NCLEX REVIEW PART 2
The nurse is assisting at a Poison Control Center telephone hotline. In which of the following cases of childhood poisoning would the nurse suggest that parents induce vomiting? A) A 14 month-old chewed two leaves of a philodendron plant B) An 18 month-old ate an undetermined amount of crystal drain cleaner C) A 20 month-old is found comatose on the bathroom floor beside an empty bottle of diazepam (Valium) D) A 30 month-old has swallowed a mouthful of charcoal lighter fluid
A) A 14 month-old chewed two leaves of a philodendron plant. With ingestion of a plant, there is no danger of aspiration or further tissue damage from emesis. Therefore, vomiting is a safe way to stop the poisoning process.
The parents of a newborn male with hypospadias want their child circumcised. The BEST response by the nurse is to inform them that A) Circumcision is delayed so the foreskin can be used for the surgical repair B) This procedure is contraindicated because of the permanent defect C) There is no medical indication for performing a circumcision on any child D) The procedure should be performed as soon as the infant is stabl
A) Circumcision is delayed so the foreskin can be used for the surgical repair. Even if mild hypospadias is suspected, circumcision is not done in order to save the foreskin for surgical repair, if needed.
An infant weighed 7 pounds 8 ounces at birth. If growth occurs at a normal rate, the nurse would expect the six month-old to A) Double the birth weight B) Triple the birth weight C) Gain 6 ounces each week D) Add 2 pounds each month
A) Double the birth weight. Although growth rates vary, infants normally double their birth weight by 6 months.
The nurse is caring for a 2 month-old child who has had a cleft lip repair. The BEST restraint to use for this child is the A) Elbow restraint B) Mummy restraint C) Jacket restraint D) Clove hitch restraint
A) Elbow restraint. The elbow restraint will prevent the child from touching the surgical site without hindering movement of other parts of his body.
A 3 year-old had a hip spica cast applied two hours ago. In order to facilitate drying, the nurse should A) Expose the cast to air and turn the child frequently B) Use a heat lamp to reduce the drying time C) Handle the cast with the abductor bar D) Turn the child as little as possible
A) Expose the cast to air and turn the child frequently. The child should be turned every two hours, with surface exposed to the air.
For a 6 year-old child hospitalized with moderate edema and mild hypertension associated with acute glomerulonephritis (AGN), which one of the following nursing interventions would be appropriate? A) Institute seizure precautions B) Weigh the child twice per shift C) Encourage the child to eat protein-rich foods D) Relieve boredom through physical activity
A) Institute seizure precautions. The severity of the acute phase of AGN is variable and unpredictable; therefore, a child with edema, hypertension, and gross hematuria may be subject to complications, and anticipatory preparation such as seizure precautions are needed.
The nurse is caring for a client with a long leg cast. During discharge teaching about appropriate exercises for the affected extremity, the nurse should recommend A) Isometric B) Range of motion C) Aerobic D) Isotonic
A) Isometric. The nurse should instruct the client on isometric exercises for the muscles of the casted extremity, i.e.., instruct the client to alternately contract and relax muscles without moving the affected part. The client should also be instructed to do active range of motion exercises for every joint that is not immobilized at regular and frequent intervals.
The nurse is teaching parents about the treatment plan for a 2 week-old infant with Tetralogy of Fallot. While awaiting future surgery, the nurse instructs the parents to IMMEDIATELY report A) Loss of consciousness B) Feeding problems C) Poor weight gain D) Fatigue with crying
A) Loss of consciousness. While parents should report any of the observations, they need to call the physician immediately if the level of alertness changes. This indicates anoxia, which may lead to death. The structural defects associated with Tetralogy of Fallot include pulmonic stenosis, ventricular septal defect, right ventricular hypertrophy and overriding of the aorta. Surgery is often delayed, or may be performed in stages.
A client treated for depression tells the nurse at the mental health clinic that he recently purchased a handgun because he is thinking about suicide. The FIRST nursing action should be to A) Notify the physician immediately B) Suggest in-client psychiatric care C) Respect the client's confidential disclosure D) Phone the family to warn them of the risk
A) Notify the physician immediately. The physician must be contacted immediately as the client is a danger to self and others. Hospitalization is indicated.
A client with schizophrenia is receiving Haloperidol (Haldol) 5 mg t.i.d. The client's family is alarmed and calls the clinic when "his eyes rolled upward." The nurse recognizes this as A) Oculogyric crisis B) Tardive dyskinesia C) Nystagmus D) Dysphagia
A) Oculogyric crisis. This refers to involuntary muscles spasm of the eye.
