NCLEX study guide
Decerebrate posturing
-"extensor posturing"; -abduction of arms, elbow and wrist extension
metabolic acidosis causes
-kidney failure -shock -diabetic ketoacidosis
A client received 20 units of NPH insulin subcutaneously at 8:00 am. The nurse should check the client for a potential hypoglycemic reaction at which time?
5:00 pm NPH is intermediate-acting insulin. Its onset of action is 1 to 2½ hours, it peaks in 4 to 12 hours, and its duration of action is 24 hours. Hypoglycemic reactions most likely occur during peak time.
The nurse reviews the laboratory results, knowing that which value is a therapeutic magnesium level?
6 mg/dL
An adult client with hepatic encephalopathy has a serum ammonia level of 120 mcg/dL and receives treatment with lactulose (Chronulac) syrup. The nurse determines that the client has the best response if the level changes to which after medication administration?
70 mcg/dL
Calcium range
8.2-10.7
The nurse in the postpartum unit notes that the result of a rubella titer drawn on a postpartum client during the antepartum period is 1:8. Which should the nurse anticipate to be prescribed by the health care provider?
Administration of a subcutaneous rubella virus vaccine
Simethicone (Mylicon)
Antiflatulent
Probable signs of pregnancy
Ballottement, Chadwick's sign, uterine enlargement, Braxton Hicks, positive pregnancy test
A client has a history of left-sided heart failure. The nurse should look for the presence of which finding to determine whether the problem is currently active?
Bilateral lung crackles
phallic stage
Children recognize differences between males and females.
A client's kidneys are retaining greater amounts of sodium. The nurse anticipates that the kidneys are also retaining greater amounts of which other substances?
Chloride and bicarbonate
A health care provider prescribes auranofin (Ridaura) for a client with rheumatoid arthritis. Which data would indicate to the nurse that the client is experiencing toxicity related to the medication?
Complaints of a metallic taste in the mouth
The nurse is collecting data on a newborn infant with a diagnosis of a hiatal hernia. Which finding should the nurse expect to note in the infant?
Coughing, wheezing, and short periods of apnea
The nurse performs an audit in the hospital intensive care unit of clients who have indwelling urinary catheters. Which observation, found in the audit, poses a risk for a health care-associated infection? Select all that apply.
Drainage bag port touching the floor Dependent loop in the catheter tubing Use of one measuring container between two clients with the same pathogen in the urine
A client with acquired immunodeficiency syndrome (AIDS) has histoplasmosis. Which sign/symptom should the nurse expect the client to experience?
Dyspnea
The nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease (COPD). Which should the nurse expect to note in this client? Select all that apply.
Dyspnea on exertion Presence of a productive cough Difficulty breathing while talking
Bladder exstrophy
Extrusion of the urinary bladder to the outside of the body through a defect in the lower abdominal wall
Hemophilia A
Factor VIII deficiency
A client who has open draining lesions from Kaposi's sarcoma needs to be bathed and have bed linens changed. Which should the nurse wear to perform these tasks?
Gown and gloves
A client has been prescribed amikacin (Amikin). Which priority baseline function should be monitored?
Hearing acuity, med is ototoxic and nephrotoxic
Which statement most accurately describes Kawasaki disease?
It is also called mucocutaneous lymph node syndrome and is a febrile generalized vasculitis of unknown cause.
The nurse should use which best method to open the victim's airway if the victim sustained a neck injury?
Jaw thrust maneuver
The nurse is assigned to care for a client with a diagnosis of hepatic encephalopathy. Which prescribed medication does the nurse anticipate administering?
Lactulose syrup (Chronulac)
Bumetanide (Bumex)
Loop Diuretic, puts pts at risks for hypokalemia
respiratory alkalosis
PCO2 less than 40 mm Hg (hypocapnia, hyperventilation)
DIC labs: Increases
PT, PTT, thrombocytopenia, FDP, D-dimer levels
which is characteristic of scarlet fever
Pastia's sign
The nurse caring for a client with abruptio placentae is monitoring the client for signs of disseminated intravascular coagulopathy (DIC). The nurse would suspect DIC if which is observed?
