, checking the lab work
the client is scheduled to have an intravenous cholangiogram. before the procedure, the nurse should assess the patient for:
shellfish allergies
the nurse is preparing a client with an axillo-popliteal bypass graft for discharge. the client should be taught to avoid:
sitting in a straigh chair
diverticulitis
small bulging sacs form on the inner wall of the large intestine (colon)
the first exercise that should be performed by the client who had a mastectomy is:
squeezing a ball
a client 3 days post-splenectomy
stable enough for LVN
a client with cancer is admitted to the oncology unit. stat lab values reveal Hgb 12.6, WBC 6500, K+ 1.9, uric acid 7.0, Na+ 136, and platelets 178,000. the nurse evaluates that the client is experiencing which of the following?
Hypokalemia (decreased K+ in the blood K<3)
an elderly client is diagnosed with ovarian cancer. she has surgery followed by chemotherapy with a fluorouracil (Adrucil) IV. what should the nurse do if she notices crystals and cloudiness in the IV medication?
discard the solution and order a new bag
the client with diabetes is preparing for discharge. during discharge teaching, the nurse assesses the clients ability to care for himself. which statement made by the client would indicate a need for follow-up after discharge?
"I have trouble seeing"
the client is scheduled for a pericentesis. which instruction should be given to the client before the exam?
"you need to empty your bladder before the procedure" position during exam: sitting up or leaning over a table
pernicious anemia
- dt loss of intrinsic factor; decreased in RBC that occurs when the body cannot absorb vit 12in the GI tract. vit 12 is necessary for RBC developmen
the physician has ordered atropine sulfate 0.4mg IM before surgery. the medication is supplied in 0.8mg per milliliter. the nurse should administer how many milliliters of the medication?
0.5mL
the client is admitted to the unit after a cholescystectomy. Montgomery straps are utilized with this client. The nurse is aware that Montgomery straps are utilized on this client because
the client will require frequent dressing changes
a client who has chosen to breastfeed complains to the nurse that her nipples became very sore while she was breastfeeding her older child. which measure will help her to avoid soreness of the nipples?
breaking suction by placing a finger between the baby's mouth and the breast when she terminates the feeding
Theodur
bronchodilator
bilirubin
brownish/yellow substance found in bile--> excreted through the kidneys
a client arrives in the emergency room with a possible fractured femur. the nurse should anticipate an order for
bucks traction-realign leg and decrease spasms and pain
the nurse is planning room assignments for the day. which client should be assigned to a private room if only one is available?
the client with cushings disease
which client can best be assigned to the newly licensed practical nurse?
the client with diverticulitis
the nurse is making assignments for the day. which client should be assigned to the nursing assistant?
the elderly client with a thyroidectomy 4 days ago
the client is admitted to the postpartum unit with an order to continue the infusion of Pitocin. which finding indicated that the Pitocin is having the desired effect?
the fundus is firm and in the midline
the client is admitted with a BP of 210/120. her doctor orders furosemide (Lasix) 40mg IV stat. how should the nurse administer the prescribed furosemide to this client?
by giving it over 1-2 minutes. should be administered 1mL per minute to prevent hypotension
while caring for a client with hypertension, the nurse notes the following vital signs: BP of 140/20, pulse 120, respirations 36, temperature 100.8F. the nurse's initial action should be to:
call the doctor
a client is being monitored using a central venous pressure monitor. if the pressure is 2cm of water, the nurse should:
call the doctor immediately
powder and hot water rinse after bathing
dries out skin
the client is diagnosed with multiple myoloma. the doctor has ordered cyclophosphamide (Cytoxan). which instruction should be given to the client?
drink at least eight large glasses of water a day
Cyclophosphamide (Cytoxan) self care tip
drink two to three quarts of water
xerostomia
dry mouth
the physician has ordered sodium warfarin (Coumadin) for the client with thrombophlebitis. the order should be entered to administer the medication at:
1700-late afternoon allows for accurate bleeding times to be drawn in the morning
lochia-rubra
1st discharge after birth and lasts 3-5 days
subdural hematoma
An accumulation of blood beneath the dura mater but outside the brain.
ischemia
An inadequate blood supply to an organ or part of the body, esp. the heart muscles.
an infant weighs 7 pounds at birth. the expected weight by 1 year should be:
21 pounds
when the nurse is gathering information for the assessment, the patient states my stomach hurst about 2 hours after i eat, based upon this information, the nurse knows the patiend likely has a:
duodenal ulcer
Lactulose
a synthetic sugar used to treat constipation. It is broken down in the colon into products that pull water out from the body and into the colon. This water softens stools. Lactulose is also used to reduce the amount of ammonia in the blood of patients with liver disease. It works by drawing ammonia from the blood into the colon where it is removed from the body
cerebral palsy
a term used to describe a group of chronic conditions affecting body movement and muscle coordination. It is caused by damage to one or more specific areas of the brain, usually occurring during fetal development; before, during, or shortly after birth; or during infancy. Thus, these disorders are not caused by problems in the muscles or nerves.
intravenous cholangiogram
dye procedure so check for allergies to iodine or shellfish
the nurse on the 3-11 shift is assessing the chart of a client with an abdominal aneurysm scheduled for surgery in the morning and finds that the consent form has been signed, but the client is unclear about the surgery and possible complications. which is the most appropriate action?
call the surgeon and ask him or her to see the client to clarify the information
Quinidine
can cause widened Q-T intervals and heart block
a client with osteomylitis has an order for a trough level to be done because he is taking Gentamycin. when should the nurse call the lab to obtain the trough level?
