NCLEX Questions

A client at 37 weeks gestation is at a prenatal visit and states that she sometimes feels dizzy when lying directly on her back. Which of the following is the nurse's best response?

"This may be due to the uterus putting pressure on a blood vessel."

Which finding should a nurse identify as requiring further investigation?

A platelet count of 115,000 is abnormal and requires further investigation. Normal values are 150,000 to 400,000 platelets; 5,000 to 10,000 WBCs; 4.5 to 5.3 million RBCs; and an average hematocrit of 45%.

Which task may a nurse delegate to a nursing assistant?

Assisting a client who had surgery to ambulate in the hallway

A nurse is caring for a client admitted to the unit with a seizure disorder. The client seems upset and asks the nurse, "What will they do to me? I'm scared of the tests and of what they'll find out." The nurse should focus her teaching plans on which diagnostic tests?

EEG, blood cultures, and neuroimaging studies

A child with hemophilia is brought to the clinic with spontaneous soft tissue bleeding of the right knee. Immediately on the child's arrival, what should the nurse do?

Elevate the right knee. The goal is to decrease the bleeding. This can be aided by decreasing circulation to the area. Elevating the part and applying cold decreases circulation to the area. The child will also receive cryoprecipitate.

Interferon alfa-2b has been prescribed to treat a client with chronic hepatitis B. The nurse should assess the client for which common adverse effects?

Flulike symptoms. Interferon alfa-2b most commonly causes flulike adverse effects, such as myalgia, arthralgia, headache, nausea, fever, and fatigue.

A 10-year-old boy is 24 hours post appendectomy. He is awake, alert, and oriented. He tells the nurse that he is experiencing pain. He has a prescription for morphine 1 to 2 mg PRN for pain. What is the priority nursing action in managing the child's pain?

Obtain vital signs with a pain score. The child is in pain and needs intervention, but before the nurse can determine how to proceed, it is essential to know the client's pain score to determine the appropriate morphine dose. In addition, the nurse cannot evaluate the effectiveness of the pain medication if there is no pain score prior to administering the medication. Changing the child's position and administering pain medication may be helpful to relieve the child's pain, but the nurse must first know the severity of the pain before determining the appropriate intervention. The nurse must perform a head to toe assessment, but it is not the priority in managing the child's pain.

The nurse is caring for a client in the recovery room after electroconvulsive therapy (ECT). Which of the following would be the priority nursing assessment?

Vital signs. Headache, disorientation, and memory loss are common short-term side effects, but the priority assessment would be client vital signs in the postictal state. The nurse would not be able to assess the client's response to ECT immediately post-procedure.

A client with a tentative diagnosis of myasthenia gravis is admitted for a diagnostic workup. Myasthenia gravis is confirmed by:

a positive edrophonium test.

A client with schizophrenia comes to the outpatient mental health clinic 5 days after being discharged from the hospital. The client was given a 1-week supply of clozapine. The client tells the nurse that she has too much saliva and frequently needs to spit. The nurse interprets the client's statement as being consistent with which factor?

expected adverse effect of clozapine

When evaluating a pregnant client's fundal height, the nurse should measure in which way?

from symphysis pubis notch to highest level of fundus.

The nurse teaches the client to report signs and symptoms of which potential complication after hypophysectomy?

hypopituitarism Most clients who undergo adenoma removal experience a gradual return of normal pituitary secretion and do not experience complications. However, hypopituitarism can cause growth hormone, gonadotropin, thyroid-stimulating hormone, and adrenocorticotropic hormone deficits. The client should be taught to monitor for change in mental status, energy level, muscle strength, and cognitive function. Acromegaly and Cushing's disease are conditions of hypersecretion.

A client and her spouse, both 25 years old, are having trouble conceiving. Infertility in this couple is defined as:

inability to conceive after 1year of unprotected attempts.

A nurse is caring for a client whose membranes ruptured prematurely 12 hours ago. When assessing this client, the nurse's highest priority is to evaluate:

maternal vital signs and fetal heart rate (FHR).

