Nclex review ( health promotion and maintenance)

The nurse in the clinic would recognize which client statement as most indicative of gallbladder disease?

"Yesterday, when I ate a hamburger and french fries, my belly really hurt."

Ice causes vasoconstriction and is most effective if applied soon after the birth to prevent edema and to numb the area. Chemical ice packs or clean gloves filled with ice may be used during the first 12 hours after a vaginal birth. Witch hazel contains chemicals called tannins. When applied directly to the skin, witch hazel might help reduce swelling and help repair broken skin. Analgesics such as __ and __such as ibuprofen frequently are prescribed to provide relief for mild to moderate discomfort. ___ anesthetic may be used as needed to decrease surface discomfort and allow more comfortable ambulation. Sexual intercourse prior to healing of the episiotomy may contribute to further perineal damage.

- Acetaminophen and NSAID - Topical

Timolol does decrease __ humor formation; therefore decreasing intraocular pressure (IOP).

- aqueous

If you need to remove hair use?

- clippers and hair removal cream

A LPN/VN plans to reinforce education that was provided to a group of new parents about how to prevent burn injuries in children. What points should be included?

1. Eliminate use of placemats. 2. Establish "no" zones for space heaters. 3. Cover unused electrical outlets.

What information should the nurse give a pregnant client who comes to the clinic reporting hemorrhoids and constipation?

1. Increased rectal pressure from the gravid uterus may result in hemorrhoids. 2. Hormones decrease maternal GI motility, resulting in constipation. 3. More fluid and fiber is needed in the diet. Increase daily fluid intake.

The palliative care nurse is reinforcing instructions with the family of a client who is experiencing nausea and vomiting on methods of controlling these symptoms. What methods should the nurse include?

1. Offer electrolyte replacement drinks or broths. 2. Avoid cooking close to the client. 3. Provide light, bland food.

A client is admitted with a diagnosis of myasthenia gravis. What nursing interventions will assist in managing the client's swallowing and chewing impairment?

1. Provide foods that are soft and tender. 2. Allow client to rest between bites. 3. Encourage client to drink thickened liquids. head tilted FORWARD

What actions should the nurse take when administering fentanyl?

1. Remove old fentanyl patch prior to applying new patch. 2. Cleanse area of old fentanyl patch. Place fentanyl patch over dry skin.

Hold sulfonylureas for BS <__ until the client eats.

100

A temperature of ___ F (38.05° C) or greater in a client more than 24 hours postpartum is likely an indication of infection. This client should be kept separate from other mothers and babies.

100.5

Posterior fontanel closes at _ months.

2

An 8 year old smiles when mom places the "B" paper on the refrigerator. Which Erikson developmental stage is this child displaying?1. Autonomy vs. Shame and Doubt 2. Initiative vs. Guilt 3. Industry vs. Inferiority 4. Identity vs. Role Confusion

3

When prescribed any medication along with sucralfate, the client should avoid taking the medication at the same time with sucralfate. Sucralfate can make it harder for the body to absorb lansoprazole because it forms a "coating" or "barrier" on the stomach lining. Therefore, the client should wait at least __minutes after taking the lansoprazole before taking sucralfate.

30

After report, the nurse is assigned to care for 4 adult clients. Which client should the nurse collect data on first? 1. Admitted 3 hours ago post appendectomy with small amount of drainage on dressing. 2. Diagnosed with early onset of Alzheimer's disease with confusion. 3. Post operative internal fixation of the femur with crust forming on the Steinman pins. 4. Receiving treatment for dehydration, and is now picking at bedding and IV tubing.

4. Restless is a sign of hypoxia, oxygen takes priority over other choices

Administering a beta blocker to a client who has a heart rate less than __ could possibly cause the client to develop symptomatic bradycardia and hypotension.