30 minutes before the fourth dose
the physician prescribes regular insulin, 5 units subcutaneous. regular insulin begins to exert an effect:
30-60 minutes-regular onset of insulin
normal WBC
4,500-10,000
carbamazepine (Tegretol)
can suppress the bone marrow and decrease the WBC count -used to treat epilepsy
distant metastasis
cancer that has spread from one part of the body to other parts
Methergine
causes uterine contractions
a 25 year old male is brought to the emergency room with a piece of metal in his eye. which action by the nurse is correct?
cover both eyes with paper cups
a client is 2 days post operative colon resection. after a coughing episode, the client's wound eviscerates. which nursing action is most appropriate?
cover the wound with a sterile saline-soaked dressing
myelosuppression
Bone marrow depression resulting in decreased blood cells, white cells, and platelets
the nurse is planning care for the patient with celiac disease. in teaching about the diet, the nurse should instruct the patient to avoid which of the following for breakfast?
cream of wheat
the nurse is assisting a client with diverticulosis to select appropriate foods. which food should be avoided?
cucumber salad-avoid foods with seeds
Isoniazid (INH) has been prescribed for a family member exposed to tuberculosis. the nurse is aware the length of time that the medication will be taken is
6 months
oliguria
decreased output of urine (hypovresis) below 50ml/day=anuria
acidosis
decreased ventilation (hypoventilation) increases the concentration of carbon dioxide in the blood and decreases the blood's pH
cephalohematoma
A collection of blood under the scalp (specifically between the periosteum and the cranium, therefore a cephalohematoma does not cross suture lines) of a newborn usually located over the parietal bone. Risk factors include large neonatal birth weight, forceps delivery and mother's first pregnancy.
heart block
A failure of any part of the cardiac conduction system to conduct an action potential is referred to as _____.
Tis
A group of similar cells that perform the same function. cancer cells are only growing in the most superficial layer of tissue. also called Situ
osteoporosis
A medical condition in which the bones become brittle and fragile from loss of tissue
trendelenburg position
A position in which the patient's feet and legs are higher than the head. Also referred to as the shock position.
the client with a myocardial infarction comes to the nurses station stating that he is ready to go home because there is nothing wrong with him. which defense mechanism is the client using?
denial
which laboratory test would be the least effective in making the diagnosis of a myocardial infarction?
AST
leukocytosis
Abnormally elevated levels of white blood cells is called _____________
tachycardia
Abnormally rapid heartbeat greater than 100 beats/minute.
bradycardia
Abnormally slow heartbeat
aphasia
Absence or impairment of the ability to communicate through speech, writing, or signs because of brain dysfunction.
perineal
Area between anus and genitals
the client is scheduled for a Tensilon test to check for Myasthenia Gravis. Which medication should be kept available during the test?
Atropine sulfate
a 6-month-old client is admitted with possible intussuception. which question during the nursing history is least helpful in obtaining information regarding the diagnosis?
describe his usual diet
muscle tetany
Calcium deficit, due to hypocalcimia on the nerve (low calcium); a dangerous complication of hypoparathyroidism
diverticulosis
Condition of having diverticulum (small pouches turned inside out in the colon)
the client has an order for gentamycin to be administered. which lab results should be reported to the doctor before beginning the medication?
Creatinine
laryngeal cancer
Hoarseness, stridor, dysphagia, odynophagia, hemoptysis, weight loss, mass is neck, referred otalgi
the nurse is caring for a client with peripheral vascular disease. to correctly assess the oxygen saturation level, the monitor may be placed on the:
Earlobe
polyuria
Excessive urination
Rho(D) immune globulin
Given to a pregnant woman whose blood type is Rh-negative to keep the baby's blood from interacting with the mother's. Also treats a blood cell disorder called idiopathic thrombocytopenic purpura (ITP).
alendronate (Fosamax)
Lowers serum alkaline phosphatase, enzyme associated with bone turnover. Prevention and treatment of osteoporosis in postmenopausal women, treatment of corticosteroid-induced osteoporosis, treatment of increase bone mass in men with osteoporosis, treatment of Paget's disease. Take on empty stomach 2 hrs before breakfast and remain upright for at lease 30 min.Take with water only. GI side effects. Not for pts with osteomalacia. Caution in pts with renal impairment, Heart failure, hyperphosphatemia, liver disease, fever or infection, active upper GI problems and pregnancy
shortly after the client was admitted to the postpartum unit, the nurse notes heavy lochia-rubra with large clots. the nurse should anticipate an order for:
Methergine
caput succedaneum
Most common form of birth trauma of the scalp; Subcutaneous edema over presenting part of head during delivery; occurs over the OCCIPUT & Crosses suture lines; scalp feels soft; edges are poorly defined; edema goes away in a few days
the 84 year old male has returned from the recovery room following a total hip repair. he complains of pain and is medicated by morphine sulfate and promethazine. which medication should be kept available for the client being treated with opoid analgesics?
Nalozone (Narcan)
mediastinal tube
Placed to drain the pericardium after open-heart surgery are positioned directly under the sternum.
RhoGam
Preventing certain blood problems that may occur during pregnancy or blood transfusion. RhoGAM is an immunoglobulin (Ig), which contains antibodies to the Rho(D) antigen.
promethazine
Prevents and controls motion sickness, nausea, vomiting, and dizziness. Also used to relieve or prevent allergic reactions, helps people go to sleep, and control their pain or anxiety before or after surgery or other procedures.
the client is admitted to the emergency room with shortness of breath, anxiety, and tachycardia. his ECG reveals atrial fibrillation with a ventricular response rate of 130 beats per minute. the doctor orders quinidine sulfate. while he is receiving quinidine, the nurse should monitor his ECG for:
Prolonged QT interval
abdominal aortic aneurysm
Pulsating abdominal mass
the nurse is caring for the client following a cerebral vascular accident. which portion of the brain is responsible for taste, smell, and hearing?