Petechiae, oozing from injection sites, and hematuria DIC is a state of diffuse clotting in which clotting factors are consumed, which leads to widespread bleeding. Platelet counts are decreased, because they are consumed by the process. Coagulation studies show no clot formation (clotting times are thus prolonged), and fibrin plugs may clog the microvasculature diffusely rather than in an isolated area.
Betamethasone
Prenatal/Labor, corticosteroid, used to help mature fetal lungs in premature labor.
A client has just undergone lumbar puncture (LP). The nurse assists the client into which optimal position?
Prone, with a pillow under the abdomen
Ballottement
Rebound of unengaged fetus
The nurse is reinforcing instructions to a client regarding epoetin alfa (Epogen) that will be administered subcutaneously by the client at home. The nurse tells the client to do which action?
Refrigerate the medication.
The nurse is caring for a client with a somatic disorder and knows that which interventions would be most helpful to this client? Select all that apply.
Reinforce the client's problem-solving abilities. Assess "secondary gains" that the somatic illness provides the client.
The nurse reviews the plan of care for a child with Reye's syndrome. The nurse prioritizes the nursing interventions included in the plan and prepares to monitor for which complication?
Signs of increased intracranial pressure
The nurse explains that site marking involves which action
The surgeon marking the area of the operative procedure
Megestrol acetate (Megace), an antineoplastic medication, is prescribed for the client with metastatic endometrial carcinoma. The nurse reviews the client's history and contacts the registered nurse if which diagnosis is documented in the client's history?
Thrombophlebitis
Which laboratory data indicates that the client is experiencing a protein deficiency?
Transferrin, 90 mg/dL
A client has been prescribed cyclobenzaprine (Flexeril) in the treatment of painful muscle spasms accompanying a herniated intervertebral disk. The nurse should withhold the medication and question the prescription if the client has concurrent prescriptions of which medication?
Tranylcypromine (Parnate) The client should not receive cyclobenzaprine if the client has taken a monoamine oxidase (MAO) inhibitor such as tranylcypromine (Parnate) or phenelzine (Nardil) within the past 14 days. Otherwise, the client could experience hypertensive crisis, seizures, or death. Options 1, 2, and 3 are not contraindicated with the use of this medication.
Chadwick's sign
Violet discoloration of the vaginal mucosa, presumptive evidence of pregnancy.
The nurse is providing care to a client diagnosed with multiple sclerosis and prescribed baclofen (Lioresal). Which information should the nurse plan to reinforce in the client instructions?
Watch for urinary retention as a side effect.
