NCLEX review

A client with esophageal cancer decides against placement of a jejunostomy tube. Which ethical principle is a nurse upholding by supporting the client's decision?

autonomy

A client has an abdominal wound that requires irrigation. Where should the nurse place the client's old dressing after removal?

a biohazardous trash container

Prochlorperazine is prescribed postoperatively. The nurse should evaluate the drug's therapeutic effect when the client expresses relief from which symptom?

nausea

When preparing for a spiritual counselor to visit a hospitalized client, the nurse should

take measures to ensure privacy during the counselor's visit;

A client is discharged after an aortic aneurysm repair with a synthetic graft to replace part of the aorta. The nurse should instruct the client to notify the health care provider (HCP) before having which procedure?

tooth extraction; The client with a synthetic graft may need to be treated with prophylactic antibiotics before undergoing major dental work and should notify the HCP before any such procedure. Prophylactic antibiotic treatment reduces the danger of systemic infection caused by bacteria from the oral cavity.

A client complains of abdominal discomfort and nausea while receiving tube feedings. Which intervention is most appropriate for this problem?

Stop the feedings and check for residual volume;If residual volume is greater than 100 ml, hold the feeding and notify the physician. Feedings are normally given at room temperature to minimize abdominal cramping; however, this action doesn't help assess why nausea and discomfort are occurring. Elevating the head of the client's bed to at least 30 degrees prevents aspiration during feeding. Also, feeding containers are changed daily to prevent bacterial growth.

A client is scheduled for an appendectomy. What is the nurse's highest priority when planning preoperative teaching for this client?

The client should begin coughing and deep-breathing exercises as soon as the client is able to follow instructions.

The nurse is receiving over the telephone a laboratory results report of a neonate's blood glucose level. What should the nurse do?

Write down the results, read back the results to the caller from the laboratory, and receive confirmation from the caller that the nurse understands the results.

Which finding requires immediate intervention when planning care for an adolescent with cystic fibrosis (CF)?

chest pain with dyspnea

To evaluate a client's cerebellar function, a nurse should ask

"Do you have any problems with balance?"; To evaluate cerebellar function, the nurse should ask the client about problems with balance and coordination.

A nurse manager overhears a nurse caring for a client with an I.V. make this statement: "If you don't stop playing with your I.V., I will tie your hand to the side rail." What is the most appropriate response by the nurse manager to address this situation?

"I need to inform you that your behavior is within the definition of assault."

The nurse instructs a client recovering from a myocardial infarction (MI) about cardiac rehabilitation. The client states, "I will not be able to do rehabilitation because I have very bad knees." What is the nurse's best response?

"The rehabilitation team will assess you and recommend activities that accommodate for your knee problems."

A nurse is instructing a client with asthma on the use of an inhaler with a spacer. The client asks what the purpose of the spacer is. The nurse's best response is

"The spacer traps medicine from the inhaler, then breaks up and slows down the medication particles, so you get more medication."

The supervisor is performing a chart review. The nurse can be held legally liable for which documentation?

1200 Administered cephalosporin. The client has an allergy to penicillin -BSmith, RN; There is a cross-sensitivity between cephalosporin and penicillin, and the drug should not have been given.

A nurse is teaching the parents of a child with cystic fibrosis about proper nutrition. Which instruction should the nurse include?

Encourage a high-calorie, high-protein diet; The child should be encouraged to eat a high-calorie, high-protein diet. In cystic fibrosis, the pancreatic enzymes (lipase, trypsin, and amylase) become so thick that they plug the ducts. In the absence of these enzymes, the duodenum can't digest fat, protein, and some sugars; therefore, the child can become malnourished. A child with cystic fibrosis needs to drink plenty of fluid and take salt supplements, especially on warm days or when exercising, to help maintain hydration and adequate sodium levels. Water-soluble forms of the fat-soluble vitamins (A, D, E, and K) are essential.

A nurse is working in a clinic where a family member's spouse is treated for a sexually transmitted disease. The nurse is concerned about the risk to family members. What is the most appropriate action for the nurse to take?