Temporal
the nurse is caring for a client with laryngeal cancer. which finding ascertained in the health history would not be common for this diagnosis?
diarrhea
the nurse is making initial rounds on a client with a C5 fracture and crutchfield tongs. which equipment should be kept at the bedside?
a torque wrench
CVP reading
a direct measurement of the blood pressure in the right atrium and vena cava. It is acquired by threading a central venous catheter (subclavian double lumen central line) into any of several large veins. It is threaded so that the tip of the catheter rests in the lower third of the superior vena cava. The pressure monitoring assembly is attached to the distal port of a multilumen central vein catheter.
the nurse is taking the blood pressure of an obese client. if the blood pressure cuff is too small, the results will be:
a false elevation
the licensed practical nurse assigned to the post-partal unit is preparing to administer RhoGam to a postpartum client. Which woman is not a candidate for RhoGam?
a gravida IV para 2 that is Rh negative with an Rh-negative baby
when assessing a client for risk of hyperphosphatemia, which piece of information is most important for the nurse to obtain?
a history of radiation treatment in the neck region
the client is admitted with thrombophlebitis and an order for heparin. the medication should be administered using:
a tuberculin syringe
premature ventricular beats
a ventricular contraction preceding the normal impulse initiated by the SA node
furosemide (Lasix)
a loop diuretic (water pill) that prevents your body from absorbing too much salt, allowing the salt to instead be passed in your urine. treats fluid retention (edema) in people with congestive heart failure, liver disease, or a kidney disorder such as nephrotic syndrome. This medication is also used to treat high blood pressure (hypertension).
gastroenteritis
a medical condition from inflammation of the gastrointestinal tract that involves both the stomach and the small intestine. It causes some combination of diarrhea, vomiting, and abdominal pain and cramping. Dehydration may occur as a result
which action by the novice nurse indicates a need for further teaching?
a nurse fails to wear gloves to remove a dressing
the nurse is performing an assessment on a client with possible pernicious anemia. which data would support this diagnosis?
a red, beefy tongue
the nursing is participating in discharge teaching for the post-partal client. the nurse is aware that an effective means of managing discomfort associated with an episiotomy after discharge is:
Sitz baths-helps with swelling and improves healing
abdominal perineal resection
Surgery preformed for lower sigmoid or rectal malignancies is an?
cyclophosphamide (Cytoxan)
Treats cancer, including leukemia and lymphomas, and nephrotic syndrome.
captopril (Capoten)
Treats high blood pressure and heart failure. A lower blood pressure will reduce the risk of stroke and heart attack. Also used in the first few days after a heart attack to help reduce the risk of death and to treat kidney problems caused by diabetes.
prednisone
Treats inflammation (swelling), severe allergies, complications of chronic illnesses, and other medical problems. Also used to decrease some symptoms of cancer. This medicine is a steroid
effective lab tests that help make the diagnosis of myocardial infarction:
Troponin, CK-MB, Myoglobin->also evaluated in burns and trauma to muscles
dissulfiram (Antabuse)
Used as part of a treatment plan for problem drinking. Creates an unpleasant reaction when drinking alcohol, which reduces the desire to drink. This medicine is part of a recovery program that includes medical supervision and counseling.
Lidocaine is a medication frequently ordered for the client experiencing:
Ventricular tachycardia
the nurse is caring for a client with epilepsy who is being treated with carbamazepine (Tegretol). which laboratory value might indicate a serious side effect of this drug?
WBC 2,000 per cubic millimeter
post-lobectomy
a surgical procedure performed to remove one of the lobes of the lungs. The procedure may be performed when an abnormality has been detected in a specific part of the lung. When only the affected lobe of the lung is removed, the remaining healthy tissue is spared to maintain adequate lung function.
a client is admitted with a Ewings sarcoma. which symptoms would be expected due to this tumors location?
bone pain
which of the following is the best indicator of the diagnosis of HIV?
Western Blot
the nurse employed in the emergency room is responsible for triage of four clients injured in a motor vehicle accident. which of the following clients should receive priority in care?
a 15-year-old with sternal bruises-possible airway and 02 problems
assuming that all have achieved normal cognitive and emotional development, which of the following children is at greatest risk for accidental poisoning?
a 4 year old
due to a high census, it has been necessary for a number of clients to be transferred to other units within the hospital. which client should be transferred to the postpartum unit?
a 40-year-old female with a hysterectomy
sitz baths
a bath in which a person sits in water up to the hips. It is used to relieve discomfort and pain in the lower part of the body, for example, due to hemorrhoids (piles), anal fissures, rectal surgery, an episiotomy, uterine cramps, inflammatory bowel disease, and infections of the bladder, prostate or vagina. It works by keeping the affected area clean and increasing the flow of blood to it.
thrombophlebitis
a blood clot blocks one or more of your veins
myoloma
a cancer of plasma cells
abduction pillow
a certain kind of pillow used to immobilize a patient's legs just after hip surgery. It is made of a large, thick piece of foam shaped like an acute triangle.
diabetes mellitus
a chronic, lifelong condition that affects your body's ability to use the energy found in food
the licensed practical nurse is working with a registered nurse and a patient care assistant. which of the following clients should be cared for by the registered nurse?
