NCLEX Prep

The nurse has completed discharge instructions for a client with application of a halo device. Which statement indicates that the client needs further clarification of the instructions?

"I will drive only during the daytime." The halo device alters balance and can cause fatigue because of its weight. The client should cleanse the skin daily under the vest to protect the skin from ulceration and should avoid the use of powder or lotions. The liner should be changed if odor becomes a problem. The client should have food cut into small pieces to facilitate chewing and use a straw for drinking. Pin care is done as instructed. The client cannot drive at all because the device impairs the range of vision.

A CD4+ lymphocyte count is performed in a client with human immunodeficiency virus (HIV) infection. When providing education about the testing, what should the nurse tell the client?

"It establishes the stage of HIV infection." Human immunodeficiency virus (HIV) can cause acquired immunodeficiency syndrome, which is a viral disease that destroys T cells, thereby increasing susceptibility to infection and malignancy. A CD4+ lymphocyte count is performed to establish the stage of HIV infection, to help with decisions regarding the timing of initiation of antiretroviral therapy and prophylaxis for opportunistic infections and to monitor treatment effectiveness. The remaining options are unrelated to the CD4+ lymphocyte count.

The nurse provides discharge instructions to the mother of a child following a myringotomy with insertion of tympanoplasty tubes. Which statement by the mother indicates the need for further teaching?

"My child can swim in the lake or pool as long as the water is not too deep." Bath water and lake water are potential sources of bacterial contamination. Diving and swimming deeply under water are prohibited. Parents need to be instructed that the child should not blow the nose for 7 to 10 days. The child's ears need to be kept dry, and Vaseline on cotton balls or earplugs can be placed in the ears during a bath or shower.

The nurse is caring for a client who is pulseless and experiencing this dysrhythmia. Which interventions should the nurse anticipate implementing in collaboration with the health care provider (HCP)? Select all that apply. Refer to Figure.

CPR, amiodarone, epinephrine. Pulseless ventricular tachycardia is treated the same way as ventricular fibrillation with measures that include defibrillation, CPR and medication therapy, with agents such as epinephrine and amiodarone and others.

A client with appendicitis is scheduled for an appendectomy. The nurse providing preoperative teaching for the client describes the location of the appendix by stating that it is attached to which part of the gastrointestinal (GI) system

Cecum The appendix, sometimes referred to as the vermiform appendix, is attached to the apex of the cecum. The other locations listed are incorrect.

The nurse is reviewing the record of a client admitted to the hospital with a diagnosis of Hodgkin's disease. Which assessment findings noted in the client's record are associated with this diagnosis? Select all that apply.

Fever, weight Loss, night sweats; and enlarged, painless lymph nodes. Assessment of a client with Hodgkin's disease most often reveals enlarged, painless lymph nodes along with fever, malaise, and night sweats. Weight loss may be a feature in metastatic disease. Visual changes are not specifically associated with Hodgkin's disease.

The nurse is teaching a client who is being started on imipramine about the medication. The nurse should inform the client to expect maximum desired effects at which time period following initiation of the medication?

In 2 to 3 weeks The maximum therapeutic effects of imipramine may not occur for 2 to 3 weeks after antidepressant therapy has been initiated. Options 1, 3, and 4 are incorrect time periods

The nurse is reviewing a plan of care for a client with cancer of the cervix who is undergoing treatment with a cesium (radiation) implant. Which nursing interventions are most appropriate for this client? Select all that apply.

Maintain the client on bed rest. Place the client on a low-fiber diet. Stand at the entrance of the room to communicate with the client when possible. During application of the cesium implant, the client is on bed rest. The client may be logrolled from side to side, and the head of the bed may be raised to 45 degrees. The client is given a low-fiber diet to prevent frequent bowel movements, which is a side effect of the radiation. To minimize radiation exposure, the nurse stands at the head of the bed or at the entrance to the room. Visitors are limited to 30 minutes per day in the radiation area.

The nurse in the health care clinic is performing a neurological assessment and is testing the motor function of cranial nerve V (trigeminal nerve). Which technique should the nurse implement to test the motor function of this nerve?

Separate the client's jaw by pushing down on the chin. The motor function (muscles of mastication) of cranial nerve V (trigeminal nerve) is assessed by palpating the temporal and masseter muscles as the person clenches the teeth. The muscles should feel equally strong on both sides. The nurse should try to separate the client's jaws by pushing down on the chin; normally, the jaws cannot be separated. Asking the client to puff out the cheeks tests the facial nerve. Placing an object on the client's tongue tests sense of taste and the sensory function of the facial nerve. Checking for equal strength by asking the person to rotate the head forcibly against resistance applied to the side of the client's chin assesses cranial nerve XI, the spinal accessory nerve.

The nurse is preparing a list of home care instructions for a client who has been hospitalized and treated for tuberculosis. Which instructions should the nurse include on the list? Select all that apply.