A client with asthma has low pitched wheezes present on the final half of exhalation. One hour later the client has high pitched wheezes extending throughout exhalation. What does this change in assessment indicate to the nurse? A) The client's airway obstruction is worsening B) The client's airway obstruction is improving C) The client needs to be suctioned D) The client is hyperventilating
A) The client''s airway obstruction is worsening. The higher pitched a sound is, the more narrow the airway; therefore, the obstruction has worsened. There is no evidence to support a need for suctioning; inhaled corticosteroids are not used during an acute attack.
A client complained of nausea, a metallic taste in her mouth, and fine hand tremors 2 hours after her first dose of lithium carbonate (Lithane). The nurse's BEST explanation would be A) These side effects are common and should subside in a few days B) She is probably having an allergic reaction and should discontinue the drug C) Taking the lithium on an empty stomach should decrease these symptoms D) Decreasing dietary intake of sodium and fluids should minimize the side effects
A) These side effects are common and should subside in a few days. Nausea, metallic taste and fine hand tremors are common side effects that usually subside within days.
The nurse is assessing an infant with developmental dysplasia of the hip. Which of the following findings would the nurse anticipate? A) Unequal leg length B) Limited adduction C) Diminished femoral pulses D) Symmetrical gluteal folds
A) Unequal leg length. Shortening of a leg is a sign of developmental dysplasia of the hip.
Which response by the nurse would BEST assist the chemically impaired client to deal with issues of guilt? A) "Addiction usually causes people to feel guilty. Don't worry, it is a typical response due to your drinking behavior." B) "What have you done that you feel most guilty about and what steps can you begin to take to help you lessen this guilt?" C) "Don't focus on your guilty feelings. These feelings will only lead you to drinking and drugging." D) "You've caused a great deal of pain to your family and close friends, so it will take time to undo all the things you've done."
B) "What have you done that you feel most guilty about and what steps can you begin to take to help you lessen this guilt?". This response encourages the client to get in touch with their feelings and utilize problem solving steps to reduce guilt feelings.
To prevent a valsalva maneuver in a client recovering from an acute myocardial infarction, the nurse would A) Assist the client to use the bedside commode B) Administer stool softeners every day as ordered C) Administer antidysrhythmics prn as ordered D) Maintain the client on strict bed rest
B) Administer stool softeners every day as ordered. Administering stool softeners every day will prevent straining on defecation which causes the Valsalva maneuver. If constipation occurs then laxatives would be necessary to prevent straining. If straining on defecation produced the valsalva maneuver and rhythm disturbances resulted then antidysrhythmics would be appropriate.
A newborn has been diagnosed with hypothyroidism. In discussing the condition and treatment with the family, the nurse should emphasize A) They can expect the child will be mentally retarded B) Administration of thyroid hormone will prevent problems C) This rare problem is always hereditary D) Physical growth/development will be delayed
B) Administration of thyroid hormone will prevent problems. Early identification and continued treatment with hormone replacement corrects this condition.
A home health nurse is caring for a client with diabetes and arthritis who has difficulty drawing up insulin. It would be MOST appropriate for the nurse to refer the client to A) A social worker B) An occupational therapist C) A physical therapist D) A home health aid
B) An occupational therapist An occupational therapist can assist a client to improve the fine motor skills needed to prepare an insulin injection.
The physician has ordered transdermal nitroglycerin patches for a client. The nurse should instruct the client to A) Remove the patch when swimming or bathing B) Apply the patch to any non-hairy area of the body C) Apply a second patch with chest pain D) Remove the patch if ankle edema occurs
B) Apply the patch to any non-hairy area of the body. The patch may be applied to any non-hairy area on the body.
The nurse is assessing a client who has taken haldol (Haloperidol) for several months. Which of the following is a side effect of this medication and must be reported IMMEDIATELY to the physician? A) Muscle flaccidity B) Dystonic reaction C) Mood swings D) Dry, harsh cough
B) Dystonic reaction Haldol is a neuroleptic antipsychotic drug that may cause distonic reaction. Dosage may have to be adjusted.
On admission to the psychiatric unit, the client is trembling and appears fearful. The nurse's INITIAL response should be to A) Give the client orientation materials and review the unit rules and regulations B) Introduce him/herself and accompany the client to the client's room C) Take the client to the day room and introduce her to the other clients D) Ask the nursing assistant to get the client's vital signs and complete the admission search
B) Introduce him/herself and accompany the client to the client's room. Anxiety is triggered by change that threatens the individual's sense of security. In response to anxiety in clients, the nurse should remain calm, minimize stimuli, and move the client to a calmer, more secure/safe setting.