a client 2 days post-thoracotomy
this nurse has just received a change-of-shift report. which client should the nurse assess first?
a client 2 hours post-lobectomy with 150 ccs drainage
the nurse is making assignments for the day. which client should be assigned to the nursing assistant?
a client with Alzheimers disease
a home health nurse is making preparations for morning visits. which one of the following clients should the nurse visit first?
a client with congestive heart failure complaining of nighttime dyspnea -airway #1!
which of the following roommates would be most suitable for the client with myasthenia gravis?
a client with hypothyroidism-because they are quiet
a home health nurse is planning for her daily visits. which client should the home health nurse visit first?
a client with laryngeal cancer with a laryngetomy- potential airway altercation
which of the following roommates would be best for the client newly admitted with gastric resection?
a client with phlebitis
a client 2 days post-appendectomy and a client 1 week post-thyroidectomy
both ready for discharge
which of the following best describes the language of a 24 month old?
able to verbalize needs
hyperphosphatemia
abnormally high serum phosphate levels-could have damaged parathyroid glands-located on thyroid glands and interfere with calcium and phosphorous regulation
the nurse is caring for a client with a diagnosis of hepatitis who is experiencing pruritis. which would be the most appropriate nursing intervention?
add baby oil to the clients bath water-helps with dry skin and itching
molding
adjusting of the shape and size of the fetal head to the birth canal during labor
the nurse identifies ventricular tachycardia on the heart monitor. which action should the nurse prepare to take?
administer an antiarrythmic medication such as Lidocaine
the nurse is teaching a group of new graduates about the safety needs of the client receiving chemotherapy. before administering chemotherapy, the nurse should:
administer an antiemetic
the client has an order for FeSo4 liquid. which method of administration would be best?
administer the medication with orange juice (vitamin C)
intrathecally
administered via spinal cord for: -metasases -chronic pain -cerebrospinal infections
corticosteroid
adrenal gland secretes-stress response and immune response and regulation of inflammation
pyelogram
an X ray of the kidneys and ureters
Dilantin (phenytoin)
an anti-epileptic drug, also called an anticonvulsant. It works by slowing down impulses in the brain that cause seizures
Foscarnet
an antiviral medicine that prevents certain virus cells from multiplying in your body, used to treat cytomegalovirus (CMV) retinitis in people with AIDS, also used to treat herpes simplex virus (HSV) in people with a weak immune system. usually given for HSV after other antiviral medications have been tried without successful treatment.
a client with an abdominal aortic aneurysm is admitted in prepareation for surgery. which of the following should be reported to the doctor?
an elevated white blood cell count
thoracotomy
an incision into the pleural space of the chest
episiotomy
an incision made in the perineum — the tissue between the vaginal opening and the anus — during childbirth
ulcerative colitis
an inflammatory bowel disease (IBD) that causes long-lasting inflammation and ulcers (sores) in your digestive tract
crutchfield tongs
an instrument that is attached to the skull to hyperextend the head and neck of patients with fractured cervical vertebrae for the purpose of immobilizing and aligning the vertebrae
Stadol
analgesic
what is not associated with serum sodium levels of 170meq/L?
anger, depression, psychosis
which is true regarding the administration of antacids?
antacids should be administered within 1-2 hours of all other medication
tetracycline
antibiotic that treats acne and skin infection
a client in the cardiac step-down unit requires suctioning for excess mucous secretions. the nurse should be most careful to monitor the client for which dysrhythmia during this procedure?
bradycardia
a 20 year old female has a prescription for tetracycline. while teaching the client how to take her medicine, the nurse learns that the client is also taking Ortho-Novum oral contraceptive pills. which instructions should be included in the teaching plan?
antibiotics can decrease the effectiveness of oral contraceptives, so the client should use an alternate method of birth control
phenergan
antiemetic
torque wrench
apply additional leverage to a fastener; looks like a socket wrench but has additional internal mechanisms designed to measure and limit the amount of force being applied
the nurse is working in the emergency room when a client arrives with severe burns of the left arm, hands, face, and neck. which action should receive priority?
applying oxygen start IV and medicate for pain are next. obtaining blood gases-ordered by doctor
the nurse is assessing the client recently returned from surgery. the nurse is aware that the best way to assess pain is to:
as the client to rate his pain on a scale of 0-5
a client with cancer is to undergo an intravenous pyelogram. the nurse should
as the client to void immediately before the study
the charge nurse is making assignements for the day. after accepting the assignement to a client with leukemia the nurse tells the charge nurse that her child has chickenpox. which action should the charge nurse take?
ask the nurse if she has ever had the chickenpox
the nurse witnesses the nursing assistant hitting the client in the long-term care facility. the nursing assistant can be charged with:
assault
the nurse is preparing to administer a feeding via a nasogastric tube. the nurse would perform which of the following before initiating the feeding?
assess for tube placement by aspirating stomach content
SLE
autoimmune disease bodys immune system mistakenly attacks healthy tissure
myasthenia gravis
autoimmune neuromuscular disease-->muscle weakness and fatigue
the nurse is caring for a patient with suspected diverticulitis. the nurse would be more prudent in questioning which of the following diagnostic tests ordered?
barium enema
vitals signs are taken
before any chemotherapy agent is given, if given intravenously check the IV site as well
the doctor has ordered antithrombolic stockings to be applied to the legs of the client with peripheral vascular disease. the nurse knows taht the proper method of applying the stockings is:
before rising in the morning
the nurse understand that the diagnosis of oral cancer is confired with
biopsy
histamine blocker
blockade of histamine activity can be useful for disorders such as continual seasonal allergies or ulcers.