Encourage the client to speak with the family member about the diagnosis if the client has not already done so.

The nurse is caring for a client with a Jackson-Pratt drain. Which action by the nurse would be the most appropriate?

Ensure that the drainage receptacles are kept compressed to maintain suction; Portable wound drainage systems are self-contained and can be emptied and compressed to reestablish negative pressure, which promotes drainage. The other choices are incorrect because a Jackson-Pratt drain needs negative pressure in the bulb to promote drainage.

At 8 a.m. (0800), a nurse assesses a client who is scheduled for surgery at 10 a.m. (1000). During the assessment, the nurse detects dyspnea, a nonproductive cough, and back pain. What would the nurse do next?

Immediately notify the healthcare provider of these findings; The nurse would notify the healthcare provider immediately because dyspnea, a nonproductive cough, and back pain may signal a change in the client's respiratory status. The nurse would then check the results of any ordered tests (such as a chest X-ray, serum electrolyte levels, and CBC) because this information may help explain the change in the client's condition. The nurse would sign the preoperative checklist after notifying the healthcare provider of the client's condition and learning whether the provider will proceed with the scheduled surgery.

Which nursing interventions would be appropriate to prevent hyperbilirubinemia and the need for phototherapy? Select all that apply.

Monitor intake and output. Assess for jaundice when vital signs are measured. Encourage breastfeeding for a minimum of every 3 hours; To prevent and/or manage hyperbilirubinemia, nurses should monitor intake and output in the form of hydration and stool monitoring to promote elimination of bilirubin, assess for jaundice when vital signs are measured, and encourage breastfeeding 8 to 12 times per day. Supplementation with water or dextrose is discouraged, and there is currenlty not a recommendation for routine bilirubin monitoring. Bilirubin checks every 8 to 12 hours will not prevent hyperbilirubinemia; rather it is a form of monitoring it once there is a problem.

A client has arterial blood gas results of pH 7.32; PaCO2 50; HCO3 23; and SaO2 80%. These results indicate:

Respiratory acidosis; Respiratory acidosis is correct because the pH is decreased and the PCO2 is increased.

The nurse is caring for a postoperative client who has not voided since before surgery. Which is the nurse's most appropriate action?

Palpate for the bladder above the symphysis pubis; Anesthesia may cause urinary retention. The kidneys typically produce 35-55 mL of urine per hour; when full, the bladder becomes palpable above the symphysis pubis. The first step is to assess if the bladder is distended by palpating the suprapubic area.

The nurse is caring for a patient with Parkinson disease. The patient informs the nurse that the patient has been angry with God because of the worsening illness, but after talking to the hospital chaplain, the patient is ready to return to the church choir and become active again in the group at the church. What is an appropriate nursing diagnosis for this patient?

Readiness for Enhanced Spiritual Well-Being

A nurse is caring for a client with an endotracheal tube who receives enteral feedings through a feeding tube. Before each tube feeding, the nurse checks for tube placement in the stomach as well as residual volume. The purpose of the nurse's actions is to prevent

aspiration

The nurse creates a program to decrease the primary cause of disability and death in children. What is the most important action to include in the plan?

Teach health and safety practices to children and their parents; The primary cause of disability and death in children is injury from accidents.

Twenty-four hours after a bone marrow aspiration, the nurse is evaluating the client's postprocedure status. Which outcome is expected?

There is no bleeding at the aspiration site; After a bone marrow aspiration, the puncture site should be checked every 10 to 15 minutes for bleeding. For a short period after the procedure, bed rest may be prescribed. Signs of infection, such as redness and swelling, are not anticipated at the aspiration site. A mild analgesic may be prescribed for pain, but if the client has pain longer than 24 hours, the nurse should assess the client for internal bleeding or increased pressure at the puncture site which may be the cause of the pain and should consult the health care provider (HCP).

Why are antacids administered regularly, rather than as needed, in peptic ulcer disease?