The nurse enters the room as a three year-old is having a generalized seizure. Which of the following should the nurse do FIRST? A) Clear the area of any hazards B) Place the child on the side C) Restrain the child D) Give the prescribed anticonvulsant
B) Place the child on the side. Protecting the airway is the top priority in a seizure. From the Pediatric reference below, it is stated (pg.1055) 'if a child is actively convulsing, a patent airway and oxygenation must be assured....If the event occurs when the child is in a chair or standing, the child should be gently be helped to the ground and placed on one side and any nearby objects moved out of the way.' Thus, first note that the test question topic is about a generalized seizure. Given the options, most test takers narrow it to options a or b, which are both correct. Based on the data above and what you know to deal with airway first, ask yourself, 'Which action supports airway maintenance?' Of course, option b is the best answer. Protection from the environment, option a, is the second action.
A client is two days post operative. The vital signs are: BP - 120/70, HR - 110, RR - 26, and Temperature - 100.4 degrees F (38 degrees C). The client suddenly becomes profoundly short of breath, skin color is gray. Which assessment would have alerted the nurse FIRST to the client's change in condition? A) Heart rate B) Respiratory rate C) Blood pressure D) Temperature
B) Respiratory rate. Tachypnea is one of the first clues that the client is not oxygenating appropriately. The compensatory mechanism for decreased oxygenation is increased respiratory rate.
While planning care for a two year-old hospitalized child, the nurse expects that behavior would be MOST affected by A) Strange bed and surroundings B) Separation from parents C) Presence of other toddlers D) Unfamiliar toys and games
B) Separation from parents. Separation anxiety if most evident from 6 months to 30 months of age. It is the greatest stress imposed on a toddler by hospitalization. If separation is avoided, young children have a tremendous capacity to withstand other stress.
The nurse is caring for a newly delivered woman with HIV/AIDS. The client asks about the infant's risk of developing AIDS. Which of the following responses by the nurse is based on an understanding of perinatally acquired AIDS? A) "Your baby is at high risk immediately after birth." B) "Most newborns are immune to the HIV virus." C) "The first 18 months are the time of greatest risk." D) "Breast feeding will reduce your baby's risk."
C) "The first 18 months are the time of greatest risk.". The majority of infants with perinatally acquired AIDS develop symptoms within the first 18 months of life.
A client is scheduled for an Intravenous Pyelogram (IVP). In order to prepare the client for this test, the nurse would A) Instruct the client to maintain a regular diet the day prior to the examination B) Restrict the client's fluid intake 4 hours prior to the examination C) Administer a laxative to the client the evening before the examination D) Inform the client that only one x-ray of his abdomen is necessary
C) Administer a laxative to the client the evening before the examination. Bowel prep is important because it will allow greater visualization of the bladder and ureters.
The nurse is caring for a post-surgical client at risk for developing deep vein thrombosis. Which of the following is an effective preventive measure? A) Place pillows under the knees B) Use elastic stockings continuously C) Encourage range of motion and ambulation D) Massage the legs twice daily
C) Encourage range of motion and ambulation. Mobility reduces the risk of deep vein thrombosis in the post-surgical client and the adult at risk.
A client was admitted to the psychiatric unit after complaining to her friends and family that neighbors have bugged her home in order to hear all of her business. She remains aloof from other clients, paces the floor and believes that the hospital is a house of torture. Nursing interventions for the client should appropriately be directed toward A) Convincing the client that the hospital staff is trying to help B) Helping the client to enter into client group recreational activities C) Helping the client learn to trust staff D) Arranging the environment to limit the client's contact with other clients
C) Helping the client learn to trust staff. This establishes trust, facilitates a therapeutic alliance between staff and client.
A mother brings her 26 month-old to the well-child clinic. She expresses frustration and anger due to her child's constantly saying "no" and his refusal to follow her directions. The nurse explains this is normal for his age, as negativism is attempting to meet which developmental need? A) Trust B) Initiative C) Independence D) Self-esteem
C) Independence Independence and autonomy versus shame and doubt are the developmental tasks of toddler hood.
The nursing care plan for a client with decreased adrenal function should include A) Encouraging activity B) Placing client in reverse isolation C) Limiting visitors D) Measures to prevent constipation
C) Limiting visitors. Any exertion, either physical or emotional, places additional stress on the adrenal glands which could precipitate an addisonian crisis. The plan of care should protect this client from the physical and emotional exertion of visitors.
The nurse is caring for a 13 year-old following spinal fusion for scoliosis. Which of the following interventions is appropriate in the immediate post-operative period? A) Raise the head of the bed at least 30 degrees B) Encourage ambulation within 24 hours C) Maintain in a flat position, logrolling as needed D) Encourage leg contraction and relaxation after 48 hours
C) Maintain in a flat position, logrolling as needed. The bed should remain flat for at least the first 24 hours to prevent injury. Logrolling is the best way to turn for the client while on bed rest.