the client is receiving total parenteral nutrition (TPN), which lab test should be evaluated while the client is receiving TPN?
blood glucose
hyphema
blood in frontal area of the eye
AST
blood test for aspartate aminotransferase (AST) is usually used to detect liver damage
six hours after birth, the infant is found to have an area of swelling over the right parietal area that does not cross the suture line. the nurse should chart this finding as
cephalohematoma
bran
cereal-helps prevent constipation
the client has an order for heparin to prevent post-surgical thrombi. immediately following a heparin injection, the nurse should:
check the site for bleeding
Methytrexate
chemotherapy agent
which of the following post-operative diets is most appropriate for the client who has had a hemorroidectomy?
clear liquid
cushings disease
client has adrenocortical hypersecretion. this increase in the level of cortisone causes the client to be immune suppressed
things you should do when assessing the CVP
client in a supine position to read the manometer, turn the stop-cock to the off position from the IV fluid to the client, note the level at the top of the meniscus
a removal of the left lower lobe of the lung is performed on a client with lung cancer. which post-operative measure would usually be included in the plan?
closed chest drainage
the client is admitted with chronic obstructive pulmonary disease. blood gases reveal pH 7.36, CO2 45, O2 84, HCO3 28. the nurse would assess the client to be in:
compensated respiratory acidosis
a 5-year old is admitted to the unit following a tonsillectomy. which of the following would indicate a complication of the surgery?
constant swallowing-may indicate bleeding
the client has a prescription for a calcium carbonate compound to neutralize stomach acid. the nurse should assess the client for:
constipation
the nurse is caring for the client who has been in a coma for 2 months. he has signed a donor card, but the wife is opposed to the idea of organ donation. how should the nurse handle the topic or organ donation. why?
contack organ retrieval to come talk to the wife
the nurse is preparing a client for surgery. which item is most important to remove before sending the client to surgery?
contact lenses
the client returns to the unit from surgery with a blood pressure of 90/50, pulse 132, respirations 30. which action by the nurse should receive priority?
contact the physician
the nurse is performing discharge teaching on a client with diverticulitis who has been placed on a low-roughage diet. which food would have to be eliminated from this client's diet?
cooked broccoli-gas forming
foods high in tyramine
could cause malignant hypertension. is found in: cheese, sour cream, chianti wine, sherry, beer, pickled herring, liver, canned figs, raisins, bananas, avocados, chocolate, soy sauce, fava beans, and yeast
the client arrives in the emergency room with a hyphema. which action by the nurse would be best?
elevate the head of the bed and apply ice to the eye
a 4 year old male is admitted to the unit with nephotic syndrome. he is extremely edematous. to decrease the discomfort associated with scrotal edema, the nurse should:
elevate the scrotum on a small pillow
hypernatremia
elevated sodium level in blood Na>145 mEq/L
the nurse overhears the patient care assistant speaking harshly to the client with dementia. the charge nurse should:
explore the interaction with the nursing assistant
the client with brain cancer refuses to care for herself. which action by the nurse would be best?
expolore the reason for the lack of motivation seen in the client
Levine tube
facilitates intestinal decompression
a client has rectal cancer and is scheduled for an abdominal perineal resection. what should be the priority nursing care during this post-op period?
facilitating perineal wound drainage
malpractice
failing to act appropriately
negligence
failing to perform care
a client with glomerulonephritis is placed on a low-sodium diet. which of the following snacks is suitable for the client with sodium restriction?
fresh peach-lowest amount of sodium
the physician has ordered a culture for the client with suspected gonorrhea. the nurse should obtain which type of culture?
genital secretions
the nurse is caring for a client with cerebral palsy. the nurse should provide frequent rest periods because:
grimacing and writhing movements decrease with relaxation and rest
the client arrives in the emergency room with a "bull's eye" rash. which question would be most appropriate for the nurse to ask the client?
have you found any ticks on your body?
side effects of Dilantin therapy
headache, nausea, vomiting, constipation, dizziness, drowsiness, slurred speech, loss of balance or coordination, swollen or tender gums, sleep problems (insomnia), nervousness, tremors, or rash.
implantable defibrillator
helps treat irregular heartbeats
baby oil
helps with dry skin and itching
the nurse is assisting in the care of a patient with diverticulosis, which of the following assessment findings would necessitate a report to the doctor?
hemoglobin 26% and hematocrit 32
the child with seizure disorder is being treated with Dilantin (phenytoin). Which of the following statements by the patients mother indicates to the nurse that the patient is experiencing a side effect of Dilantin therapy?
her gums look too big for her teeth
the doctor is preparing to remove chest tubes from the client's left chest. in preparation for the removal, the nurse should instuct the client to:
hold his breath and bear down
the physician has prescribed tranylcypromine sulfate (Parnate) 10mg bid. the nurse should teach the client to refrain from eating foods containing tyramine because it may cause
hypertension
a 60 year old diabetic is taking glyburide (Diabeta) 1.25mg daily to treat type II diabetes mellitus. which statement indicates the need for further teaching?
i often skip dinner because i don't feel hungry -the client should be taught to eat his meals, even if he is not hungry, to prevent a hypoglycemic reaction
the nurse is obtaining a history of an 80 year old client. which statement made by the client might indicate a possible fluid and electrolyte imbalance?
i often use a laxative for constipation
the nurse is teaching the client regarding use of sodium warfarin. which statement made by the client would require further teaching?