diclofenac sodium (Voltaren) is
an NSAID
Calcium Channel Blockers Rx for
angina, hypertension, and dysrhythmias
Sutilanis (Travase) or Collagenase (Santyl)
are enzymatic drugs that eat dead tissue so new tissue can grow, moisten with normal saline or sterile water
Clomipramine (Anafranil)
are used to treat obsessive compulsive behavior. (OCD)
intussusception manifestations
blood and mucus in the stools
d/c teaching for pt taking carbonate (Lithobid)
check with psychiatrist before using any OTC or Rx med
metabolic acidosis
decreased pH (< 7.35) , and decreased HCO3 (<22). PaCo2 is normal
autograft
elevate and immobilize for 3-7 days to allow graft to adhere to wound bed
a child with aortic stenosis (narrowing of the aorta) s/sx
exercise intolerance, chest pain, and dizziness when standing for long periods
prescribed for a client with a burn injury, may cause local discomfort and burning when applied
mafenide acetate (Sulfamylon)
nizatidine (Axid)
med used to produce less stomach acid
CF with high protein and low glucose levels, isolation precautions for 24 after antibiotics
meningitis
MAles inherit hemophelia from their
mothers
TB skin test induration of 8mm is
negative
50mg/dL glucose reading on an infant is
normal
cranial nerve III
oculomotor, innvercates extraocular movement
Etoposide (Toposar) adverse effect
orthostatic hypotension
s/sx of Hodgkin's diease
painless, firm, and movable lymph nodes in the cervicle area
hypokalemia
potassium level lower than 3.5 mEq/L
metabolic alkalosis causes
prolonged vomiting, NG suctioning, ingestion of HCO3
wound evisceration
protrusion of internal organs and tissues through incision
position after a tonsillectomy
semiprone or side lying
psoriasis
silvery scales
Goodell's sign
softening of the cervix
calculus
stone
abnormal deviation of the eyes, s/sx frequent headaches, Squints, or tilts the head to see
strabismus
Bethanechol (Urecholine) injection is administer by
subcutaneous injection
Nagele's Rule, EDC
subtract 3 months from LMP add 7 days
liver biopsy position
supine with the right side of the upper abd exposed, afterwards right side lying with a small pillow under the puncture site
early sign of heart failure
tachycardia
compete with estradiol for binding to estrogen and tissues containing high concentrations of receptors, monitor pt for hypercalcemia
tamoxifen (Soltamox)
glomerulus
tiny ball of capillaries in the kidney
cranial nerve V
trigeminal, sensation to facial muscles
The uterus weighs about
2oz
Which is a normal amount of blood loss during a menstrual period that the nurse should compare with the client's loss?
40 mL
In planning activities for the depressed client, especially during the early stages of hospitalization, which is best?
Encourage the client to participate in a structured daily program of activities.
Histoplasmosis
Fungal infection of the lungs
team nursing
Nursing staff are led by the nurse when providing care to a group of clients.
The nurse prepares to have which available in the event that an overdose of enoxaparin sodium (Lovenox) occurs?
Protamine sulfate
When collecting physical assessment data, the nurse understands that the spleen is located in which abdominal quadrant? Refer to figure.
RUQ
cephalic presentation
head first, the most common presentation
What is a common symptom associated with bladder cancer
hematauria
mild clumsiness
initial s/sx of ALS
Digoxin toxicity
nausea, vomiting, anorexia, and fatigue, >2ng/ml
Cranial Nerve XI
Accessory Nerve Major function: Control head and shoulder muscles
A client with chronic kidney disease has been on dialysis for 3 years. The client is receiving the usual combination of medications for the disease, including aluminum hydroxide as a phosphate-binding agent. The client now has mental cloudiness, dementia, and complaints of bone pain. Which does this data indicate?
Aluminum intoxication
A preliminary diagnosis is made for a child with acute lymphoblastic leukemia (ALL). In reviewing the complete blood cell count (CBC) of the child, the nurse should expect to find which?
An erythrocyte (red blood cell) count of 2 cells in 1 mL of peripheral blood
Decorticate posturing
Flexion (inward rotation)
The nurse is providing dietary instructions to a client with renal calculi, and the laboratory analysis has revealed that the calculus is composed of uric acid. The nurse tells the client that it would be helpful to make which dietary changes?
Increase intake of legumes in the diet. Dietary instructions to the client with a uric acid type kidney stone include increasing legumes, green vegetables, and fruits (except prunes, grapes, cranberries, and citrus fruits) to increase the alkalinity of the urine. The client should also be instructed to decrease purine sources such as organ meats, gravies, red wines, goose, venison, and seafood.
Atropine sulfate is prescribed for a client with gastrointestinal hypermotility, and the nurse reviews the client's record before administering med. What is a contraindication of this med?
