NCLEX PREP 1
4. The licensed practical nurse assigned to the post-partal unit is preparing to administer Rhogam to a postpartum cdient. Which woman is not a candidate for RhoGam?
A gravida V 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 nurse is performing an assessment on a client with possible pernicious anemia. Which data would support this diagnosis?
A red, beefy tongue
The client is admitted with thrombophlebitis and an order for heparin. The medication should be administered using:
A tuberculin syringe
200. Assuming that all have achieved normal cognitive and emotional development, which of the following children is at greatest risk for accidental poisoning?
A4-year-old
Which laboratory test would be the least effective in making the diagnosis of a myocardial infarction?
AST
Which of the following best describes the language of a 24-month-old?
Able to verbalize needs
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 client's bath water
The nurse identifies ventricular tachycardia on the heart monitor. Which action should the nurse prepare to take?
Administer an antiarrythmic me dication 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 best?
Administer the me dication with orange juice
40. A client with an abdominal aortic aneurysm is admitted in preparation for surgery. Which of the following should be reported to the doctor?
An elevated white blood cell count
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.
The charge nurse is making assignments for the day. After accepting the assignment to a dient 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 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
The client is scheduled for a Tensilon test to check for Myasthenia Gravis. Which medication should be kept available during the test?
Atropine sulfate
The client is admitted with a BP of 210/120. Her doctor orders furosemide (Lasix) 40mg V stat. How should the nurse administer the prescribed furosemide to this client?
By giving it over 1-2 minutes
The child with seiaure disorder is being treated with Dilantin (phenytoin). Which of the following statements by the patient's 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 client with diabetes is preparing for discharge. During discharge teaching, the nurse assesses the client's 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 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 indicates inadequate understanding of the medication?
"I will check the PTT before administering the medication"
87. The nurse is asked by the nurse aide, "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." /
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 irritation 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."
A client visits the clinic after the death of a parent. Which statement made by the client's sister signifies abnormal grieving?
"Sally has not been sad at all by Daddy's death. She acts like nothing has happened."
The doctor has ordered a patient-controlled analgesia (PCA) pump for the dient 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 overdosing to occur."
A new diabetic is learning to administer his insulin. He receives 10U of NPH and 120 of 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 duodenal ulcer. When teaching about this medication, the nurse would say:
"While taking this medication, alcoholic beverages and products containing alcohol should be avoided."
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."
The nurse is caring for a patient with a colostomy. The patient asks, Will lever be able to swim again?" The nurse's best response would be:
"Yes, you should be able to swim again, even with the colostomy."
The physician has ordered sodium warfarin (Coumadin) for the client with thrombophlebitis. The order should be entered to administer the medication at:
1700
The nurse is making assignments for the day. Which dient should be assigned to the nursing assistant?
A client with Alzheimer's disease/
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
3. Which of the following roommates would be best for the client newly admitted with gastric resection?
A client with phlebitis
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 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
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, 02 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
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 handle the topic of organ donation with the wife?
Contact organ retrieval to come talk to the wife
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
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
A client has rectal cancer and is scheduled for an abdominal perineal resection. What should be the priority nursing care during the post-op period?
Facilitating perineal wound drainage
The nurse is found to be 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 the patient with ulcerative colitis, the nurse identifies which nursing diagnoses as a priority?
Fluid volume deficit
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
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 registered nurse is conducting an in-service for colleagues about peptic ulcers. The nurse would be correct in identifying which of the following as a causative factor?
H. pylori
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
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 infant's fluid intake
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 /
Which of the following examples represents parallel play?
Jimmy plays with his car beside Mary, who is playing with her doll.
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
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
The client is admitted to the hospital in chronic renal failure. A diet low in protein is ordered. The rationale for alow-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 nurse is teaching about irritable bowel syndrome (IBS). Which of the following would be most important?
Reinforcing the need for a balanced diet
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%
156. The doctor orders 2% nitroglycerin ointment in a 1-inch dose every 12 hours. Proper application of nitroglycerin ointment includes:
Rotating application sites
The client is receiving peritoneal dialysis. If the dialysate returns cloudy, the nurse should:
Send a 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 limits
Which information obtained from the mother of a child with cerebral palsy most likely correlates to the diagnosis?
She had meningitis when she was 6 months old.
96. 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 nurse is preparing a client with an axilo-popliteal bypass graft for discharge. The client should be taught to avoid:
Sitting in a straight chair
The nursing is participating in discharge teaching for the postpartal clent. The nurse is aware that an effective means of managing discomfort associated with an episiotomy after discharge is:
Sitz bath
The first exercise that should be performed by the client who had a mastectomy is:
Squeezing a ball
The client with an ileostomy is being discharged. Which teaching should be included in the plan of care?