A nurse who is evaluating a mentally retarded two year-old in a clinic should stress the following goal when talking to the child's mother A) Teaching the child self care skills B) Preparing for independent toileting C) Promoting the child's optimal development D) Helping the family decide on long term care
C) Promoting the child''s optimal development. The primary goal of nursing care for a mentally retarded child is to promote the child''s optimum development.
A PRIORITY goal of involuntary hospitalization of the severely mentally ill client is A) Re-orientation to reality B) Elimination of symptoms C) Protection from self-harm and harm to others D) Return to independent functioning
C) Protection from self-harm and harm to others Involuntary hospitalization may be required for persons considered dangerous to self or others or for individuals who are considered gravely disabled.
The nurse is caring for a client in the late stages of Amyotrophic Lateral Sclerosis (A.L.S.). Which of the following assessments would the nurse expect to find? A) Confusion B) Loss of half of visual field C) Shallow respirations D) Tonic-clonic seizures
C) Shallow respirations. A.L.S. is a chronic progressive disease that involves degeneration of the anterior horn of the spinal cord as well as the corticospinal tracts. When the intercostal muscles and diaphragm become involved, the respirations become shallow and coughing is ineffective.
Which of the following measures would be appropriate for the nurse to teach the parent of a nine monthold infant about diaper dermatitis? A) Use only cloth diapers that are rinsed in bleach B) Do not use occlusive ointments on the rash C) Use commercial baby wipes with each diaper change D) Discontinue a new food that was added to the infant's diet just prior to the rash
D) Discontinue a new food that was added to the infant''s diet just prior to the rash. The addition of new foods to the infant''s diet may be a cause of diaper dermatitis.
A nurse is using an interpreter to teach a client about home care. It is IMPORTANT for the nurse to A) Speak directly to the interpreter while presenting content B) Talk to the interpreter in advance and leave the client and interpreter alone C) Include family member and direct comments to that person D) Face the client while presenting content
D) Face the client while presenting content. Communication is the cornerstone of an effective teaching plan, especially when the nurse and client do not share the same cultural heritage. Even if the nurse uses an interpreter, it is critical that the nurse use conversational style and spacing, personal space, eye contact, touch, and orientation to time strategies that are acceptable to the client. Therefore, face the client and present the content to the client, allow the interpreter to translate the content. Facing the client allows non-verbal communication to take place between the client and nurse.
A 16 year-old client is admitted to a psychiatric unit with a diagnosis of attempted suicide. The nurse is aware that the most frequent cause for suicide in adolescents is A) Progressive failure to adapt B) Feelings of anger or hostility C) Reunion wish or fantasy D) Feelings of alienation or isolation
D) Feelings of alienation or isolation. The isolation may occur gradually resulting in a loss of all meaningful social contacts. Isolation can be self imposed or can occur as a result of the inability to express feelings.
The nurse prepares to administer eye drops to a six year-old child. The CORRECT way to give the eye drops is to instill them A) Directly on the anterior surface of the eyeball B) In the corner where the lids meet C) Under the upper lid as it is pulled upward D) In the conjunctival sac as the lower lid is pulled down
D) In the conjunctival sac as the lower lid is pulled down. Eye drops should be placed in the sac between the eye and the lower lid. This sac is formed by pulling the lower lid down.
Following a diagnosis of acute glomerulonephritis (AGN) in their 6 year-old child, the parents remark that they are unclear as to how he caught the disease. The nurse's response is based on the understanding that A) AGN is a streptococcal infection involving the kidney tubules B) The disease is easily transmissible in schools and camps C) The illness is usually associated with chronic respiratory infections D) It is not "caught" but is a response to a previous B-hemolytic strep infection
D) It is not "caught" but is a response to a previous B-hemolytic strep infection. AGN is generally accepted as an immune-complex disease in relation to an antecedent streptococcal infection, and is considered as a noninfectious renal disease.
Which of the following behavioral characteristics describes the domestic abuser? A) Alcoholic B) Over confident C) High tolerance for frustrations D) Low self-esteem
D) Low self-esteem. Batterers are usually physically or psychologically abused as children or have had experiences of parental violence. Batterers are also manipulative, have a low self-esteem, and have a great need to exercise control or power-over partner.
The nurse is teaching a client with chronic obstructive pulmonary disease to use occasional pursed-lip breathing. What is the MAJOR reason for this? A) Maintain an open airway B) Expel carbon dioxide C) Avoid dry mucous membranes D) Prevent alveolar collapse
D) Prevent alveolar collapse. Clients with chronic obstructive pulmonary disease have difficulty exhaling fully as a result of their disease process. Alveolar collapse can be avoided by using pursed-lip breathing.