Narrow-angle glaucoma
nephroblastoma (Wilms tumor)
cancerous kidney tumor of childhood, genetic, data collection; abd Mass, urinary retention/hematuria, anemia, pallor, anorexia, wt loss, contraindication- palpate the abd
cranial nerve VII
facial, motor activity to facial muscles
aplastic anemia
failure of blood cell production in the bone marrow, tx of choice bone marrow transplant, s/sx petechia, purpura, bleeding, pallor, weakness, tachycardia, & fatigue
hershberger's disease manifestation
foul-smelling, ribbon-like stools
cranial nerve IX
glossopharyngeal (gag reflex)
Willebrand's disease
hereditary bleeding disorder characterized by a deficiency or a defect in the protein called Von Willebrand factor, tx admin clotting factor, s/sx epistaxis, gum bleeding, bruising
cranial nerve XII
hypoglossal, the subjects ability to protrude their tongue is assessed
What a pain med that is not recommended for a child with sickle cell disease because of the risk for it inducing seizures
meperidine (Demerol)
Positive Brudzinski's sign
passive flexion of the hip and knee in respy to neck flexion and reports pain in vertebral column
Vincristine (Vincasar) adverse effect
peripheral neuropathy
paronychia
red, shiny skin around the nail bed
pituitary gland
regulates the osmotic pressure of extracellular fluid by regulating the amount of water reabsorbed by the kidney
a sulfonamide used to treat urinary tract infections. PT teaching includes drinking extra fluids
trimethoprim (Proloprim)
The nurse is caring for a client who has undergone pelvic exenteration. In addressing psychosocial issues related to the surgery, which statement by the nurse should be therapeutic?
"How do you feel about your body?" Postoperatively, a woman begins to deal with the trauma of the surgery by expressing grief about her mutilated body. Later she may become depressed or withdrawn or even angry or hostile. The woman needs intense emotional support if she is to adapt to her altered body image and functions. Option 3 is the only option that addresses the client's feelings
cranial nerve IV
trochlear, downward and inward eye movement
The nurse reinforces medication instructions to a client with peptic ulcer disease. Which statement by the client indicates the best understanding of the medication therapy?
"The nizatidine (Axid) will cause me to produce less stomach acid."
Triamterene/HCTZ, Spironolactone, Amiloride hydrochloride
#spirotriami, potassium sparing diuretic, puts pts at risk for hyperkalemia
cranial nerve VIII
vestibulocochlear, hearing
umbilical cord
2 arteries, 1 vein
Hemophilia B
Factor IX deficiency
respiratory acidosis
PCO2 greater than 40 mm Hg (hypercapnia, hypoventilation)
The nurse should place the child who had a tonsillectomy in which position?
Side-lying position
The nurse is caring for a postoperative adrenalectomy client. Which finding does the nurse specifically monitor for in this client?
Signs and symptoms of hypovolemia
Buerger's disease (thromboangitis obliterans)
Small/medium-artery vasculitis, common in young men who smoke
A client who is taking lithium carbonate (Lithobid) is scheduled for surgery. The nurse should reinforce what information in the preoperative teaching about this medication?
The medication will be discontinued 1 to 2 days before the surgery and resumed as soon as full oral intake is allowed.
A client, who is 36 hours post-myocardial infarction, has ambulated for the first time. The nurse determines that the client best tolerated the activity if which observation is made?
The preactivity pulse rate is 86 beats per minute; the postactivity pulse rate is 94 beats per minute.
hemorrhoidectomy post op position
lateral, to prevent pain and bleeding
beef
a chemotherapy patient tells the nurse that which food on the meal tray taste bitter
wound dehiscence
a partial of complete seperation of the outer wound layers
cranial nerve VI
abducens, controls lateral eye movement
dystocia
difficult labor
hernia strangulation manifestations that requires hcp notification
vomiting
what not to do after myringotomy with tube placement
wash hair the next day irrigate the ear expect to feel pressure in the ear
adrenal glands, through the secretion of aldosterone
what aids with controlling the extracellular fluid volume by regulating the amount of sodium reabsorbed by the kidneys
bp
what do you monitor in pt taking Betaxolol hydrochloride (Betoptic) for glaucoma
5:00pm
8:00am dose of NPH, nurse should check it for potential hypoglycemic reaction at
The nurse is providing directions to the unlicensed assistive personnel (UAP) regarding clients' hygiene needs. Which is the priority order in which the UAP should assist the clients? Arrange the actions in the order that they should be performed. All options must be used.
