NCLEX-RN
A client with type 1 diabetes must undergo bowel resection in the morning. How should the nurse proceed while caring for him on the morning of the surgery?
Administer half of the client's typical morning insulin dose as ordered. Reason: If the nursed administers the client's normal daily dose of insulin while he's on nothing-by-mouth status before surgery, he'll experience hypoglycemia. Therefore, the nurse should administer half the daily insulin dose as ordered.
A young man with early-stage testicular cander is scheduled for a unilateral orchieotomy. The clients confides to the nurse that he is concerend about what effect the surgery will have on his sexual performance. Which of the following responses by the nurse provides accurate information about sexual performance after orchietomy?
Because your surgery does not involve other organs or tissues, you'll likely not notice much change in your sexual performance. Reason: Although there may not be a big change in sexual function with a unilateral orchietomy, the loss of gonad and testerone may result in decreased libido and sterility. Sperm banking may be an option woth exporing if the number and motility of sperm are adequate.
A client with gastroenteritis is admitted to an acute care facility and presents with severe dehyrdration and electrolyte imbalances. Diagnostic tests reveal the Norwalk virus as the cause of gastroenteritis. Based on this information, the nurse knows that:
Enteric precautions must be continued. Reason: The nurse must continue enteric precautions for a client with gastroenteritis caused by the Norwalk virus because this virus is transmitted by the fecal-oral route. No safe and effective antiviral agent is available specifically for treating viral gastroenteritis.
When performing a physical assessment on an 18-month-old child, whidh of the following would be best?
Have a parent hold the toddler. Reason: The best strategy for assessing a toddler is to have the parent hold the toddler. Doing so is comforting to the toddler.
On initial assessment of a 7-year-old with rheumatic feveer, which of the following would require contacting the primary care provider immediately?
Heart rate of 150 beats / minute. Reason: A heart rate of 150 beats / minute is very high for a 7-year-old child and may indicate carditis. For this age group, the normal heart rate while awake is 70 to 110 beats / minute.
A 57-year-old Hispanic woman with breast cancer who does not speak english is admitted for lumpectomy. her daughter, who speaks English, accompanies her. In order to obtain admission information from the client, what should the nurse do?
Obtain a trained medical interpreter. Reason: a trained medical interpreter is requried to ensure safety, accuracy of history data and client's confidentiality. The medical interpreter knows the client's rights and is familiar with the client's culture.
When assessing a client for early septic shock, the nurse should access the client for which of the following?
Warm, flushed skin. Reason: Warm, flushed skin from a high cardiac output with vasodilation occurs in warm shock or the hyperdynamic phase (first phase) of septic shock.
A client with a tentative diagnosis of psychosis is admitted to the psychiatric unit. A physician orders the phenothiazine thiridazine 50 mg by mouth three times per day. Phenothiazines differ from CNS depressants in their sedative effects by producing:
A calming effect from which the client is easily aroused. Reason: Shortly after phenothizine administration, a quieting an dcalming effect occurs, but the client is easily aroused, alert and responsive and has good motor coordination.
A nurse, an LPN, and a nursing are caring for a group of clients. The nurse asks the nursing assistant to check the pulse oximentry level of a client who underwent laminectomy. The nursing assistant reports that the PulseOx reading is 89%. The nurse is currently assesing a postoperative client whou just returned from the postoanesthesia care unit. How should the nurse proceed?
Ask the LPN to obtain vital signs and administer oxygen at 2L/min to the client that underwent laminectomy. Reason: Because it's important to get more information about the client with a decreased PulseOx level, the nurse should aske the LPN to obtain vital signs and administer oxygen as ordered. The nurse must attend to the newly admitted client without delayinig treatment to the client that is already in her care.
Before discharge, which instruction should a nurse give to a client receiving digoxin (Lanoxin)?
Call the physician if your heart rate is above 90 beats/minute. Reason: The nurse shoul dinstruct the client to notify the physician if th eheart rate is greater than 90 beats / minute because cardiac arrythmias may occur with digoxin toxicity. To prevent toxicity, the nurse should instruct the client to never take an extra dose of digoxin if he misses a dose.
A nurse is caring for a client with lower back pain who is scheduled for myelography using metrizamide (a water-soluble contrast dye). After the test, the nurse should place the client in which position?
Head of bed elevated 45-degrees. Reason: after a myelogram, positioning depends on the dye injected. When water-soluble dye such as metrizamide is intected, the head of the bed is elevated 45 degrees to slow the upward dispersion of the dye.
A client with Rh isoimmunization gives birth to a neonate with an enlarged heart and sever, generalized edema. The neonate is immediately transferred to the neonatal ICU. Which nursing diagnosis is most appropriate for the client?