A nulligravid client calls the clinic and tells the nurse that she forgot to take her oral contraceptive this morning. The nurse should tell the client to:

take the medication immediately

When explaining the risk for having a child with cystic fibrosis to a husband and wife, the nurse should tell them:

the risk is greatest when both clients have the recessive gene.

Which of the following client statements indicates the need for further teaching about percutaneous umbilical blood sampling (PUBS) to assess fetal hemoglobin and hematocrit?

"I will lie on my back in a cylinder-type machine."

Which of the following statements indicates that a new graduate nurse understands central venous pressure (CVP) measurement when used on a client?

"It will assess pressure and volume changes in the right atrium."

A client with asthma who has wheezing and shortness of breath asks the nurse if it is all right to use the salmeterol inhaler during exercise. What is the nurse's best response?

"No, this drug is a maintenance drug, not a rescue inhaler." Salmeterol is a beta2-agonist, a maintenance drug that the asthmatic client uses twice daily, every 12 hours. Albuterol is used as the "rescue inhaler" for bronchospasms. Salmeterol can be used to prevent exercise-induced bronchospasms, but it should be taken 30 to 60 minutes before exercise. If the client is taking salmeterol twice daily, it should not be used in additional doses before exercise; twice daily is the maximum dosage. Indications for salmeterol include only asthma and bronchospasm induced by chronic obstructive pulmonary disease.

A client who is at 38 weeks gestation has been admitted to the hospital for meconium stained rupture of membranes. The nurse inserts an internal fetal scalp electrode (FSE). The client appears anxious and asks why she requires the FSE. What is the nurse's most appropriate response?

"The baby needs to be observed more closely. It is not ethical to tell this woman that her baby is "fine." The passage of meconium indicates that the fetus has experienced a stressor in the intrauterine environment, but the severity of the distress cannot be confirmed. The well being of the fetus is not yet known and requires further observation and evaluation with the internal FSE. (less)

The client with breast cancer is prescribed tamoxifen 20 mg daily. The client states she does not like taking medicine and asks the nurse if the tamoxifen is really worth taking. The nurse should tell the client:

"This drug has been found to decrease metastatic breast cancer and to improve the survival rate. The drug causes hot flashes as an adverse effect.

The nurse is caring for a client receiving digoxin who has begun vomiting and reports seeing colorful halos around the lights in the room. Which of the following actions should the nurse implement? Select all that apply.

1. D/C digoxin. 2. Begin continuous ECG monitoring for cardiac dysrhythmias. 3. Determine serum digoxin and electrolyte levels. Symptoms of digoxin toxicity include severe sinus bradycardia, colorful halos around lights, nausea, anorexia, and vomiting.

The nurse is caring for a client experiencing panic post fireworks display over the holiday weekend. The client routinely takes a prescribed dose of alprazolam 1.5 mg PO TID. A PRN dosage is also prescribed as 1.5 mg PO every four hours. The maximum daily dose is 8 mg. How many doses of the PRN medication might the client take safely?"

2 . The client would have a regularly prescribed dose of 1.5mg X 3 (tid)= 4.5mg. The client only has 2 doses or 3 mg possible to remain under the maximum dosage cap.

Which of the following clients is at greatest risk for Buerger's disease?

A 29-year-old male with a 14-year history of cigarette smoking. Thromboangiitis obliterans (Buerger's disease) is a nonatherosclerotic, inflammatory vasoocclusive disorder. The disorder occurs predominantly in younger men < 40 years of age and there is a very strong relationship with tobacco use. Diagnosis is based on age of onset, history of tobacco use, symptoms, and exclusion of diabetes mellitus.

A client with a history of hypertension is diagnosed with primary hyperaldosteronism. This diagnosis indicates that the client's hypertension is caused by excessive hormone secretion from which gland?

Adrenal cortex. Excessive secretion of aldosterone in the adrenal cortex is responsible for the client's hypertension. This hormone acts on the renal tubule, where it promotes reabsorption of sodium and excretion of potassium and hydrogen ions. The pancreas mainly secretes hormones involved in fuel metabolism. The adrenal medulla secretes the catecholamines — epinephrine and norepinephrine. The parathyroids secrete parathyroid hormone.