A confused client who is incontinent of stool and urine A client who is on bed rest after multiple trauma A client who was admitted for dehydration and failure to thrive A client who is independent with ADLs (activities of daily living)
The nurse is assisting in preparing to care for a child with a brain tumor who will be returning from the recovery room following debulking of the tumor. Which item should the nurse place at the bedside in preparation for the child's return from surgery?
A cooling blanket
A client experiences an episode of Bell's palsy and complains about increasing clumsiness. The nurse should prepare the client for which diagnostic study (studies) to determine the cause of the complaints? Select all that apply.
Cerebral angiography Lumbar puncture (LP) Computed tomography
Before attempting to deliver the placenta after a precipitate delivery, the nurse waits for which sign as an indication of placental separation?
Change in uterine shape
The nurse is caring for a client with severe diarrhea. The nurse monitors the client closely, understanding that this client is at risk for developing which acid-base disorder?
Metabolic acidosis
The nurse is assisting in caring for a client who is receiving amphotericin B intravenously (IV) to treat disseminated candidiasis. The nurse reviews the plan of care and implements which action during the administration of the medication?
Monitors urinary output
The nursing student is developing a plan of care for the hospitalized client with bulimia nervosa. The nursing instructor intervenes if the student documents which incorrect intervention in the plan?
Observe for excessive exercise.
The nurse is collecting data on a client with severe preeclampsia. Which signs and symptoms would be noted in severe preeclampsia? Select all that apply.
Oliguria Proteinuria 3+ Blood pressure 168/116 mm Hg
The nurse assists a health care provider with the insertion of a Miller-Abbott tube. After insertion of the tube, the nurse should assist the client to which position?
On the right side
ataxia
lack of muscle coordination, tested by having pt run the heel of 1 foot down the lower anterior surface of the other leg
nurses initial action when fat embolism is suspected
place the client in a Fowler's position
fatigue
s/sx of acute viral hepatitis
visual disturbances, nausea and vomiting, serum digoxin level of 2.3
s/sx of digoxin toxicity
An AIDS pt who will be receiving ganciclovir (Cytovene). Which intervention should be included in the plan of care?
Instruct the client to use an electric razor for shaving.
Kernig's sign
The child is not able to extend the leg when the thigh is flexed anteriorly at the hip.(meningitis)
When evaluating the diagnostic results, the nurse should expect to note which evidence if this child has Hodgkin's disease?
The presence of Reed-Sternberg cells
A client is being treated for depression with amitriptyline hydrochloride. During the initial phases of treatment, which is the most important nursing intervention?
Getting baseline postural blood pressures before administering the medication and each time the medication is administered
The nurse is assessing a client with bipolar disorder who is taking lithium carbonate and who has a lithium level of 1.7 mEq/L. The nurse would expect to find which sign/symptoms of lithium toxicity associated with this level? Select all that apply.
Incoordination Mental confusion Muscle hyperirritability
A client who is pregnant will be treated by a dermatologist for acne. The nurse understands that which treatment for acne should be avoided with this client?
Oral tetracycline hydrochloride
Serosanguineous
Pale, red, watery: mixture of clear and red fluid
A child is admitted to the hospital with a probable diagnosis of nephrotic syndrome. Which findings should the nurse expect to observe? Select all that apply.
Pallor Edema Anorexia Proteinuria
A client diagnosed with hyperthyroidism will be taking propylthiouracil (PTU). The nurse reinforces medication instructions and determines that the client understands the information if the client states that it is most important to report which symptoms to the health care provider?