60

A nurse is caring for a client following a TURP procedure. Which of the following assessment findings most concerns the nurse? Heart rate of 116 beats/min. Urine output of 20 mL/hr Urinary retention Small blood clots in the urine

A TURP procedure involves the surgical insertion of a thin instrument called a resectoscope through the urethra. Clients who undergo TURP are at risk for both local and systemic complications. A heart rate of 116 beats/min. could be a sign of infection. This symptom, along with fever, should be monitored for and reported after surgery.

provide meals 30 min before or after cholinesterase inhibitor?

AFTER

TB is ___ so use a ___ mask

Airborn, N95

Which finding should a nurse expect when collecting data on a healthy 65 year old client?

As the lens becomes less flexible, the near point of focus gets further away. This condition, presbyopia, usually begins in the 40s. Reading glasses to magnify objects are required.

The nurse monitors the client's pain level after administering an oral analgesic. The client states that the pain is better but continues to report a backache. Which non-pharmacologic interventions may help the client's backache?

Assisting the client into a side lying position. 3. Providing a back massage. 4. Providing heat therapy. 5. Using distraction techniques.

The primary healthcare provider prescribes a combination of pyrazinamide and isoniazid to treat a client with tuberculosis. The client asks the nurse why he is taking two drugs. Which explanation should the nurse give?

Bacterial resistance is decreased

If a pregnant woman gets rubella from an unimmunized child during the first trimester, there is a chance the child will have a ___ ___

Birth defect Goal is to prevent defects of of child in utero

A nurse working on the medical-surgical floor is caring for a post-op client who is on bowel rest after a small bowel resection and is prescribed total parenteral nutrition (TPN). The nurse monitors the client closely for which of the following?

Blood glucose, because TPN can elevate blood glucose levels even in clients without diabetes

The nurse is helping a client to bed when the client begins having a generalized seizure. Which action should the nurse take?

By assisting the client to the floor, the nurse prevents harm to the client. The side-lying position prevents aspiration should the client vomit. It helps to keep the airway clear and this is the first priority.

Which assigned postpartum client should the nurse identify as being at highest risk for hemorrhage?

C-section delivery A client with a surgical wound is at risk for hemorrhage and is at greater risk than birth from a vaginal delivery. The surgical opening of the abdomen and the uterus makes this the highest risk.

Priority when giving pre op meds? - consent - check id band

Check id band

The nurse is caring for an immobile client. Which complication is the nurse's priority?

Deep vein thrombosis

What symptoms does the nurse expect to see in a client with bulimia nervosa?

Diagnostic criteria for bulimia nervosa are recurrent episodes of binge eating; recurrent inappropriate compensatory behavior to prevent weight gain such as laxative, diuretic, or enema use, induced vomiting, fasting, and excessive exercise; and feeling of self-worth unduly influenced by weight.

initiate what with whooping cough, pneumonia, influenza, and bacterial mennigitis?

Droplet

A term male infant was just delivered vaginally. Which action by the nurse has priority?

Dry the baby, cold stress is biggest danger to newborn

Always use what when drawing meds from an ampule?

Filter

least restictive to most restrictive

First, verbally tell the client to stop the unacceptable behavior and escort client to another part of the day room. This is the least restrictive. Second, walk the client out to the courtyard. This removes the client from the situation while still allowing some freedom. Third, take the client to the quiet room for a time out. This removes the client from the situation but also sets restrictions on where and with whom they can interact. Fourth, place client in the isolation room with staff observation. This is more restrictive than the quiet room, but doesn't require restraints. Fifth, restrain client's arms with wrist restraints. This is a two point restraint which is much more restrictive than the isolation room. Lastly, use four point soft cloth restraints. This is the most restrictive.

Where should a nurse place the stethoscope when auscultating heart sounds?

Fourth intercostal space to the left of the sternum to hear sounds from the tricuspid area. 3. Second intercostal space to the right of the sternum to hear sounds from the aortic valve area.

Which suggestion should the nurse provide to a client reporting frequent episodes of constipation?

Fruit is high in fiber. Increased fiber intake may help to establish regular elimination habits by promoting the movement of material through the digestive system and increasing stool bulk.