Stomahesive is the best skin protector.
Which of the following lab studies should be done periodically if the client is taking sodium warfarin (Coumadin)?
Stool specimen 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
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 mastectomy
The nurse is assigning staff for the day. Which assignment should be given to the nursing assistant?
Taking the vital signs of the 10-ye ar-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
The nurse is caring for a client with a malignancy. The classification the primary tumor is Tis. The nurse should plan care for 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.
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 his face/
The nurse is making assignments for the day. Which dient should be assigned to the pregnant nurse?
The client receiving linear accelerator radiation therapy for lung cancer
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 and is preparing to make rounds. Which client should be seen first?
The client who was admitted 1 hour ago with shortness of breath
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.
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 Cushing's 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 dient 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 indicates that the Pitocin is having the desired effect?
The fundus is firm and in the midline.
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 action by the novice nurse indicates a need for further teaching?
The nurse fails to wear gloves to remove a dressing
Which nurse should be assigned to care for the postpartal client with preedampsia?
The nurse with 3 years of experience in labor and delivery
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
To ensure safety while administering a nitroglycerine patch, the nurse should:
Wear gloves
Which of the following is the best indicator of the diagnosis of HIV?
Western Blot
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 meal and snack
The doctor has ordered 80mg of furosemide (Lasix) two times per day. The nurse notes the patient's potassium level to be 2.5meg/L. The nurse should:
Withhold the drug and call the doctor
27. 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:
a cephalohematoma
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/
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
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 caring for a patient with suspected diverticulitis. The nurse would be most prudent in questioning which of the following diagnostic tests ordered?
barium enema
The nurse understands that the diagnosis of oral cancer is confirmed with:
biopsy
The client is receiving total parenteral nutrition (TPN). Which lab test should be evaluated while the dient is receiving TPN?
blood glucose
A client is admitted with a Ewing's sarcoma. Which symptoms would be expected due to this tumor's location?
bone pain
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
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
Which of the following post-operative diets is most appropriate for the client who has had a hemorroidectomy?
clear-liquid
Which of the following roommates would be most suitable for the client with myasthenia gravis?
client with hypothyroidism
The client has prescription for a calcium carbonate compound to neutralize stomach acid. The nurse should assess the client for:
constipation/
The nurse is preparing a client for surgery. Which item is most important to remove before sending the client to surgery?
contact lenses
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
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 client has an order for gentamycin to be administered. Which lab results should be reported to the doctor before beginning the medication?
creatinine
The nurse is assisting a client with diverticulosis to select appropriate foods. Which food should be avoided?
cucumber salad
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 graduate's action can result in what type of charge:
fraud
The physician has ordered a culture for the client with suspected gonorrhea. The nurse should obtain which type of culture?
genital secretions
The doctor is preparing to remove chest tubes from the client's left chest. In preparation for the removal, the nurse should instruct the dient to:
hold this 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 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
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
The physician prescribes regular insulin, 5 units subcutaneous. Regular insulin begins to exert an effect:
in 30-40 minutes
The physician has ordered that the client's medication be administered intrathecally. The nurse is aware that medications will be administered by which method?
into the CSF/
The client is newy diagnosed with juvenile onset diabetes. Which of the following nursing diagnoses is a priority?
knowledge deficit
21. A client is admitted to the acute care unit. Initial laboratory values reveal serum sodium of 170meg/L. What behavior changes would be most common for this cient?
mania
The nurse recognizes that which of the following would be most appropriate to wear when providing direct care to a client with cough?
mask
140. Shortly after the client was admitted to the postpartum unit, the nurse notes heavy lochia rubra with large dlots. The nurse should anticipate an order for:
methergine
A client is being monitored using a central venous pressure monitor. If the pressure is 2cm of water, the nurse should:
of the Call the doctor immediately
The nurse is assessing the client admitted for possible oral cancer. The nurse identifies which of the following as a late-occurring 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
The physician prescribes captopril (Capoten) 25mg po tid for the client with hypertension. Which of the following adverse reactions can occur with administration of Capoten?
persistent cough
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 10-year-old is being treated for asthma. Before administering Theodur, the nurse should check the:
pulse
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/
The client is scheduled to have an intravenous cholangiogram. Before the procedure, the nurse should assess the patient for:
shellfish allergies
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 caring for the client following a cerebral vascular accident. Which portion of the brain is responsible for taste, smell, and hearing?
temporal
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
Before administering Methytrexate orally to the client with cancer, the nurse should check the:
vital signs
The client with brain cancer refuses to care for herself. Which action by the nurse would be best?