Sore throat An adverse effect of PTU is agranulocytosis. The client should be alert for this effect by noting the presence of fever or sore throat, which should be reported immediately. Muscle aches, weight loss, and excitability are neither side effects nor adverse effects of this medication.
The nurse is assisting in monitoring a client who may be started on parenteral nutrition (PN). The nurse reviews the client's laboratory results and determines that the client is at risk of severe malnutrition if the albumin level report indicates which critical level?
2.8 g/dL The serum albumin level is a critical indicator of the need for PN. The client whose albumin level is 2.8 g/dL is at severe risk for malnutrition. The normal serum albumin level in the adult is 3.4 to 5 g/dL. Options 1, 2, and 3 identify normal albumin levels.
The nurse is caring for a client with respiratory insufficiency. The arterial blood gas results indicate a pH of 7.50 and a PCo2 of 30 mm Hg, and the nurse is told that the client is experiencing respiratory alkalosis. Which additional laboratory value should the nurse expect to note?
A potassium level of 3.2 mEq/L
A client with hepatic cirrhosis has been consuming a diet with optimal amounts of protein. The nurse determines that the client's consumption of dietary protein has been most effective if the total protein level is which value?
6.8 g/dL The normal range for the protein level in the adult client is 6 to 8 g/dL, which makes the value of 6.8 g/dL the correct choice. The remaining options are all low levels and do not indicate that the diet has been most effective.
Ortolani maneuver
Reducing the dislocated femoral head back into the acetabulum
A client in the mental health unit engages in repeated hand washing throughout the day. The nurse understands that these repetitive behaviors develop for which reason?
The client is unconsciously attempting to control unpleasant thoughts or feelings.
nephrotic syndrome
characterized by massive proteinuria caused by glomerular damage. corticosteroids are the mainstay
Obtunded
client opens eyes to loud voice, responds slowly w/ confusion, seems unaware of environment
Kawasaki disease
coronary artery vasculitis/thrombosis/aneurysms in children, manifestation is conjunctival hyperemia (red eyes)
glomerulonephritis
inflammation of the glomeruli of the kidney
pleurisy (pleuritis)
inflammation of the pleura, s/sx knife like pain that worsens on inspiration
Asparaginase (Elspar) contraindicated if
it has hx of pancreatitis
Positive Romberg sign
loss of balance that occurs when closing the eyes.
hypophysectomy
removal of the pituitary gland, post op elevate hob to prevent increase in ICP
weakness
result of uncontrolled muscle pain
GERD positioning
reverse Trendelenburg to promote gastric emptying
The nurse must ambulate a client who has a nephrostomy tube attached to a drainage bag. The nurse plans to do this most safely and effectively by performing which action?
Changing the drainage bag to a leg collection bag The safest approach to protect the integrity and safety of the nephrostomy tube with a mobile client is to attach the tube to a leg collection bag. This allows for greater freedom of movement while alleviating worry over accidental disconnection or dislodgement. The other options do not present the most safe and effective methods to ensure the integrity of the tube.
The nurse should anticipate that which medication is the most likely to be prescribed prophylactically for a child with spina bifida (myelomeningocele) who has a neurogenic bladder?
Sulfisoxazole A neurogenic bladder prevents the bladder from completely emptying because of the decrease in muscle tone. The most likely medication to be prescribed to prevent urinary tract infection would be an antibiotic. A common prescribed medication is sulfisoxazole. Prednisone relieves allergic reactions and inflammation rather than preventing infection. Furosemide promotes diuresis and decreases edema caused by heart failure. IVIG assists with antibody production in immunocompromised clients.
Hemophilia
A disorder in which blood doesn't clot normally, mothers pass on to sons, tx replacement of missing clotting factor
metabolic alkalosis
increased pH (> 7.45) & increased HCO3 (> 26) , normal PaCO2 levels
Specifically related to cell destruction that occurs with chemotherapy
increased uric acid levels