i take aspirin for a headache
Dalteparin (Fragmin) has been ordered for a client with pulmonary embolis. which statement made by the graduate nurse inidicates inadequate understanding of the medication?
i will check the PTT before administering the medication
the nurse is caring for a client scheduled for a surgical repair of a sacular abdominal aortic aneurysm. which assessment is most crucial during the preoperative period?
identification of peripheral pulses because aorta is clamped during surgery which decreases blood circulation
cholangiogram
imaging of bile duct
acromegaly
increase growth horomone
the nurse is assigned to care for an infant with physiologic jaundice. which action by the nurse would facilitate elimination of the bilirubin.
increasing the infants fluid intake
cloudy dialysate could mean?
infection might be present
tuberculosis
infection that affects the lungs
phlebitis
inflammation of the blood vessel and is not infectious
hepatitis
inflammation of the liver
pancreatitis
inflammation of the pancreas
which assignment should not be performed by the licensed practical nurse?
initiating a blood transfusion
a client with pancreatitis has been transferred to the intensive care unit. which order would the nurse anticipate?
insertion of a levine tube
the nurse is assessing the abdomen. the nurse knows the best sequence to perform the assessment is:
inspection, auscultation, palpation
the physician has ordered that the clients medication be administered intrathecally. The nurse is aware that medications will be administered by which method?
into the cerebrospinal fluid
quinidine sulfate
is an antiarrhythmic. It works by stabilizing the heart rhythm in conditions in which the heart is beating too fast or in an irregular rhyth
tranylcypromine sulfate (Parnate)
is an antidepressant. This medication treats depression by restoring the balance of certain natural substances (neurotransmitters) in the brain.
periorbital cellulites
is an inflammation and infection of the eyelid and portions of skin around the eye
glomerulonephritis
is inflammation of the tiny filters in your kidneys (glomeruli). Glomeruli remove excess fluid, electrolytes and waste from your bloodstream and pass them into your urine. Also called glomerular disease, glomerulonephritis can be acute — a sudden attack of inflammation — or chronic — coming on gradually
pruritis
itching
which of the following examples represents parallel play?
jimmy plays with his car beside mary who is playing with her doll
a client with pylonephritis
kidney infection-->frequent urinating
the client is newly diagnosed with juvenille onset diabetes. which of the following nurseing diagnoses is a priority?
knowledge deficit
the nurse is assisting in the care of a patient who is 2 days post operative from a hemorroidectomy. the nurse would be correct in instructing the patient to
use a sitx bath after each bowel movement to promote cleanliness and comfort
the nurse is ready to begin an exam on a 9 month old infant. the child is sitting in his mother's lap. what should the nurse do first?
listen to the heart and lung sounds
a client with bronchitis
lots of coughing
the registered nurse is caring for the patient's post-surgical removal of a 6mm oral cancerous lesion. the priority nursing measures would be to:
maintain a patent airway
the graduate licensed practical nurse is assigned to care for the client on ventilator support, pending organ donation. which goal should receive priority?
maintain the clients systolic blood pressure at 70mmHg or greater
a client is admitted to the acute care unit. initial laboratory values reveal serum sodium of 170meq/L. what behavior changes would be most common for this client?
mania
the nurse recognizes that which of the following would be most appropriate to wear when providing direct care to a client with a cough?
mask
a 20-year old is admitted to the rehabilitation unit following a motorcyle accident. which would be the appropriate method for measuring the client for crutches?
measuring 3 inches under the axilla
Tensilon
medicine that strengthens muscles
an obstetrical client decides to have an epidural anesthetic to relieve pain during labor. following administration of the anesthesia, the nurse should:
monitor the client for respiratory depression
the client is taking prednisone 7.5mg po each morning to treat his systemic lupus errythymatosis. which statement best explains the reason for taking the prednisone in the morning?
morning administration mimics the body's natural secretion of corticosteroid
C5 fracture
most common level of cervical spinal injury in adults
Western Blot
most definitive diagnostic tool for HIV
the nurse asked the client if he has an advance directive. the reason for asking the client this question is:
much confusion can occur with the client's family if he does not have an advanced directive.
the nurse is caring for a client scheduled for removal of the pituitary gland. the nurse should be particularly alert for?
nasal congestion
white blood cell count
not the best but less than 3500 requires investigation-for a diagnosis of HIV
signs of myocardial toxicity
notched P waves, widened QRS complexes. common side effects are diarrhea, nausea, and vomiting, tinnitus, vertigo, headache, visual disturbances, and confusion
expected time for contact to TB is
one year
lumpectomy
only the tumor is removed
glyburide (Diabeta)
oral blood glucose lowering drug
the nurse is assessing the client admitted for possible oral cancer. the nurse identifies which of the following as a late-occuring symptom of oral cancer?
pain
the nurse is taking the vital signs of the client admitted with cancer of the pancreas. the nurse is aware that the fifth vital sign is:
pain
hemiplegia
paralysis of one side of the body
the nurse is asked by the nurse aid are peptic ulcers really caused by stress? the nurse would be correct in replying with which of the following:
peptic ulcers are associated with H. pylori, although there are other ulcers that are associated with stress
Valsalva maneuver
performed by moderately forceful attempted exhalation against a closed airway, usually done by closing one's mouth, pinching one's nose shut while pressing out as if blowing up a balloon.
the physician prescribes captopril (Capoten) 25 mg po tid for the client with hypertension. which of the following adverse reactions can occur with administration of Capoten?