A nurse is conducting a teaching session with a group of parents on infant care and safety to assist parents in appropriately preparing to take their neonates home. Which statement about automobile restraints made by one of the parents would indicate to the nurse that learning has taken place?

An infant should ride in a rear-facing car seat until he or she weighs 20 lb and is 1 year old." Until the infant weighs 20 lb and is 1 year old, he should ride in a rear-facing car seat.

The risk for injury during an attack of Ménière's disease is high. The nurse should instruct the client to take which immediate action when experiencing vertigo?

Assume a reclining or flat position." The client needs to assume a safe and comfortable position during an attack, which may last several hours. The client's location when the attack occurs may dictate the most reasonable position. Ideally, the client should lie down immediately in a reclining or flat position to control the vertigo. The danger of a serious fall is real. Placing the head between the knees will not help prevent a fall and is not practical because the attack may last several hours. Concentrating on breathing may be a useful distraction, but it will not help prevent a fall. Closing the eyes does not help prevent a fall. (less)

A laboring client's membranes rupture, and the nurse notes that the amniotic fluid is meconium stained. Which of the following activities should the nurse immediately perform?

Begin continuous fetal heart rate monitoring. Meconium staining in the amniotic fluid is not always a sign of fetal distress but is correlated with its occurrence. It reveals that the fetus has had an episode of loss of sphincter control. This clinical situation requires further investigation with fetal heart rate monitoring. There is no indication that birth is imminent. Changing the client to left lateral position may enhance uteroplacental exchange, allowing more oxygen to reach the fetus; however, it is most critical to assess the fetal heart rate, as this provides immediate information surrounding the health and safety of the fetus.

The nurse is working at the local family planning clinic doing family education. When devising a teaching plan, in which client group would the nurse stress the importance of an annual Papanicolaou test?

Clients infected with the human papillomavirus (HPV). Annual Papanicolaou testing is a screening to detect potential precancerous and cancerous cells in the endocervical canal of the female reproductive system. HPV causes genital warts, which are associated with an increased incidence of cervical cancer. Recurrent candidiasis, pregnancy before age 20, and use of oral contraceptives do not increase the risk of cervical cancer.

The physician has prescribed sodium chloride for a hospitalized 51-year-old client in metabolic alkalosis. Which nursing actions are required to manage this client? Select all that apply.

Compare ABG findings with previous results. • Maintain intake and output records. • Document presenting signs and symptoms. Metabolic alkalosis results in increased plasma pH because of accumulated base bicarbonate or decreased hydrogen ion concentrations. The result is retention of sodium bicarbonate and increased base bicarbonate.

A client is 37 weeks gestation and is experiencing preeclampsia. The physician has ordered magnesium sulfate, increased fetal surveillance, and increased nursing interventions. The nightshift charge nurse is preparing the patient-nurse assignment before the morning shift begins. Which of the following factors should be the primary factor in the decision surrounding who should care for this client?

Complexity of care requirements Registered nurses are responsible for exhibiting critical thinking skills and caring for clients with fluctuating changes in their condition. This client requires extensive nursing care because she has experienced a change in health status and requires enhanced surveillance. It is critical that the nurse caring for her recognizes if her condition further deteriorates. While it is appropriate to consider senior nursing staff, client wishes and continuity of care, it is the responsibility of nurses to provide safe and ethical care. Therefore, in this context, client safety is the priority and requires that the charge nurse considers the complexity of her care requirements when assigning the appropriate care provider.

The nurse-manager of an outpatient facility isn't satisfied with discharge planning policies and procedures. Knowing other managers at similar facilities regarded as the "best" in the country, which steps should the nurse-manager take as part of a continuous quality-improvement process?

Contact the nurse-managers at the best facilities and compare their discharge planning policies and procedures with those of her facility. Benchmarking is a good approach for the nurse-manager to take. Benchmarking is the process of comparing an organization's delivery of client care practices in one organization to those in the best health care organizations.

A client is diagnosed with myocardial infarction. Which data collection findings indicate that the client has developed left-sided heart failure? Select all that apply.