Impaired parenting related to the neonate's transfer to the ICU. Reason: Because the neonate is severley ill and needs to be placed in the NICU, the client may have a nursing diagnosis of impaired parenting related to the neonate's transfer to the NICU. (Another pertinent nursing diagnosis may be Comprised family coping ralated to lack of opportunity for bonding).
The nurse is assessing the development of a 7-month old. The child should be able to:
Sit without support. The majority of infants (90%) can sit without support by 7 months of age.
The nurse is assessing a client at her postpartum checkup 6 weeks after vaginal delivery. The mother is bottle feeding the baby. Which client finding indicates a problem at this time.
Firm fundus at the symphysis. By 4 to 6 weeks postpartum, the fundus should be deep in the pelvis and the size of a nonpregnant uterus. Subinvolution, cuased by infection or retained placental fragments, is a problem associated with a uterus that is larger than expected at this time.
Family members of a client with bipolar disorder tell a nurse that they are concerned that the client is becoming manic. The nurse knows that the manic phase is marked by:
Flight of ideas and invflated self-esteem. Reason: the manic phase of bipolar disorder is characterized by recurrent episodes of a persistently equphoric and expansive or irritable mood. This phase is diagnosed if the client experiences four of the following signs and symptoms for at lease a week: flight of ideas; inflated self-esteem; unusual talkativeness; increased social, occupational, or sexual activity; physical restlessness; a decreased involvement in activities; a decreased need for sleep; increased distractability; and excessive involvement in activities with a high potential for painful but unrecognized consequences.
A client with pneumonia has a temperature of 102.6F (39.2C), is diaphoretica and has a productive cough. The nurse should include which of the following measures in the plan of care?
Frequent linen changes Reason: Frequent linen changes are appropriate for this client because of diaphoresis. Diaphoresis produces general discomfort. The client should be kept dry to promote comfort.
A client comes to the outpatient department complaining of vaginal discharge, dysuria, and genital irriataion. Suspecting an STD, the physician orders diagnostic testing of the vaginal discharge. Which STD must be reported to the health department?
Gonnorrhea
Total parenteral nutrition (TPN) is prescribed for a client who has recently had a significant small and large bowel resection and is currently not taking anything by mouth. The nurse should:
Handle TPN using strict aseptic technique. Reason: TPN is hypertonic, high-calorie, high-protein, intravenous (IV) fluid that should be provided to clients without functional gastrointestinal tract mobility, to better support their metabolic needs and to support optimal nutrition and healing. TPN is ordered once daily, based on the client's current electrolyte and fluid balance and must be handled with strict aseptic technique (because of its high glucose content, it is a perfect medium for bacterial growth). Also, because of its high tonicity, TPN must be administered via central venous access, not a peripheral IV line.
The comatose victim of a car accident is to have a gastric lavage. Which of the following positions would be most appropriate for the client during this procedure?
Lateral Reason: An unconscious client is best positioned in a lateral or semiprone position because these positions allow the jaw and tongue to fall forward, fascilitate the drainage of secretions, and prevent aspiration.
The neonate of a client with type 1 diabetes is at risk of hypoglycemia. An initial sign the nurse should recognize as indicating hypoglycelmia in a neonate is:
Lethargy Reason: Lethargy in the neonate may be seen with hypoglycemia because of lack of glucose in the nerve cells.
The nurse observes that the right eye of an unsconscious client does not close completely. Which nursing intervention is most appropriate?
Lightly tape the eyelid shut. Reason: When the blink reflex is absent or the eyes do not close completely, the cornea may become dry and irritated. Corneal abrasion can occur. Taping the eye closed will prevent injury.
A client is experiencing early postpartum hemorrhage. Which item in the client's care plan requires revision?
Pad count Reason: By the time the client is hemorrhaging, a pad count is no longer appropriate.
Just after delivery, a nurse measures a neonate's axillary temperature at 94.1 degrees F (34.5 C). What should the nurse do?
Rewarm the neonate gradually. Reason: A neonate with a temperature of 94.1 F is experiencing cold stress. To correct cold stress while avoiding hyperthermia and its complications, th enurse should rewarm the neonate gradually, observing closely and checking vital signs every 15 to 30 minutes.
A client is irritable and hostile. He becomes agitated and verbally lashes out when his personal needs are not being met by the staff. When the client's request for a pass is refused by the primary care provider, he utters a stream of profanities. Which of the following statements best describes the client's behavior?
The client's anger is not intended personally. Reason: Staff members sometimes are the recipients of a client's angry behavior because they are safe targes for attack. The display of anger is rarely intended to be personal.
A client has a episiotomy to widen her birth canal. Birth extends the incision into the anal sphincter. The complication is called:
Third-degree laceration Reason: Birth may extend and episiotomy incision into the anal sphincter (a third-degree laceration).