Three hours after delivery of a client's newborn, the nurse monitors for bladder distention. What signs would the nurse note if the client's bladder is distended?

Fundus 3 cm above umbilicus 2. Excessive lochia . Tenderness above symphysis pubis

A nurse working in a locked psychiatric unit is caring for a client diagnosed with paranoia. The client becomes very agitated and shouts, "I am not going to my session today!" What action by the nurse would be most appropriate?

Get them active. Redirect their activity. This is a much more therapeutic and effective intervention to help the paranoid client.

How should the nurse respond to a pregnant client who asks, "How will I know when it is time to go to the hospital?"

Go to the hospital immediately if your membranes rupture."The client should go when contractions are 5 minutes apart, for 1 hour if it is her first pregnancy. Labor may be faster for the woman who has given birth before than for the nullipara. Multiparas are instructed to go to the hospital when contractions are regular, 10 minutes apart, for 1 hour.

Post partum psychosis is characterized by depressed mood, agitation, indecision, lack of concentration, guilt, and an abnormal attitude toward bodily functions. There is a lack of interest in or rejection of the baby, or a morbid fear that the baby may be harmed. Risks of suicide and infanticide should not be overlooked.

If client calls about this- have them come to office

Clients prescribed warfarin will need to reduce the intake of food sources with high levels of vitamin _. High levels of vitamin K interfere with __ by decreasing the effectiveness of warfarin to prevent blood clots. The vitamin K level of 1 cup of raw spinach is 144.87 mcg. The vitamin K level of 1 cup of raw broccoli is 92.46 mcg. Because spinach and broccoli are high in vitamin K, the client should eat sparingly or refrain from eating spinach, and broccoli.

K Warfarin

A nurse is providing care to a post-operative parathyroidectomy client. Which complication takes priority?

Layngospasm

Nurse doesn't know how to do a procedure, do what?

Look up how to perfrom the procedure in policy and procedure manual

Which ethical principle is involved in reporting a medication error to the primary healthcare provider?

Nonmaleficence is best illustrated with the nurse's action, as the goal is to do no harm to the client. With timely reporting of an error, further complications may be prevented.

The nurse is admitting a client with a fifteen year history of poorly controlled diabetes mellitus. During the initial data collection, the client reports experiencing "numb feet." What is the nurse's first action?

Observe the client's feet for signs of injury.

What should the nurse include when reinforcing teaching to a client in renal failure about peritoneal dialysis

Once the prescribed dwell time has ended, the bag is lowered and the fluids, along with the toxins, are drained out into a bag over a period of 15 - 30 minutes. The fluid should be clear in appearance (should be able to read a paper through it). Cloudy return could indicate infection. Since the dialysate has a lot of glucose in it, the client frequently reports a constant sweet taste.

How do you stop bleeding from a puncture site? With ____, right? Yes. So where is the liver? In the ___ ___ abdomen under the rib cage. So position the client on the right side so that pressure is applied to the liver's puncture site. Then apply pressure with a sand bag or rolled up towel. This will help to stop bleeding.

Pressure Right upper

A client is diagnosed with a duodenal ulcer due to Helicobacter pylori (H Pylori). In addition to antibiotic therapy, the nurse anticipates that the client will also receive what class of pharmacologic agent?

Proton pump inhibitor

theres a fire in the clients room, steps for this?

RACE Remove the client from the room. Activate the fire alarm. Close the door to the client's room. Obtain the fire extinguisher. Extinguish the fire.

Client has hep b, reinforce what to family?

Reinforce to not share personal items, such as razors of toothbrush

During the acute stage of ___ ____, rest is crucial for the heart and cardiovascular system. Resting while listening to music, or even watching television, would allow the child to relax while being entertained.

Rheumatic fever

The nurse is caring for a woman in labor. The woman becomes irritable, restless, complains of nausea, and has heavier show. The membranes just ruptured spontaneously. The nurse understands that this indicates:

She is in the transition phase of labor

What actions would be appropriate for a nurse who is administering ear drops to a six year old child?

