NCLEX Unit 8-18 and 6

The nurse has a prescription to give a first dose of hydrochlorothiazide (HCTZ) to an assigned client. The nurse should question the prescription if the client had a history of allergy to which item?

Sulfa drugs

The nurse is reinforcing home care instructions to a client following a gastric resection. The nurse should include which instruction?

Take action to prevent dumping syndrome

The nurse reviews the phenytoin level of a client who is taking phenytoin (Dilantin). The nurse notes that the plasma drug level is 9 mcg/mL. Which does the nurse anticipate to be prescribed for the client?

An increase in present dosage

An adult client was burned as a result of an explosion. The burn initially affected the client's entire face (the anterior half of the head) and the upper half of the anterior torso, and there were circumferential burns to the lower half of both of the arms. The client's clothes caught on fire, and the client ran, which caused subsequent burn injuries of the posterior surface of the head and the upper half of the posterior torso. According to the rule of nines, what is the extent of this client's burn injury? Fill in the blank

36%

A perforated eardrum is suspected in a client who was hit in the ear with a basketball. Which documented observation concerning an otoscopic examination supports this suspicion?

A round or oval darkened area on the eardrum

A client with myocardial infarction suddenly becomes tachycardic, shows signs of air hunger, and begins coughing frothy, pink-tinged sputum. The nurse listens to breath sounds, expecting to hear which breath sounds bilaterally?

Crackles

The nurse notes that a client's urinalysis report contains a notation of positive red blood cells (RBCs). The nurse interprets that this finding is unrelated to which item that is part of the client's medical record

DM

The nurse notes that the medical record of a client with cirrhosis states that the client has asterixis. To verify this information the nurse should take which action?

Ask the client to extend their arms

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

A 15-year-old child is scheduled to receive a series of the hepatitis B vaccine. The child arrives at the clinic for the first dose. The nurse collects data on the child before administering the vaccine and asks the child about a history of an allergy to which product?

Baker's Yeast

The nurse is beginning to ambulate a client with activity intolerance caused by bacterial endocarditis. The nurse determines that the client is best tolerating ambulation if which parameter is noted?

Blood pressure that increases from 114/82 to 118/86 mm Hg

The use of peritoneal dialysis for the treatment of chronic kidney disease would be contraindicated for which clients?

COPD

The nurse is reinforcing medication instructions to a client with peptic ulcer disease. Which represents correct information given by the nurse?

Cimetidine (Tagamet) results in decreased secretion of stomach acid

The nurse who is reinforcing instructions to a client following gastric resection should include which suggestions? Select all that apply.

Eat small frequent meals Take action to avoid dumping

A client who has undergone a subtotal gastrectomy is being prepared for discharge. Which items concerning ongoing self-management should the nurse reinforce to the client? Select all that apply.

Eat smaller and more frequent meals Drink fluids between meals not with them

The nurse is reinforcing instructions to a client regarding the use of a hearing aid. Which statement by the client indicates a need for further teaching?

I should turn the hearing aid off after removing it from my ear

A client is brought to the emergency department in an unresponsive state, and a diagnosis of hyperglycemic hyperosmolar state (HHS) is made. The nurse who is assisting with care for the client obtains which item in preparation for the treatment of this syndrome?

Intravenous (IV) infusion of normal saline

A client diagnosed with gout has been started on medication therapy with allopurinol (Zyloprim). The nurse reinforces teaching with this client regarding which point about this medication

It is important to drink 3L of fluid per day

The nurse is assigned to care for a client hospitalized with Ménière's disease. The nurse expects that which would most likely be prescribed for the client?

Low sodium diet

The nurse is caring for a client diagnosed with scabies who has just been prescribed crotamiton (Eurax). The nurse provides which instruction for application of this medication?

Massage the medication into the skin from the chin downward, and apply a second application in 24 hours, followed up with a cleansing bath 48 hours after the second application.

A client in the emergency department reports right lower quadrant abdominal pain. After noting a white blood cell count of 16,500 cells/mm3, the nurse should question which prescriptions? Select all that apply.

Milk of Mag Heat pad to the abdomen

A client with no history of respiratory disease is admitted to the hospital with respiratory failure. The nurse reviews the arterial blood gas reports for which results that are consistent with this disorder?

Pao2 49 mm Hg, Paco2 52 mm Hg

A client is experiencing blockage of the eustachian tubes. The nurse teaches the client that which activities by the client may forcibly open the eustachian tube?

Performing the Valsalva maneuver

The nurse is reviewing the health care record of a client with a diagnosis of otosclerosis. The nurse should expect to note documentation of which early symptom of this disorder?

Ringing in the ears

A client with an infected leg wound that is draining purulent material has a prescription for sodium hypochlorite (Dakin solution) to be used in the care of the wound. The nurse should perform which action while using this solution?

Rinse off the solution immediately following irrigation

A client is taking lansoprazole (Prevacid) for the chronic management of Zollinger-Ellison syndrome. If prescribed, which medication would be appropriate for the client if needed for a headache?

Tylenol

A client with a diagnosis of rapid rate atrial fibrillation asks the nurse why the health care provider is going to perform carotid massage. The nurse responds that this procedure may stimulate which?

Vagus nerve to slow the heart rate

The nurse is reinforcing discharge instructions with a client who is being discharged following a fenestration procedure for the treatment of otosclerosis. Which should be included on the list of instructions prepared for the client?

You need to avoid air travel

The nurse is monitoring a client with Graves' disease for signs of thyrotoxic crisis (thyroid storm). Which signs and symptoms noted in the client should alert the nurse to the presence of this crisis? Select all that apply

Fever Sweating Agitation

A client receiving total parenteral nutrition (PN) has a history of heart failure. The health care provider has prescribed furosemide (Lasix) 40 mg orally daily to prevent fluid overload. The nurse should monitor which laboratory value to identify an adverse effect from this medication?

Potassium

The nurse is explaining how sound is conducted from the middle ear to the inner ear in teaching a client who is experiencing hearing loss. The nurse plans to use a diagram that illustrates how which bones connects to the cochlea at the oval window?

Stapes