Explore the reason for the lack of motivation seen in the client
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?"
A 60-year-old diabetic is taking glyburide (Diabeta) 1.25mg daily to treat Type l diabetes mellitus. Which statement indicates the need for further teaching?
"1 often skip dinner because I don't feel hungry."
A 6-month-old client is admitted with possible intussuception. Which question during the nursing history is least helpful in obtaining information regarding this diagnosis?
"Describe his usual diet."
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."
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."
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."
Which is true regarding the administration of antacids?
* Antacids should be administered within 1-2 hours of all other medications.
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 client grimaces during care.
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?
0.5 ml
78. An infant weighs 7 pounds at birth. The expected weight by 1 year should be:
21 Ib
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 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
Isoniazid (INH) has been prescribed for a family member exposed to tuberculosis. The nurse is aware that the length of time that the medication will be taken is:
6 months
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
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
The doctor has ordered antithrombolic stockings to be applied to the legs of the dient with peripheral vascular disease. The nurse knows that the proper method of applying the stockings is:
Before rising in the morning
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? OA Feeding the baby during the first 48 hours after delivery OB. Breaking suction by placing a finger between the baby's mouth and the breast when she terminates the feeding OC. Applying warm, moist soaks to the breast several times per day O D. Wearing a support bra
Breaking suction by placing a finger between the baby's mouth and the breast when she terminates the feeding
153. A client arrives in the emergency room with a possible fractured femur. The nurse should anticipate an order for:
Buck's traction
While caring for a client with hypertension, the nurse notes the following vital signs: BP of 140/20, pulse 120, respirations 36, temperature 100.8°F. The nurse's initial action should be to:
Call the doctor
An elderly client is diagnosed with ovarian cancer. She has surgery followed by chemotherapy with a fluorouracil (Adrucil) V. 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 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
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 nurse is caring for the patient's post-surgical removal of a 6mm oral cancerous lesion. The priority nursing measure 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 client's systolic blood pressure at 70mmHg or greater /
A 20-year-old is admitted to the rehabilitation unit following a motorcycle accident. Which would be the appropriate method for measuring the client for crutches?
Measuring 3 inches under the axilla
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
178., The dient 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.
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 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)
The nurse is caring for a client scheduled for removal of the pituitary gland. The nurse should be particularly alert for:
Nasal congestion
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
An important intervention in monitoring the dietary compliance of a client with bulimia is:
Observing her for 1-2 hours after meals
The nurse has just received a change-of-shift report. Which client should the nurse assess first?
P A client 2 hours post-lobectomy with 150ccs drainage /
A home health nurse is making preparations for morning visits. Which one of the following dlients should the nurse visit first?
P A client with congestive heart failure complaining of nighttime dyspnea
The nurse is assessing the client recently returned from surgery. The nurse is aware that the best way to assess pain is to:
P Ask the client to rate his pain on a scale of 0-5
The nurse notes the patient care assistant looking through the personal items of the dient with cancer. Which action should be taken by the registered nurse?
P Report this behavior to the charge nurse/
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?
P The graduate instructs the client to perform the Valsalva maneuver during the CVP reading
The nurse is providing discharge teaching for a client taking dissulfiram (Antabuse). The nurse should instruct the client to avoid eating:
Pickles, salad with vinaigrette dressing, beef/
The schizophrenic client has become disruptive and requires secusion. Which staff member can institute seclusion?
The registered nurse
The nurse is evaluating the dient'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 102*F 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
The client is admitted from the emergency room with multiple injuries sustained from an auto accident. His doctor prescribes a histamine blocker. The reason for this order is:
To prevent stress ulcers
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
The nurse is assisting in the care of a patient who is 2 days postoperative from a hemorroidectomy. The nurse would be correct in instructing the patient to:
Use a sitz bath after each bowel movement to promote cleanliness and comfort
In terms of cognitive development, a 2-year-old would be expected to:
Use magical thinking
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
A client with cancer is to undergo an intravenous pyelogram. The nurse should:
V Ask the client to void imme diately before the study
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.
Lidocaine is a medication frequently ordered for the client experiencing:
Ventricular tachycardia
The client with a myocardial infarction comes to the nurse's station stating that he is ready to go home because there is nothing wrong with him. Which defense mechanism is the client using?
denial
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
When the nurse is gathering information for the assessment, the patient states, "My stomach hurts about 2 hours after I eat." Based upon this information, the nurse knows the patient likely has a:
duodenal ulcer
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