NCLEX review
The nurse is caring for a pregnant client who was diagnosed with acquired immunodeficiency syndrome (AIDS) and asks the nurse if she will be able to breat-feed the infant after delivery. Which response by the nurse is appropriate?
"Breast-feeding is contraindicated."
The nurse reinforces discharge instructions to the mother of a child following a myringotomy with insertion of tympanostomy tubes. Which statement by the mother indicates a need for further teaching?
"I need to be sure my child uses soft tissues to blow his nose."
The nurse has given suggestions to the client with trigeminal neuralgia about strategies to minimize episodes of pain. The nurse determines that the client needs further teaching if the client made which statement?
"I will try to eat my food either very warm or very cold."
A client in a long-term care facility is being prepared to be discharged to home in 2 days. The client has been eating a regular diet for a week, yet is still receiving intermittent enteral tube feedings and will need to receive these feedings at home. The client states concern about not being able to continue the tube feedings at home. Which nursing response would be appropriate at this time?
"Tell me more about your concerns with your feedings after going home."
A client receiving therapy with carbidopa/levodopa (Sinemet) is upset and tells the nurse that his urine has turned a darker color since he began to take the medication. The client wants to discontinue its use. In formulating a response to the client's concerns, how does the nurse interpret this development?
A harmless side effect of the medication
a nonstress test is performed on a client, and the results are documented in the chart. The results are documented as a reactive nonstress test. Which interpretation should the nurse make of these results?
A negative test
The nurse is reinforcing instructions to a new mother about cord care and how to monitor for infection. The nurse should tell the mother that which is a sign of infection?
a moist cord with discharge
A client began taking amantadine (Symmetrel) approximately 2 weeks ago. Which decreased symptom should the nurse expect to see if the medication is having a therapeutic effect?
rigidity & akinesia
The nurse is preparing a client for the administration of a tuberculin skin test. The nurse determines that which body areas are appropriate for intradermal injections? Select all that apply.
Inner aspect of the forearm Dorsal aspect of the upper arm Away from heavy pigmentation
A cooling blanket is prescribed for a child with a fever. The nurse prepares to use the cooling blanket and should avoid which action?
Keeping the child uncovered to assist in reducing the fever
The nurse administers erythromycin ointment (0.5%) to the newborn's eyes, and the mother asks the nurse why this is done. The nurse should give which response to the client?
Prevents ophthalmia neonatorum from occurring after delivery to a neonate born to a woman with an untreated gonococcal infection
The nurse assists in developing a plan of care for a client admitted to the hospital with an acute myocardial infarction (MI). Which is the priority problem during the acute phase?
The client's pain
The nurse is assisting to administer acetylcysteine to a client admitted with acetaminophen (Tylenol) overdose. Before giving this medication, the nurse ensures which factor is in place?
The stomach is empty from emesis or lavage.
A client is receiving supplemental therapy with folic acid (Folate). The nurse evaluates the effectiveness of this therapy by monitoring the results of which laboratory study?
Complete blood count
A client is admitted to a long-term care facility with the diagnosis of weight loss secondary to anorexia. The health care provide inserts a nasogastric tube and prescribes to a tube feeding of a standard formula feeding to run at 50ml/hr. The nurse plans care, knowing that which is true regarding enteral feedings?
Enteral feedings require the normal digestive capabilities of the GI tract
The nurse is monitoring a client in active labor and notes that the client is having contractions every 3 minutes that last 45 seconds. The nurse notes that the fetal heart rate between contractions is 100 beats per minute. Which nursing action is appropriate?
Notify the RN
A client begins to drain small amounts of red blood from a tracheostomy tube 36 hours after a supraglottic laryngectomy. The LPN should perform which action?
Notify the RN.
A client suffered smoke inhalation and burns to the anterior trunk during a house fire. The nurse reviews the plan of care and notes that the client has an airway problem. Which findings support an airway problem? Select all that apply.
Hoarse voice guttural respiratory sounds