To keep gastric pH at 3.0 to 3.5

An older adult client is admitted to the hospital with a diagnosis of pneumonia. The nurse learns that the client lives alone and has not been eating or drinking properly. Upon physical assessment, the nurse notes tachycardia, hypotension, and hyperthermia. Which admission order would the nurse implement first?

intravenous fluid hydration

After completing assessment rounds, which client should the nurse discuss with the health care provider (HCP) first?

a client with hepatitis whose pulse was 84 bpm and regular and is now 118 bpm and irregular; A change in a client's baseline vital signs should be brought to the HCP's attention immediately. In this case, the client's heart rate has increased, and the rhythm appears to have changed; the HCP may prescribe an ECG to determine if treatment is necessary. The nurse should also have a complete set of current vital signs as well as a physical assessment before providing the HCP information using the SBAR format.

A client who was involved in a motor vehicle accident is admitted to the hospital. His wife arrives on the unit 6 hours after her husband's accident, explaining that she has been out of town. She is distraught because she was not with her husband when he needed her. The nurse should:

allow her to verbalize her feelings and concerns; Verbalizing feelings and concerns helps decrease anxiety and allows the wife to move on to understanding the current situation. Describing events or explaining condition or treatment is appropriate when the person is not distraught and is ready to learn.

The nurse is justified in assessing for sexual dysfunction among male clients who are taking

anti-hypertensives

A nurse is assigned to care for a client with chest pain in the intensive care unit. The client is reading a book when the nurse observes a flat line on the monitor and the alarm rings. What is the nurse's priority intervention at this time?

assessing the client; The priority action of the nurse would be to assess the client to determine if the client is having a loss of consciousness with cessation of respiration or pulse. The electrodes may have lost connection with the client's skin. The other choices would be inappropriate actions until an assessment has been performed.

An older adult is having abdominal surgery. The nurse should assess the client for which postoperative concern related to normal changes in the integumentary system of an older adult?

decreased healing

A client must take streptomycin for tuberculosis. Before therapy begins, the nurse should instruct the client to notify the physician if which health concern occurs?

decreased hearing acuity; Decreased hearing acuity indicates ototoxicity, a serious adverse effect of streptomycin therapy. The client should notify the physician immediately if it occurs so that streptomycin can be discontinued and an alternative drug can be ordered.

A client hospitalized for treatment of a pulmonary embolism develops respiratory alkalosis. Which clinical findings commonly accompany respiratory alkalosis?

light-headedness or paresthesia

Immediately following an automobile accident, a 21-year-old client has severe pain in the right chest from hitting the steering wheel and a compound fracture of the right tibia and fibula and multiple lacerations and contusions. What is the priority nursing goal for this client?

maintain adequate oxygenation; Blunt chest trauma can lead to respiratory failure. Maintenance of adequate oxygenation is the priority for the client

Which factor should a nurse anticipate having the most influence on the outcome of a client facing a crisis situation?

previous coping skills

After a total laryngectomy, the client has a feeding tube. What is the purpose of the feeding tube? The feeding tube:

provides nutrition

Before discharge from the hospital after a myocardial infarction, a client is taught to exercise by gradually increasing the distance walked. Which vital sign should the nurse teach the client to monitor to determine whether to increase or decrease the exercise level?

pulse rate; The pulse rate can be expected to increase with exercise, but exercise should not be increased if the pulse rate increases more than about 25 bpm from baseline or exceeds 100 to 125 bpm. The client should also be taught to discontinue exercise if chest pain occurs.

The nurse is reviewing the chart information for a client with increased ascites. The data include the following: temperature 98.9°F (37.2°C), heart rate 118 bpm, shallow respirations 26 breaths/min, blood pressure 128/76 mm Hg, and SpO2 89% on room air. What should the nurse do first?

raise the HOB

The nurse is reconstituting a powdered medication in a vial. After adding the solution to the powder, the nurse should

roll the vial gently between the palms.

The nurse should instruct a client with heart disease to avoid which foods that contribute to increases in serum cholesterol?

saturated fat; Saturated fats raise blood cholesterol.Polyunsaturated fats maintain blood cholesterol.Monounsaturated fats may help to maintain or lower blood cholesterol. Phospholipids do not have an effect on cholesterol but act as emulsifiers, keeping fats dispersed in water.

