NCLEX unit 6

The nursing student is assigned to care for an adolescent female client in the health care clinic, and the instructor reviews the menstrual cycle with the student. The instructor determines that the student understands the process of the secretion of follicle-stimulating hormone (FSH) and luteinizing hormone (LH) if the student makes which statement?

"FSH and LH are released from the anterior pituitary gland."

The nurse has reinforced instructions to a client receiving enalapril maleate (Vasotec). Which statement by the client indicates a need for further teaching?

"I need to notify the health care provider if nausea occurs."

The nurse reinforces instructions to a client with myxedema about the dosage, method of administration, and side effects of levothyroxine sodium (Synthroid). Which statement by the client indicates an understanding of the nurse's instructions?

"I will report any episodes of palpitations, chest pain, or dyspnea."

A miotic medication has been prescribed for the client with glaucoma. The client asks the nurse about the purpose of the medication. The nurse should tell the client which?

"The medication causes the pupil to constrict and will lower the pressure in the eye."

The health care provider has prescribed silver sulfadiazine (Silvadene) for the client with a partial-thickness burn, which has cultured positive for gram-negative bacteria. The nurse is reinforcing information to the client about the medication. Which statement made by the client indicates a lack of understanding about the treatments?

"The medication will permanently stain my skin."

An adult client with muscle spasms is taking an oral maintenance dose of baclofen (Lioresal). The nurse reviews the medication record, expecting that which dose would be prescribed?

15 mg 4 times a day

Isoniazid is prescribed for a 2-year-old child with a positive tuberculin skin test. The mother of the child asks the nurse how long the child will need to take the medication. Which time frame is the appropriate response to the mother?

9 months

The clinic nurse is collecting data on a client being admitted. The nurse notes that the client is taking azelaic acid (Azelex). Because of the medication prescription the nurse should suspect that the client is being treated for which condition?

Acne

The camp nurse asks the children preparing to swim in the lake if they have applied sunscreen. The nurse reminds the children that chemical sunscreens are most effective when applied at which time?

At least 30 minutes before exposure to the sun

The nurse is applying a topical corticosteroid to a client with eczema. The nurse should monitor for the potential for increased systemic absorption of the medication if the medication is being applied to which body area?

Axilla

A client has an arteriovenous (AV) shunt in place for hemodialysis. The nurse should take which priority precaution, knowing that bleeding is a potential complication?

Ensure that small clamps are attached to the AV shunt dressing.

A client has just had skeletal traction applied following insertion of pins. The nurse should place highest priority on performing which action?

Ensuring that the weights on the traction setup are hanging free

A client with a neurological impairment experiences urinary incontinence. Which nursing action should help the client adapt to this alteration?

Establishing a toileting schedule

The burn client is receiving treatments of topical mafenide acetate (Sulfamylon) to the site of injury. The nurse monitors the client knowing that which indicates a systemic effect has occurred?

Hyperventilation

The nurse is planning to administer hydrochlorothiazide (HydroDIURIL) to a client. Which are concerns related to the administration of this medication?

Hypokalemia, hyperglycemia, sulfa allergy

Mafenide acetate (Sulfamylon) is prescribed for the client with a burn injury. When applying the medication, the client complains of local discomfort and burning. Which is the most appropriate nursing action?

Informing the client that this is normal

A client arrives in the emergency department with an eye injury resulting from metal fragments that hit the eye while the client was drilling into metal. The nurse checks the eye and notes small pieces of metal floating on the eyeball. Which action should the nurse take first?

Irrigate the eye with sterile saline.

The client scheduled for a right femoropopliteal bypass graft is at risk for compromised tissue perfusion to the extremity. The nurse takes which action before surgery to address this risk?

Marking the location of the pedal pulses on the right leg

The nurse is caring for a client who is receiving an intravenous (IV) infusion of an antineoplastic medication. During the infusion, the client complains of pain at the insertion site. During an inspection of the site, the nurse notes redness and swelling. The nurse should take which appropriate action?

Notify the registered nurse.

Oral iron supplements are prescribed for a 6-year-old child with iron deficiency anemia. The nurse reinforces instructions to the mother and tells the mother to administer the iron with which best food item?

Orange juice

The nurse is monitoring the results of periodic serum laboratory studies drawn on a client with diabetic ketoacidosis (DKA) receiving an insulin infusion. The nurse determines that which value needs to be reported?

Potassium 3.1 mEq/L

Oxybutynin chloride (Ditropan XL) is prescribed for a client with neurogenic bladder. Which sign would indicate a possible toxic effect related to this medication?

Restlessness

The client's B-type natriuretic peptide (BNP) level is 691 pg/mL. Which intervention should the nurse institute when providing care for the client?

Take daily weights and monitor trends.

The nurse is collecting data from a client with varicose veins. Which finding would the nurse identify as an indication of a potential complication associated with this disorder?

The client complains of leg edema, and skin breakdown has started.

The nurse is assigned to assist in caring for a client who has a pneumothorax. The nurse notes continuous bubbling in the water seal chamber of the client's closed-chest drainage system. The nurse determines that this is indicative of which occurrence?

There is an air leak somewhere in the system.

Salicylic acid is prescribed for a client with a diagnosis of psoriasis. The nurse monitors the client knowing that which would indicate the presence of systemic toxicity from this medication?

Tinnitus

The nursing student is asked about the medication latanoprost (Xalatan) and how this medication helps glaucoma. The student responds correctly by identifying that which is the medication's mechanism of action?

To facilitate the outflow of aqueous humor

The nurse is caring for a client after a thyroidectomy and notes that calcium gluconate is prescribed for the client. The nurse determines that this medication has been prescribed for which reason?

Treat hypocalcemic tetany.

Isotretinoin (Amnesteem, Clavaris) is prescribed for a client with severe acne. Before the administration of this medication, the nurse anticipates that which laboratory test will be prescribed?

Triglyceride level

A client with severe acne is seen in the clinic, and the health care provider (HCP) prescribes isotretinoin (Amnesteem, Clavaris). The nurse reviews the client's medication record and should contact the HCP if the client is taking which medication?

Vitamin A