Supine with affected ear up allows for proper administration of medication. Never attempt to put drops directly on the eardrum. Administer along inside of ear so that drops flow by gravity into ear. Remaining supine for several minutes permits the fluid to be absorbed.

A client diagnosed with a duodenal ulcer is prescribed lansoprazole and sucralfate. What should the nurse reinforce to the client about how to take these medications?

Take the lansoprazole first, wait at least 30 minutes, then take the sucralfate.

What action should the nurse take when a client receiving 40 mL/hr of enteral feedings has a gastric residual volume of 250 mL?

The action is to recheck gastric residual in 1 hour. This may be a sign of intolerance. Reasons for delayed gastric emptying must be determined if 250 mL or more remains on 2 (1 hour apart) checks.

The nurse cares for a client who is diagnosed with methicillin-resistant Staphylococcus aureus (MRSA) infection. Which precaution is important for the nurse to implement?

The client's room should be stocked with dedicated equipment just for that client to prevent the nurse from spreading MRSA to other clients through cross-contamination. The nurse should perform hand hygiene before and after client contact. Clients that are infected with MRSA should be placed on contact precautions.

What foods should the nurse reinforce to the client to avoid for three days prior to a guaiac test?

The guaiac test is used to detect fecal occult blood. Foods that affect this test include raw broccoli, red meats such as steak, turnip greens, cantaloupe, radish, and horseradish. All of these could cause a false positive reading for the guaiac test.

A client, diagnosed with schizophrenia, tends to spend most of the time in bed and is very uncomfortable when other clients are in the day area of the unit. What activity would be most therapeutic for the nurse to initiate with this client?

The interaction with the nurse can keep the conversation reality based and provide interaction with someone. Clients with schizophrenia may be very withdrawn and need the presence of the nurse.

Move both crutches forward without bearing weight on the affected leg, then move the unaffected leg forward.

This method is correct for the three-point gait. Client has to bear weight on the unaffected foot and both crutches. The affected leg does not touch the ground.

What should the nurse do to prevent ageism when working with older adults client?

Understand the normal ageing process, while maintaining contact with healthy, independent, older clients

Which meal option should the client diagnosed with gout select?

Vegetable soup, whole wheat toast, skim milk This is a good choice as it is low in purine and fat. Meat and seafood increase the risk of gout. Dairy products may lower risk for gout.

Which health problem does the nurse recognize as putting the client at risk for hypomagnesemia?

We get magnesium from food. Because an alcoholic drinks, and thereby eats very little, magnesium intake is often not adequate. Also, alcohol suppresses the release of ADH. Decreased ADH leads to diuresis and magnesium loss.

A client develops pernicious anemia after a Billroth II procedure and is to receive vitamin B12 intramuscularly. What should the nurse include when reinforcing discharge instructions?

With pernicious anemia, the client lacks the intrinsic factor. Without the intrinsic factor, B12 cannot be absorbed. The client will require B12 shots throughout the lifespan.

What is the best method for the nurse to verify correct nasogastric (NG) tube placement after insertion?

X-ray of the upper GI

____is the inability to experience pleasure, which is seen in clinical depression.

anhedonia

The nurse should not continue ____ if the client is becoming so distressed. Perhaps the bath can be completed at a later time. Safety is the priority.

bathing

anticoagulants are ___ ___ meds

blood thining meds

The ___ should be removed first, followed by ___ --, removal of the protective ___, and finally removal of the ____

gloves hand washing eyewear gown

First, perform hand hygiene Second, apply ____. Tying at neck and waistThird, put __ on covering mouth and noseF ourth, place ____ snugly around face and eyesFifth, apply ___ ____

gown mask goggles clean cloves

When a client is admitted with a head injury what should we worry about?

increased ICP and seizures

Antisecretory agents like proton pump inhibitors are indicated for the treatment of ___ ___disease. Antisecretory agents decrease the secretion of gastric acids. Protein pump inhibitors, a combination of antibiotics and bismuth salts are most commonly used for treatment of H Pylori.