Cough Crackles Orthopnea Left-sided heart failure produces primarily pulmonary signs and symptoms, such as orthopnea, cough, and crackles. Right-sided heart failure primarily produces systemic signs and symptoms, such as ascites, jugular vein distention, and hepatomegaly.

Thirty minutes after a Sengstaken-Blakemore tube is inserted, the nurse observes that the client appears to be having difficulty breathing. What should the nurse do first?

Determine whether the tube is obstructing the airway

The parent of a 4-year-old expresses concern that the child may be hyperactive. The parent describes the child as always in motion, constantly dropping and spilling things. Which action would be appropriate at this time?

Explain that this is not unusual behavior. Preschool-age children have been described as powerhouses of gross motor activity who seem to have endless energy. A limitation of their motor ability is that in moving as quickly as they do, they are not always able to judge distances, nor are they able to estimate the amount of strength and balance needed for activities. As a result, they have frequent mishaps. However, if the behavior intensifies, a referral to a pediatric neurologist would be appropriate. Children who have been abused usually demonstrate withdrawn behaviors, not endless energy.

The nurse finds a client lying on the floor next to the bed. After returning the client to bed, assessing for injury, and notifying the health care provider (HCP), the nurse fills out an incident report. What should the nurse do next?

Give the incident report to the nurse-manager.

A nurse consulting with a nutrition specialist knows it's important to consider a special diet for a client with chronic obstructive pulmonary disease (COPD). Which diet is appropriate for this client?

High-protein. Breathing is more difficult for clients with COPD, and increased metabolic demand puts them at risk for nutritional deficiencies. These clients must have a high intake of protein for increased calorie consumption.

While assessing a male neonate whose mother desires him to be circumcised, the nurse observes that the neonate's urinary meatus appears to be located on the ventral surface of the penis. The primary health care provider is notified because the nurse suspects which of the following?

Hypospadias. The condition in which the urinary meatus is located on the ventral surface of the penis, termed hypospadias, occurs in 1 of every 500 male infants. Circumcision is delayed until the condition is corrected surgically, usually between 6 and 12 months of age. Phimosis is an inability to retract the prepuce at an age when it should be retractable or by age 3 years. Phimosis may necessitate circumcision or surgical intervention. Hydrocele is a painless swelling of the scrotum that is common in neonates. It is not a contraindication for circumcision. Epispadias occurs when the urinary meatus is located on the dorsal surface of the penis. It is extremely rare and is commonly associated with bladder extrophy.

A client is receiving fluid replacement with lactated Ringer's after 40% of the body was burned 10 hours ago. The assessment reveals temperature 97.1° F (36.2° C), heart rate 122 bpm, blood pressure 84/42 mm Hg, central venous pressure (CVP) 2 mm Hg, and urine output 25 mL for the last 2 hours. The IV rate is currently at 375 mL/h. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse calls the health care provider (HCP) with a recommendation fo

IV rate increase. The decreased urine output, low blood pressure, low CVP, and high heart rate indicate hypovolemia and the need to increase fluid volume replacement. Furosemide is a diuretic that should not be given due to the existing fluid volume deficit. Fresh frozen plasma is not indicated. It is given for clients with deficient clotting factors who are bleeding. Fluid replacement used for burns is Lactated Ringer's solution, normal saline, or albumin. (less

A client with bipolar disorder, mania, has flight of ideas and grandiosity and becomes easily agitated. To prevent harmful behaviors, which of the following should the nurse do initially?

Initially, the nurse would tell the client to seek out staff when feeling agitated or upset to prevent violent episodes. Doing so helps the client to redirect negative feelings in an appropriate manner, such as talking.

A nurse is assessing a client with meningitis. The nurse places the client in a supine position and flexes the client's leg at the hip and knee. The nurse notes resistance when straightening the knee and the client reports pain. The nurse should document what neurologic sign as positive?

Kernig's sign A positive Kernig's sign is a manifestation of meningeal irritation. The nurse can elicit this sign by placing the client in a supine position and flexing the leg at the hip and knee. Pain or resistance when the knee is straightened suggests meningeal irritation.