Which factor is a priority when evaluating discharge plans for an older adult after a lower left lobectomy for lung cancer?

support available for assisting the client at home; Because clients are discharged as soon as possible from the hospital, it is essential to evaluate the support for assistance and self-care at home. If the client has support at home, the distance from the hospital may be irrelevant. The client or support team will monitor vital signs as needed, but blood pressure monitoring is not specifically indicated. It is more important at this point for the client to understand how to manage his care at home, rather than knowing the causes of lung cancer.

A client is taking iron supplements. What information should the nurse give the client?

the stool will become darker

The client who is 28 weeks gestation is at the obstetric (OB) clinic reviewing lab work. The human immunodeficiency virus (HIV) test is positive, and treatment is indicated. Which medication should the nurse expect to administer that will help to prevent transmission of the virus to the fetus?

zidovudine; Zidovudine is an antiretroviral used to help to prevent the transmission of HIV infection to the neonate. The other medications are not appropriate for this client. Fluvastatin is an antilipemic used for hypercholesterolemia, dimenhydrinate is an antiemetic used for motion sickness, and disulfiram is an alcohol deterrent.

The nurse is checking the blood sugar level of a client who is at 33-weeks' gestation. This client has had type 1 diabetes since she was 12 years old. Which value would indicate to the nurse that this client's disease is controlled?

85 mg/dl

A nurse is caring for a client who has a history of sleep apnea. The client understands the disease process when they say

"I should become involved in a weight loss program."; Obesity and decreased pharyngeal muscle tone commonly contribute to sleep apnea; the client may need to become involved in a weight loss program.

A client who has a history of bacterial endocarditis is scheduled to have oral surgery to remove a tooth. What should the nurse instruct the client to do?

Be sure the dentist prescribes a prophylactic antibiotic prior to the oral surgery.

A nurse observes a consent form signed by a client indicating permission for the insertion of a feeding tube before the beginning of chemotherapy. One hour before the procedure, the client states, "I changed my mind and now don't want the feeding tube." What would be the most appropriate response by the nurse?

"You have a right to withdraw consent. Can you share more about your decision?"

Upon hearing a blood pressure reading of 146/96 mm Hg, a 58-year-old client asks whether medication will be necessary. Which would be the best response by the nurse?

"You will need to have your blood pressure reassessed before a diagnosis can be made."; Hypertension is confirmed by at least two measurements greater than 129/80 mm Hg and taken on two separate occasions. The nurse should provide factual information to the clinet, not provide false hope.

A nurse-manager is reviewing incidents that occurred recently. For which event will the manager need to make a report to the board of nursing?

A nurse documents administering narcotics to a client while personally using the medication.

Which measure should the nurse perform when suctioning a tracheostomy tube?

Administer high concentrations of oxygen before suctioning the client; Clients are hyperoxygenated before suctioning to prevent hypoxia. Suction is never applied while inserting the catheter into the airway. Laryngectomy tubes are not changed after suctioning.The suction catheter should be about half the diameter of the tube; a larger-diameter suction catheter would interfere with airflow during the procedure.

The client has returned to the surgery unit from the postanesthesia care unit (PACU). The client's respirations are rapid and shallow, the pulse is 120 bpm, and the blood pressure is 88/52 mm Hg. The client's level of consciousness is declining. What should the nurse do first?

Call the rapid response team (RRT)/medical emergency team; The nurse should first call the rapid response team (RRT) or medical emergency team that provides a team approach to evaluate and treat immediately clients with alterations in vital signs or neurological deterioration.

A client on prolonged bed rest has developed a pressure ulcer. The wound shows no signs of healing even though the client has received skin care and has been turned every 2 hours. What is the best action by the nurse?

Evaluate client protein levels; Clients on bed rest suffer from lack of movement and a negative nitrogen balance. Therefore, inadequate protein intake impairs wound healing. The nurse would evaluate the client's protein status by reviewing laboratory data.