peptic ulcer

do not use ___ jelly with oxygen

petroleum(its combustible)

Minus two station is high with the presenting part not engaged. This client is at high risk for ___ __ which would require relieving pressure on the cord and emergency cesarean delivery.

prolapsed cord

Hormonal contraceptives containing estrogen such as combination birth control pills, topical hormonal contraceptive patches, and vaginal rings are inappropriate for clients with a history of ___ ---- (blood clot in the lungs)

pulmonary embolism

The nurse is preparing to leave the client's room where personal protective equipment has been necessary. What should the nurse do first?

remove the gloves

Since Clostridium difficile is a spore (killed by sterilization), the friction performed during washing hands with soap and water rinses organisms off the hands. The nurse should also implement ___ and ____ precautions to protect the client and the nurse.

standard and contact

Most states or jurisdictions allow practical nurses to delegate, and the NCLEX assumes this. In your state, this is determined by your ___ ___ ___ ___

state nurse practice act

A newly admitted client tells the nurse, "I am hearing voices." Which response by the nurse is most appropriate?

the nurse needs to know what the voices are saying to the client. This is the first thing the nurse would ask if the newly admitted client tells the nurse about hearing voices. The nurse does not know the client or the diagnosis that might be affiliated with this statement.

UAP is relieving traction for a client that is going to an xray, should the nurse stop them from doing this?why?

yes, because you need to have an order to do this. And the pt can get an xray with traction

____, which is the unstable self-identity of an individual with schizophrenia may lead to feelings of unreality (the feeling that one's parts have changed or a sense of seeing oneself from a distance). 2. The client who exhibits ___ may purposelessly imitate movements made by others. 3. ___ is the invention of new words by a psychotic client.

- depersonalization - echopraxia - neologism

Normal Values -Platlet - WBC - RBC

- platlet: 150,000-400,000 - wbc: 5,000-10,000 - RBC: Male 4.7-6.1 Female 4.2-5.4

A positive Chovostek's and Trousseau's is indicative of ___ and low ___. This can occur if ____ are accidentally removed when the thyroid is removed.

- tetany , low calcium -parathyroids

The client is receiving a prostaglandin agonist for the treatment of glaucoma. Which comment by the client indicates a lack of understanding of the treatment regimen?

-"My eyes may be different colors, so I will use the drops in both eyes. -he color of the iris may darken in the eye being treated; however, it is important that the client understand that drops should not be placed in the unaffected eye. To do so may result in a subnormal intraocular pressure.

A hematocrit in postpartum women can drop as low as __ percent (0.2) and not require transfusion in the absence of symptoms of hypovolemia. A hematocrit of __ and lower should be reported even in the absence of dizziness, lightheadedness, shortness of breath with exertion, and syncope.

-20 -18

Frostbite prevention with teenagers who participate in cold weather activities:

-Alcohol abuse -Dehydration -Diabetes -Exhaustion

Person is in cardiac arrest. What to do? Apply? Continue? Stop? Shout?

-Apply defibrilator to bare skin -Continue CPR until advised to deliver shock -Stop CPR while machine analyzes rhythm -Shout clear

A nurse observes a therapist caring for a client leave a laptop computer open in the hallway while obtaining a drink for a visitor. While the therapist is away from the console, client information is left visible on the screen. Which of the following is the priority nursing action?

-Report the occurrence via the facility's reporting system. -t is the duty of the nurse to protect the privacy and confidentiality of clients to ensure a trusting relationship between healthcare providers and clients. The nurse should follow facility procedure to complete an incident report, which can be investigated by designated management staff.

Linens caught on fire, what type of extinguisher to use?

-Water, for type A fires -

Risk factors for osteoporosis

-sports injury to joint -Genetic -Obesity -Repetitive Joint stress

The LPN/VN is collecting health assessment data from the preoperative client scheduled for hip replacement surgery. Which statement by the client would be most important for the nurse to report to the primary healthcare provider?