A client is in the eighth month of pregnancy. To enhance cardiac output and renal function, the nurse should advise her to use which body position?

Left lateral

The nurse administers theophylline to a client. When evaluating the effectiveness of this medication, the nurse should assess the client for:

Less difficulty breathing. Theophylline is a bronchodilator that is administered to relax airways and decrease dyspnea. Theophylline is not used to treat infections and does not decrease or thin secretions.

When preparing the teaching plan for a client about lithium therapy, the nurse should teach the client about:

Maintaining an adequate sodium intake. The nurse would teach the client taking lithium and his family about the importance of maintaining adequate sodium intake to prevent lithium toxicity. Because lithium is a salt, reduced sodium intake could result in lithium retention with subsequent toxicity. Increasing sodium in the diet is not recommended and may be harmful. Increased sodium levels result in lower lithium levels. Therefore, the drug may not reach therapeutic effectiveness.

The nurse is caring for a client admitted with pyloric stenosis. A nasogastric tube placed upon admission is on low intermittent suction. Upon review of the morning's blood work, the nurse observes that the patient's potassium is below reference range. The nurse should recognize that the patient may be at risk for what imbalance?

Metabolic alkalosis. Probably the most common cause of metabolic alkalosis is vomiting or gastric suction with loss of hydrogen and chloride ions. The disorder also occurs in pyloric stenosis in which only gastric fluid is lost. Vomiting, gastric suction, and pyloric stenosis all remove potassium and can cause hypokalemia. This client would not be at risk for hypercalcemia; hyperparathyroidism and cancer account for almost all cases of hypercalcemia. The nasogastric tube is removing stomach acid and will likely raise pH. Respiratory acidosis is unlikely since no change was reported in the client's respiratory status.

Which of the following approaches to chronic pain management is most effective?

Multidisciplinary approach. A multidisciplinary approach to pain relief is needed for greatest effectiveness. In addition to the client, the nurse, and the physician, others who may be needed on the team include a social worker, an occupational therapist, a dietitian, and a psychologist or a psychiatrist. Pain relief interventions based on physiologic and psychological principles can be used simultaneously to obtain greater pain relief. Medication administration is only one option for reducing pain.

A multigravid laboring client has an extensive documented history of drug addiction. Her last reported usage was 5 hours ago. She is 2 cm dilated with contractions every 3 minutes of moderate intensity. The health care provider (HCP) prescribes nalbuphine 15 mg slow IV push for pain relief followed by an epidural when the client is 4 cm dilated. Within 10 minutes of receiving the nalbuphine, the client states she thinks she is going to have her baby now. Of the drugs available at the time of the

Naloxone. Naloxone would not be used in a client who has a history of drug addiction. Naloxone would abruptly withdraw this woman from the drug she is addicted to as well as the nalbuphine. The withdrawal would occur within a few minutes of injection and, if severe enough, could jeopardize the mother and fetus.

During her fourth clinic visit, a client who's 5 months pregnant tells the nurse she was exposed to rubella during the past week and asks whether she can be immunized now. How should the nurse respond?

No. Because the live viral vaccine is contraindicated during pregnancy.

A boy, age 2, is diagnosed with hemophilia, an X-linked recessive disorder. His parents and newborn sister are healthy. The nurse explains how the gene for hemophilia is transmitted. Which statement by the father indicates an understanding of X-linked recessive disorders?

Our newborn daughter may be a carrier of the trait." The father stating that his newborn daughter may be a carrier of the trait demonstrates understanding of X-linked recessive disorders. X-linked recessive genes behave like other recessive genes. A normal dominant gene hides the effects of an abnormal recessive gene. However, the gene is expressed primarily in male offspring because it's located on the X chromosome. Male offspring of a carrier mother and an unaffected father have a 50% chance of expressing the trait whereas female offspring are more likely to carry the trait than express it. These parents may produce offspring who neither express nor carry the trait for hemophilia.

Which finding is an early indicator of bladder cancer?