Which is a priority nursing assessment of a reddened heel in a bed-ridden client?

Test for blanching to the affected area; When a fingertip is pressed over the reddened area and the area does not blanch but remains consistently reddened, it is an indication of deep tissue injury.

In preparing the client and the family for a postoperative stay in the intensive care unit (ICU) after open-heart surgery, what should the nurse tell the family?

The client will receive medication to relieve pain; Management of postoperative pain is a priority for the client after surgery, including valve replacement surgery. The client and family should be informed that pain will be assessed by the nurse and medications will be given to relieve the pain. The client will stay in the ICU as long as monitoring and intensive care are needed.

Which factors influence safe and effective medication administration for elderly clients?

There is less efficient absorption, detoxification, and elimination.

While reviewing the admission assessment of a client scheduled for colorectal surgery, the nurse discovers that the client stopped taking medications to treat emphysema 3 months ago. What would be a priority in planning collaborative care with the respiratory therapist?

Timely administration of breathing treatments.

The nurse has provided teaching for a client who will be taking lorazepam upon discharge. The nurse determines that teaching was effective when the client states the need to avoid

alcohol

A client with a recent history of rectal bleeding is being prepared for a colonoscopy. Initially. The nurse knows that positioning the client lying on their left side with the knees bent is an appropriate intervention. The nurse recognizes that this position will

allow proper visualization of the large intestine.

For which client is the nursing assessment of pain most likely to result in undertreatment?

an older adult who grimaces and states no pain after a gastrostomy tube placement; Clients at risk for insufficient pain control are older adults and those of ethnic origins that hold the tradition of stoicism, such as many Asian and Hispanic cultures. The nurse must assess carefully to provide culturally appropriate care. Clients who request medication, or are allowed to regulate their own medications, are more likely to have their pain controlled.

A client is admitted to the hospital through the emergency department with chest pain. Which intervention is the priority?

assessing troponin 1 levels; Troponin 1 rises with myocardial infarction. This assessment will best determine the cause of the client's chest pain and allow for immediate treatment. Monitoring the white blood count and platelet count and assessing the B-type natriuretic peptide levels are important, but not the priority.

If a client is receiving rescue breaths, and the chest wall fails to rise during cardiopulmonary resuscitation, what should the rescuer do first?

reposition the airway

A client with a longstanding diagnosis of generalized anxiety disorder presents to the emergency room. The triage nurse notes upon assessment that the patient is hyperventilating. The triage nurse is aware that hyperventilation is the most common cause of:

respiratory alkalosis; The most common cause of acute respiratory alkalosis is hyperventilation.

The nurse is reviewing the medical record and finds orders to apply graduated compression stockings on a client. What is the next action by the nurse?

measure the client's legs; After receiving orders for graduated compression stockings, the nurse would explain the procedure to the client and then measure the client's legs to determine the appropriate sized stocking. Improperly fitting stockings are uncomfortable and may be harmful to the client. Compression stockings should be placed in the morning, before the client is out of bed for the day to prevent blood vessels from being congested with blood, therefore, the nurse should place the compression stockings prior to having the client use the restroom. The nurse would not want to massage the legs. If a blood clot is present, this may cause the clot to break away from vessel and circulate in the bloodstream. Applying graduated compression stockings may be delegated to unlicensed assistive personnel, but only after the nurse has determined the correct size stocking by measuring the client's legs.

A nurse cares for a client who believes in Hinduism. The nurse understands that Hindus believe illness is caused by which type of behavior?

past and current life actions

A 5-year-old child diagnosed with cerebral palsy has just been prescribed oral baclofen. Which assessment finding by the nurse would indicate effective drug therapy?

the child is exhibiting less spasticity; Baclofen is a skeletal muscle relaxant that is effective in reducing overall spasticity. It is not an anti-seizure drug. Significant side effects of this drug are drowsiness and confusion, so this child would not be sleeping less, nor demonstrating a better ability to concentrate on mental activities.

A nurse has made a medication error. Which information is appropriate to include in the incident report?

what the nurse saw and did