. "I had rheumatic fever when I was 10 years old."After having rheumatic fever, a client would need to be pre-medicated with antibiotics prior to any surgical or dental procedure to prevent the development of infective endocarditis.

A nurse is reinforcing teaching with a client who has frequent urinary tract infections on how to prevent future infections. What statement by the client would indicate to the nurse that this has been successful?

. "I will go to the bathroom as soon as the urge to void hits me." "I should eat foods such as plums and prunes to increase the acidity of my urine." When I clean after voiding, I will discard toilet paper after each swipe."

The drug nadolol is prescribed to a client with stable angina. Which findings would the nurse expect to observe?

. Decreased anxiety 2. Relief of chest pain lowered BP

When caring for young adult clients, which developmental tasks would the nurse expect to see?

. Developing meaningful and intimate relationships. 3. Giving and sharing with an individual without asking what will be given or shared in return.

A client who has chronic renal failure has been prescribed synthetic erythropoietin for the prevention of anemia. Which data should be reported to the primary healthcare provider?

. Swelling of feet and ankles Swelling of feet and ankles may indicate the beginning of a cardiovascular problem. Clients taking this drug are at risk for myocardial infarctions and risk of blood clots.

The nurse is caring for a client admitted with heart failure. Which prescriptions would necessitate that the nurse seek clarification from the primary healthcare provider? . Furosemide 20.0 mg p.o. daily. 2. Rosuvastatin 5 mg p.o hs 3. Digoxin 0.125 mg PO every 8 hours for three doses 4. Folic acid 1 mg daily. 5. Heparin 1000 IU subcutaneously daily.

1 4 5

What statement by a new LPN would indicate an understanding of how to maintain skin integrity for a client on bedrest?

1. "Clients on bedrest should be placed on therapeutic mattresses."3. "I will assess the skin using the Braden scale." 4. "A pillow will be placed between the knees when client is side lying." 5. "The incontinent client will be kept clean and dry."

A client is diagnosed with emphysema. Which clinical signs should the nurse expect to see?

2. Barrel chest 3. Tachypnea 4. Use of accessory muscles with respiration

The nurse sees that the new medication noted in a recent prescription is on the client's list of allergies. What actions should the nurse take to ensure client safety?

2. Notify the primary healthcare provider immediately that the medication prescribed is on the client's list of medication allergies. 3. Stop the medication on the client's medication administration record. 4. Check the client's allergy band against the list of client allergies documented in the medical record.

On morning rounds, the nurse finds a somnolent client with a blood glucose of 89 mg/dL(4.9 mmol/l). A sulfonylurea and a proton pump inhibitor are scheduled to be administered. What is the nurse's best action?

Give proton pump inhibitor and hold sulfonylurea until client eats

What does a non-stress test tell the nurse about a pregnant client?

The baby is doing well and the placenta is providing enough oxygen at this time

The nurse is planning care for a client who has a fractured hip. Which nursing interventions are appropriate for this client?

The client must be turned every two hours. You may not be able to turn the client totally on the side of the fracture, but you must relieve pressure points. Place pillow between legs to keep affected leg in abducted position. Encourage fluid intake and ankle and foot exercises to prevent deep vein thrombosis (DVT).

The nurse is cleaning and dressing a foot ulcer of a diabetic client. Which actions are appropriate? Do not use what?

The nurse needs to wear sterile gloves when cleaning the wound. Normal saline solution is the preferred cleansing agent because, as an isotonic solution, it doesn't interfere with the normal healing process. Gently clean the wound in a full or half circle, beginning in the center and working toward the outside. - do not use a wash cloth

The primary healthcare provider is preparing to drain a large abdominal abscess. The client has dementia and moves about on the bed frequently. Which personal protective equipment (PPE) should the nurse wear while holding the client for the procedure?

The nurse should implement transmission based contact precautions. During drainage of an abscess, the nurse may come into direct and indirect contact of the contaminated body fluids. The nurse needs the protection of a gown, mask, face shield, and regular exam gloves. Since the nurse is not directly assisting with the wound care, regular exam gloves are appropriate.