persisten cough-might be related to an adverse reaction
the nurse is providing discharge teaching for a client taking dissulfiram (Antabuse)-no alcohol or vinegar. the nurse should instruct the client to avoid eating:
pickles, salad with vinaigrette dressing, beef
the doctor has ordered a Transcutaneous Electrical Nerve Stimulation (TENS) unit for the client with chronic back pain. the nurse teaching the client with a TENS unit should tell the client:
please report skin irritaion to the doctor
a client with suspected renal disease is to undergo a renal biopsy. the nurse plans to include which statement in the teaching session?
portions of the procedure will cause pain or discomfort -portions are painful especially when the sample is drawn
magnesium sulfate
preeclampsia
Ewings sarcoma
primary malignant bone tumor in children and young adults; arises from bone marrow
several clients are admitted to the emergency room following a three-car vehicle accident. which clients can be assigned to share a room in the emergency department during the disaster?
the client who is 6 months pregnant with abdominal pain and the client with facial lacerations and a broken arm
the nurse has just received shift report ans is preparing to make rounds. which client should be seen first?
the client who was admitted 1 hour ago with shortness of breath
in terms of cognitive development, a 2 year old would be expected to:
use magical thinking
the client is receiving heparin for thrombophlebitis of the left lower extremity. which of the following drugs reverses the effects of heparin?
protamine sulfate
the client is admitted to the hospital in chronic renal failure. a diet low in protein is ordered. the rationale for a low-protein diet is:
protein breaks down into blood urea nitrogen and metabolic waste
a client with acute leukemia develops a low white blood cell count. in addition to the institution of isolation, the nurse should:
provide foods in sealed single-serving packages
a client with cancer develops xerostomia. the nurse can help alleviate the discomfort associated with xerostomia by:
providing saliva substitute
if the nurse is unable to illicit the deep tendon reflexes of the patella, the nurse should ask the client to:
pull against the palms
the 10 year old is being treated for asthma. before administering Theodur, the nurse should check the
pulse
the nurse is teaching about irritable bowel syndrome which of the following would be most imoportant?
reinforcing the need for a balanced diet
hemorroidectomy
removal of hemorrhoids
pericentesis
remove fluid from the peritoneal cavity
the nurse notes the patient care assistant looking through the personal items of the client with cancer. which action should be taken by the registered nurse?
report this behavior to the charge nurse
a client has been receiving cyanocobalamine (B12) injections for the past 6 weeks. which laboratory finding indicates that the medication is having the desired effect?
reticulocyte count of 1%-normal count 0.5-2.5
foods not allowed on a low-roughage diet?
roasted chicken, noodles, custard
the doctor orders 2% nitroglycerin ointment in a 1-inch dose every 12 hours. proper application of nitroglycerin ointment includes:
rotating application sites-prevents skin irritation
a client visits the clinic after the death of a parent. which statement made by the clients sister signifies abnormal grieving?
sally has not been sat at all by daddy's death. she acts like nothing has happened.
ELISA
screening exam-for a diagnosis of HIV
the client is receiving peritoneal dialysis. if the dialysate returns cloudy, the nurse should:
send the specimen to the lab
the client is admitted for evaluation of aggressive behavior and diagnosed with antisocial personality disorder. a key part of the care of such a client is:
setting realistic limitations
the nurse is doing bowel and bladder retraining for the client with paraplegia. which of the following is not a factor for the nurse to consider?
sexual function
which information obtained from the mother of a child with cerebral palsy most likely correlates to the diagnoses?
she had meningitis when she was 6 months old
a 6 year old with cerebral palsy functions at the level of an 18 month old. which finding would support that assessment?
she pulls a toy behind her
the client with an ileostomy is being discharged. which teaching should be included in the plan of care?
stomahesive is the best skin protector-skin barrier
which of the following lab studies should be done periodically if the client is taking sodium warfarin (Coumadin)?
stool speciment for occult blood
a client who has been receiving urokinase has a large bloody bowel movement. what nursing action would be best for the nurse to take immediately?
stop the urokinase, notify the physician, and prepare to administer amicar
mastectomy
surgery to remove all breast tissue from a breast
illeostomy
surgical bowel diversion of the ileum to the abdominal wall. fecal drainage is liquid & continuous
cholescystectomy
surgical procedure to remove your gallbladder
The nurse is visiting a home health client with osteoporosis. The client has a new prescription for alendronate (Fosamax). which instruction should be given to the client?
take the medication with water only
the nurse is caring for the client with a mastectomy. which action would be contraindicated?
taking the blood pressure in the side of the masectomy
a 24-year-old female client is scheduled for surgery in the morning. which of the following is the primary responsibility of the nurse
taking the vital signs
the nurse is assigning staff for the day. which assignment should be given to the nursing assistant?
taking the vital signs of the 10 year old with a 2 day post-appendectomy
the client is taking rifampin 600mg po daily to treat his tuberculosis. which action by the nurse indicates understanding of the medication?
telling the client that the medication will change the color of the urine
hematocrit
test that measures % of the volume of whole blood
the nurse is caring for a client with a malignancy. the classification of the primary tumor is Tis. the nurse should plan care for a tumor:
that is in situ
the home health nurse is planning for the day's visits. which client should be seen first?
the 30 year old with an exacerbation of multiple sclerosis being treated with cortisone via a centrally placed venous catheter.
the nurse is caring for a new mother. the mother asks why her baby has lost weight since he was born. the best explanation of the weight loss is
the baby can lose up to 10% of weight due to meconium stool, loss of extracellular fluid, and initiation of breast-feeding
the nurse is performing an assessment of an elderly client with a total hip repair. based on this assessment, the nurse decides to medicate the client with an analgesic. which finding most likely prompted the nurse to decide to administer the analgesic?