Activities should be resumed gradually. A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated. Respiratory isolation is not necessary because family members already have been exposed. Cover the mouth and nose when coughing or sneezing and put used tissues in plastic bags. The nurse should provide the client and family with information about tuberculosis and allay concerns about the contagious aspect of the infection. The client needs to follow the medication regimen exactly as prescribed and always have a supply of the medication on hand. Side and adverse effects of the medication and ways of minimizing them to ensure compliance should be explained. After 2 to 3 weeks of medication therapy, it is unlikely that the client will infect anyone. Activities should be resumed gradually and a well-balanced diet that is rich in iron, protein, and vitamin C to promote healing and prevent recurrence of infection should be consumed. Respiratory isolation is not necessary because family members already have been exposed. Instruct the client about thorough hand washing, to cover the mouth and nose when coughing or sneezing, and to put used tissues into plastic bags. A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated. When the results of 3 sputum cultures are negative, the client is no longer considered infectious and can usually return to former employment.

The clinic nurse is caring for an infant who has been diagnosed with primary hypothyroidism. The nurse is reviewing the results of the laboratory tests for thyroxine (T4) and thyroid-stimulating hormone (TSH). Which laboratory finding indicates a diagnosis of primary hypothyroidism?

An elevated TSH level Diagnostic findings in primary hypothyroidism include a low T4 level and a high TSH level. The remaining options are not diagnostic findings of this condition.

The nurse is assisting in the care of a client with pheochromocytoma who has been experiencing clinical manifestations of hypermagnesemia. When evaluating the client, the nurse should determine that the client's status is returning to normal if which is no longer exhibited?

Areflexia Signs and symptoms of hypermagnesemia include neurological depression, drowsiness and lethargy, loss of deep tendon reflexes (areflexia), respiratory paralysis, and loss of consciousness. Tetany, muscular excitability, and tremors are seen with hypomagnesemia.

The home health care nurse is visiting a client who was recently diagnosed with type 2 diabetes mellitus. The client is prescribed repaglinide and metformin. The nurse should provide which instructions to the client? Select all that apply.

Diarrhea may occur secondary to the metformin. The repaglinide is not taken if a meal is skipped. The repaglinide is taken 30 minutes before eating. A simple sugar food item is carried and used to treat mild hypoglycemia episodes. Repaglinide, a rapid-acting oral hypoglycemic agent that stimulates pancreatic insulin secretion, should be taken before meals (approximately 30 minutes before meals) and should be withheld if the client does not eat. Hypoglycemia is a side effect of repaglinide and the client should always be prepared by carrying a simple sugar at all times. Metformin is an oral hypoglycemic given in combination with repaglinide and works by decreasing hepatic glucose production. A common side effect of metformin is diarrhea. Muscle pain may occur as an adverse effect from metformin but it might signify a more serious condition that warrants health care provider notification, not the use of acetaminophen.

The nurse is assessing the cultural beliefs of five clients requiring specimen collection for a diagnostic test. Which cultural assessments are correct? Select all that apply.

Insertion of a throat culture swab into the mouth of a Southeast Asian client may be perceived as threatening. Hindus collecting a stool specimen for a hemoccult screening test need to use the left hand to place the stool onto the Hemoccult card. Self-urine collection performed by a right-hand-dominant Muslim client may be collected incorrectly because only a Muslim's left hand can be used for dirty activities. The correct statements regarding cultural considerations for specimen collection are important to know. Insertion of a throat culture swab into the mouth of a Southeast Asian client may be perceived as threatening. Muslims and Hindus designate which hand can be used for clean and dirty tasks. Collecting their own stool and urine specimens may be difficult for them because only the left hand can be used for "dirty" activities. Privacy should be maintained for any client providing vaginal or urinary specimens. Gender congruent family member would be best to conduct specimen collection. However, vaginal specimens should be collected by a health care provider. Asians (not Hispanics) may consider blood irreplaceable.

The nurse plans care for an older client admitted with a fractured hip. Which analgesic prescribed by the health care provider at standard doses and frequencies would the nurse question?

Meperidine hydrochloride by intramuscular route Ibuprofen, morphine sulfate, tramadol, and meperidine are all analgesics. Ibuprofen is a nonsteroidal antiinflammatory medication and is acceptable for use in the older client. Tramadol hydrochloride is a centrally acting nonopioid analgesic used for moderate to moderately severe pain and is a suitable option in this situation. Morphine sulfate and meperidine hydrochloride are both opioid analgesics, and both are effective in treating acute pain. Because meperidine hydrochloride produces a neurotoxic metabolite, it should be used only short term and is not recommended for use in older clients.

The nurse would anticipate that the health care provider (HCP) would add which medication to the regimen of the client receiving isoniazid?

Pyridoxine Isoniazid is an antituberculosis medication. Clients receiving isoniazid can develop neuropathy, and the agent of choice to help prevent this adverse effect is pyridoxine, vitamin B6. Niacin is used to lower the cholesterol level. Gabapentin is used to prevent seizures and for peripheral neuropathy, and cyanocobalamin is used to treat anemia.

A client is scheduled for surgical creation of an internal arteriovenous (AV) fistula on the following day. The client says to the nurse, "I'll be so happy when the fistula is made tomorrow. This means I can have that other hemodialysis catheter pulled right out." Which interpretation should the nurse make based on the client's statement?

The client does not understand that the site needs to mature or develop for 1 to 2 weeks before use. An AV fistula is the internal creation of an arterial-to-venous anastomosis. This causes engorgement of the vein, allowing both the artery and the vein to be easily cannulated for hemodialysis. Fistulas take 1 to 2 weeks to mature (engorgement) or develop before they can be used for dialysis, so the current method of access must remain in place to be used during that period. Options 1, 2, and 4 are incorrect interpretations of the client's statement.