Painless hematuria. Initially, as cancer cells destroy normal bladder tissue, bleeding occurs and causes painless hematuria. (Pain is a late sign of bladder Ca.) Dysuria may indicate a urinary tract infection.

The nurse is monitoring a client who appears to be hallucinating. The client displays paranoid speech content, seems agitated, and gestures at a figure on the television. Which of the following nursing interventions is appropriate? Select all that apply.

Reinforce that the client is not in any danger. • Acknowledge the presence of the hallucinations. • Use a calm voice and simple commands. Using a calm voice, the nurse should reassure that the client is safe. The nurse should not challenge the client; rather, he or she should acknowledge the hallucinatory experience. It is not appropriate to request that the client stop the behavior. Implementing restraints is not warranted at this time. Although the client is agitated, no evidence exists that the client is at risk for harming self or others.

The nurse is educating a client on diabetes management. The client is asking questions that cause the nurse to be concerned about the client's ability to retain the information. Which of the following would be the best technique for the nurse to use to enhance the retention of information by the client?

Repeat important information during the presentation. Repetition is an effective means of reinforcing critical information and enhancing content retention. The other options will not increase the client's ability to retain information and may decrease the client's concentration and ability to retain critical information.

A client with colorectal cancer has been presented with her treatment options but wishes to defer any decisions to her uncle, who acts in the role of a family patriarch within the client's culture. By which of the following is the client's right to self-determination best protected?

Respecting the client's desire to have the uncle make choices on her behalf. The right to self-determination (autonomy) means that decision-making should never be forced on anyone. The client has the autonomous right to defer her decision making to another individual if she freely chooses to do so.

The nurse is providing care for a client with a tracheotomy whose pulse oximeter has recently alarmed, showing the oxygen saturation to be 77%. The nurse has repositioned the client and applied supplemental oxygen, interventions that have raised the oxygen levels to 80% and somewhat decreased work of breathing. The client is not in immediate distress, and level of consciousness remains high. The nurse should page which of the following practitioners?

Respiratory therapist. A respiratory therapist is an expert in lung function and oxygenation whose expertise is needed in the care of this client. Because the client is not experiencing severe distress or respiratory arrest, the nurse is justified in forgoing contact with the physician in the short term.

A nurse in a psychiatric care unit finds that a client with psychosis has become violent and has struck another client in the unit. What action should the nurse take in this case?

Restrain the client, as he is harmful to the other clients in the psychiatric care unit. Restraints should be used as a last resort and their use should be justified. Unnecessary restraining can lead to allegations of false imprisonment and battery; both are not applicable in this case, however. The nurse should inform the physician about the client, but sometimes it may not be logical to wait for orders to restrain a violent client.

A client is in the 38th week of her first pregnancy. She calls the prenatal facility to report occasional tightening sensations in the lower abdomen and pressure on the bladder from the fetus, which she says seems lower than usual. The nurse should take which action?

Review premonitory signs of labor with the client. Because the client is describing two premonitory signs of labor, Braxton Hicks contractions and tightening, the nurse should review these normal signs and reassure the client.

A nurse is evaluating a client's auditory function. To compare air conduction to bone conduction, the nurse should conduct which test?

Rinne test. The Rinne test compares air conduction to bone conduction in both ears.

A client is prescribed furosemide to manage heart failure. What laboratory values should the nurse monitor while the client receives this medication? Select all that apply.

Serum potassium, and CBC Complete blood count should be monitored, because furosemide can cause agranulocytosis, anemia, leukopenia, and thrombocytopenia. Because loop diuretics such as furosemide promote excretion of potassium, the nurse should also monitor serum potassium levels. Potassium replacement therapy may be necessary to prevent hypokalemia.

When developing the plan of care for a multigravid client with class III heart disease, the nurse should expect to assess the client frequently for which problem?

Tachycardia

The nurse assesses a client who is receiving a tube feeding. Which situation would require prompt intervention from the nurse?