the cilent grimaces during care
a 70 year old male who is recovering from a stroke exhibits signs of unilateral neglect. which behavior is suggestive of unilateral neglect?
the client is observed shaving only one side of this face
the nurse is making assignments for the day. which client should be assigned to the pregnant nurse?
the client receiving linear accelerator radiation therapy for lung cancer
the licensed practical nurse is observing a graduate nurse as she assesses the central venous pressure. which observation would indicate that the graduate needs further teaching?
the graduate instructs the client to perform the Valsalva maneuver during the CVP reading
the doctor has ordered a patient-controlled analgesia (PCA) pump for the client with chronic pain. the client asks the nurse if he can become overdosed with pain medication using this machine. the nurse demonstrates understanding of the PCA if she states:
the machine has a locking device that prevents over dosing to occur
which information should be reported to the state Board of Nursing?
the narcotic count has been incorrect on the unit for the past 3 days
which nurse should be assigned to care for the postpartal client with preeclampsia ?
the nurse with 3 years of experience in labor and delivery
the schizophrenic client has become disruptive and requires seclusion. which staff member can institute seclusion?
the registered nurse
the client with a recent liver transplant asks the nurse how long he will have to take cyclosporine (Sandimmune). which response is correct:
the rest of his life
intussuception
the sliding (enfolding) of one section of the intestine into an adjacent section; much like the parts of a collapsible telescope
the nurse is evaluating the client's pulmonary artery pressure. the nurse is aware that this test will evaluate:
the systolic, diastolic, and mean pressure of the pulmonary artery
the client is admitted to the unit after a motor vehicle accident with a temperature of 102F rectally. the nurse is aware that the most likely explanation for the elevated temperature is:
there was damage to the hypothalamus
Vitamin K (aquamephyton) is administered to a newborn shortly after birth for which of the following reasons?
to facilitate clotting
the client with cirrhosis of the liver is receiving Lactulose. the nurse is aware that the rationale for the order for Lactulose is:
to lower the ammonia level
the nurse is preparing a client for mammography. to prepare the client for a mammogram, the nurse should tell the client:
to omit creams, powders, or deodorants before the exam--> can be interpreted as abnormal
the client is admitted from the emergency room with multiple injuries sustained from an auto accident. his doctor prescribes a histamine blockers. the reason for this order is:
to prevent stress ulcers
fundus
top portion opposite from the cervix
TUPR
transurethral resection of the prostate
rifampin
treats tuberculosis
a client with a diagnosis of passive-aggressive personality disorder is seen at the local mental health clinic. a common characteristic of persons with passive aggressive personality disorder is:
underlying hostility
the client returns to the recovery room following repair of an intrathoracic aneurysm. which finding would require further investigation?
urinary output 20mL in the past hour
rifampin side effects
urine, sweat, sputum, and tears may turn purple or red; this effect is not harmful
cyclosporine (Sandimmune)
used to prevent organ rejection in people who have received a liver, kidney, or heart transplant. It is usually taken along with other medications to allow your new organ to function normally
Vitamin K (aquamephyton)
used to treat and prevent low levels of certain substances (blood clotting factors) that your body naturally produces. These substances help your blood to thicken and stop bleeding normally (e.g., after an accidental cut or injury)
fluorouracil (Adrucil)
used to treat various types of cancer. It is a chemotherapy drug that is used alone or in combination with other medications to slow or stop cancer cell growth.
Lidocaine
used to treat ventricular tachycardia, slowly exerts an anti arrhythmic effect by increasing the electric stimulation threshold of the ventricles without depressing the force of ventricular contractions
the client with AIDS tells the nurse that he has been using acupuncture to help with his pain. the nurse should question the client regarding this treatment because acupuncture:
uses needles to stimulate certain points on the body to treat pain
pituitary gland removal
usually done by a transphernoidal approach, through the nose
fundus is boggy
uterus is more flaccid than expected
the nurse is assisting in the assessment of the patient admitted with abdominal pain. why should the nurse ask about medications that the client is taking?
various medications taken by mouth can affect the alimentary tract
before administering Methytrexate orally to the client with cancer, the nurse should check the:
vital signs
a client with gastritis
vomiting and diarrhea
Myasthenia Gravis
weakness of skeletal (voluntary) muscles
to ensure safety while administering a nitroglycerin patch, the nurse should:
wear gloves
a new diabetic is learning to administer his insulin. he receives 10U of NPH and 12U or regular insulin each morning. which of the following statements reflects understanding of the nurse's teaching?
when drawing up my insulin i should draw up the regular insulin first
the patient is prescribed metronidazole (Flagyl) for adjunct treatment for a duodenal ulcer. when teaching about this medication, the nurse would say:
while taking this medication, alcoholic beverages and products containing alcohol should be avoided
monocyte count, basophil count, and neutrophil count
white blood cells
a 4 year old with cystic fibrosis has a prescription for Viokase pancreatic enzymes to prevent malabsorption. the correct time to give pancreatic enzyme is
with each snack and meal
the doctor has ordered 80mg of furosemide (Lasix) two time per day. the nurse notes the patient's potassium level to be 2.5meq/L. the nurse should:
withhold the drug and call the doctor
tort
wrongful act
the nurse is caring for a patient with a colostomy. the patient ask will i ever be able to swim again? the nurse best response would be
yes, you should be abel to swim again even with the colostomy
the nurse is assisting the RN with discharge instructions for a client with an implantable defibrillator. what discharge instruction is essential?
you should use your cellphone on your right side