The feeding that is infusing has been hanging for 8 hours. Feeding solutions that have not been infused after hanging for 8 hours should be discarded because of the increased risk of bacterial growth. Sitting the client upright during the feeding helps prevent aspiration of the feeding. A gastric residual of 25 mL is considered acceptable. A gastric residual of 100 to 150 mL, or a residual greater than 100% of the previous hour's intake, indicates delayed emptying. The feeding solution should be at room or body temperature.

The mother of a client who has a radium implant asks why so many nurses are involved in her daughter's care. She states, "The doctor said I can be in the room for up to 2 hours each day, but the nurses say they are restricted to 30 minutes." The nurse explains that this variation is based on the fact that nurses:

Work with radiation on an ongoing basis, while visitors have infrequent exposure to radiation. The three factors related to radiation safety are time, distance, and shielding. Nurses on radiation oncology units work with radiation frequently and so must limit their contact. Nurses are physically closer to clients than are visitors, who are often asked to sit 6 feet (182.9 cm) away from the client. Touching the client does not increase the amount of radiation exposure. Aseptic technique and isolation prevent the spread of infection. Age is a risk factor for people in their reproductive years.

A 10-year-old child hospitalized with acute poststreptococcal glomerulonephritis during the acute stage has elevated blood pressure and low urine output for 14 hours. The nurse should next:

assess the child's neurologic status. The nurse should assess the child's neurologic status because hypertensive encephalopathy is a major potential complication of the acute phase of glomerulonephritis. Seizure precautions also should be instituted. Hypertensive encephalopathy can result in transient loss of vision, hemiparesis, disorientation, and grand mal seizures. Encouraging the child to drink more water is inappropriate because the child has had a low urine output for 14 hours. Typically, in this situation, fluids would be restricted. Although a low-sodium diet is encouraged, it is not the priority action at this time. Initially, bed rest, not ambulation, is advocated during the acute phase of glomerulonephritis.

The nurse is checking the laboratory results of an adult client with type 1 diabetes (see chart). What laboratory result indicates a problem that should be managed?

blood glucose

During recovery from a stroke, a client is given nothing by mouth to help prevent aspiration. To determine when the client is ready for a liquid diet, the nurse assesses the client's swallowing ability once per shift. This assessment evaluates:

cranial nerves IX and X. Swallowing is a motor function of cranial nerves IX and X. Cranial nerves I, II, and VIII don't possess motor functions. The motor functions of cranial nerve III include extraocular eye movement, eyelid elevation, and pupil constriction. The motor function of cranial nerve V is chewing. Cranial nerve VI controls lateral eye movement.

To assess a client's cranial nerve function, a nurse should assess:

gag reflex. The gag reflex is governed by the glossopharyngeal nerve.

A client with a suspected diagnosis of lung cancer has a bronchoscopy with biopsy. Following the procedure the nurse should:

monitor the client for signs of pneumothorax. After a bronchoscopy with a biopsy, as well as hemorrhage. The client should not gargle with oral lidocaine; this will not allow the gag reflex to return. The client should not have any mediastinal discomfort after a bronchoscopy; if pain does occur, it should be reported promptly to the health care provider (HCP). It is not necessary to tell the client not to talk until the gag reflex returns.

A 34-year-old multiparous client at 16 weeks' gestation who received regular prenatal care for all of her previous pregnancies tells the nurse that she has already felt the baby move. How does the nurse interpret this finding?

normal because multiparous clients can experience quickening between 14 and 20 weeks' gestation

A client admitted with acute anxiety has the following arterial blood gas (ABG) values: pH, 7.55; partial pressure of arterial oxygen (PaO2), 90 mm Hg; partial pressure of arterial carbon dioxide (PaCO2), 27 mm Hg; and bicarbonate (HCO3-), 24 mEq/L. Based on these values, the nurse suspects:

respiratory alkalosis.

A client is a 43-year-old G2 P1 at 16 weeks' gestation that has completed prenatal testing for chromosomal abnormalities. The results reveal the infant is a female with Down syndrome. The parents are seeking information about this syndrome. What should the nurse tell the parents? Select all that apply.

• Down syndrome can occur in mothers of any age. • Down syndrome occurs more frequently with advanced maternal age. • Down syndrome results from a trisomy of chromosome 21.