NCLEX-Week 9
A client is scheduled for an oral cholecystography. The nurse would plan to obtain what type of diet for the evening meal before the test?
Fat-free
The nurse reinforces instructions to a client who is to return to the physician's office in 1 week for a patch test to identify the allergen causing the client's dermatitis. The nurse provides which instruction to the client?
"Discontinue the prescribed antihistamine 2 days before the test."
The nurse has just confirmed that a client has been scheduled for a mammogram for the following week. The nurse reinforces that the client would take which actions? Select all that apply.
-Avoid applying skin lotion on the day of the test. -Remove any necklaces before presenting for the procedure.
The nurse is caring for a non-English-speaking client. Best practices for client safety and quality of care incorporate which actions by the nurse? Select all that apply.
-Avoid the use of relatives as interpreters to prevent misinterpretation. -Use dialect-specific interpreters who are the same gender if possible. -Become familiar with common health care words used in the client's language. -Use interpreters who are familiar with health care.
The nurse is monitoring a postoperative client on an hourly basis. The nurse notes that the client's hourly urine output is 25 mL through an indwelling urinary catheter for the last 2 hours. Based on this finding, which would be the nurse's actions at this time? Select all that apply.
-Check the client's overall intake and output record. -Gather data about the urinary catheter and check for patency.
The nurse is assisting in caring for a client immediately following an abdominal surgical procedure who lost a significant amount of blood during surgery. Which findings would indicate a sign of a potential complication? Select all that apply.
-Increasing restlessness -A pulse rate of 108 beats per minute -A blood pressure (BP) of 88/58 mm Hg -Increasing pain unrelieved by analgesics
A 70-year-old client who has been treated for cellulitis of the leg asks the nurse how to improve resistance to infection. Which measures would the nurse reinforce in the teaching plan? Select all that apply.
-Keep skin on arms and legs well lubricated. -Wash any breaks in the skin with soap and water. -Receive recommended vaccines against influenza and pneumonia. -Balance activity and rest, and avoid stress.
A CD4+ count has been prescribed for a child with human immunodeficiency virus (HIV) infection. The parent asks the nurse about the purpose of the test and why the test needs to be done if it is already known that the child has HIV. The nurse would reinforce which information to the parent? Select all that apply.
-The CD4+ count is used to identify the risk for disease progression. -The CD4+ count identifies the need for Pneumocystis jiroveci pneumonia prophylaxis after 1 year of age. -The CD4+ count is measured at ages 1 and 3 months, every 3 months until the age of 2 years, and at least every 6 months thereafter. -More frequent monitoring of CD4+ counts is indicated when pneumonia prophylaxis and antiretroviral therapy are administered. -The CD4+ count is used to determine the child's immune status.
The nurse is assigned to care for a group of clients. On review of the clients' medical records, the nurse determines that which client is most likely at risk for a fluid volume deficit?
A client with an ileostomy
The nurse is reviewing the results of a client's serum laboratory studies. Which result indicates a deficiency of protein intake? Laboratory Results Albumin, 2.6 g/dL (3.5-5.0 g/dL) Hemoglobin, 15 g/dL (12-18 g/dL) Triglycerides, 140 mg/dL (35-160 mg/dL) Blood glucose, 78 mg/dL (70-99 mg/dL)
Albumin
A pale, lethargic child is brought to the physician's office with symptoms of periorbital edema and reduced quantity of urine output. The urine is cloudy and smoky in color. The nurse asks the parent whether the child has had any recent infections, to which the parent responds that the child had a very sore throat a few weeks ago. The physician suspects that the child might have acute poststreptococcal glomerulonephritis. Which laboratory test would rule out a past streptococcal infection in the child?
Antistreptolysin titer
The nurse is preparing to initiate a tube feeding for a client, and the physician has prescribed that the feeding be infused at 50 mL per hour. The nurse brings an electronic feeding pump to the bedside and discovers that there is no available outlet in the wall socket to plug the pump into. Which action would the nurse implement?
Contact the electrical maintenance department for assistance.
A client is determined after blood gas analysis to be in respiratory alkalosis. The nurse would monitor this client for signs of which electrolyte disorder that could accompany the acid-base imbalance?
Hypokalemia
A client has had a set of arterial blood gases drawn, and the nurse reviews the results. The nurse interprets that the client is experiencing which acid-base imbalance? Laboratory Results pH 7.34 (7.35-7.45) PaCO2 37 mm Hg (35-45 mm Hg) PaO2 79 mm Hg (80-100 mm Hg) HCO3 19 mEq/L (21-28 mEq/L)
Metabolic acidosis
The nurse reviews the platelet results of a client with a history of upper gastrointestinal bleeding. The nurse would plan to take which action after seeing the laboratory results? Laboratory Results Platelet 300,000/mm3 (150,000-400,000/mm3)
Place the normal report in the client's medical record.
The nurse is interpreting waveforms on a cardiac monitor and notes the presence of U waves. The nurse checks the client and reviews recent electrolyte results. The nurse interprets which electrolyte result as being related to the cardiac monitor findings? Laboratory Results Magnesium 2.0 mg/dL (1.8-2.6 mg/dL) Sodium 140 mEq/L (135-145 mEq/L) Potassium 3.0 mEq/L (3.5-5.0 mEq/L) Calcium 9.2 mg/dL (9-1.0.5 mg/dL)
Potassium level
A client with diabetes mellitus has a glycosylated hemoglobin A blood test done, and the nurse reviews the result. Which instruction does the nurse plan to reinforce to the client based on this test result? Laboratory Results HbA1c level 8% (<6%)
Prevent hyperglycemia.
A client is admitted to the hospital with a diagnosis of suspected myocardial infarction (MI). The nurse is reviewing the laboratory results performed on the client. Which documented laboratory result most specifically indicates the presence of an MI?
Increased creatine kinase-MB (CK-MB)
The nurse is assigned to assist in caring for a client who recently returned from the operating room. On data collection, the nurse notes that the client's vital signs are as follows: blood pressure (BP) 102/62 mm Hg, pulse 91 beats per minute, respirations 16 breaths per minute. Preoperative vital signs were BP 124/78 mm Hg, pulse 74 beats per minute, respirations 20 breaths per minute. Which action would the nurse plan to take first?
Recheck the vital signs in 15 minutes.
A 3-year-old child is hospitalized because of persistent vomiting. Which conditions would the nurse expect this child to be at high risk for? Select all that apply.
-Metabolic alkalosis -Dehydration
A client who has undergone preadmission testing has had blood drawn for serum laboratory studies, including a complete blood count, coagulation studies, and electrolytes and creatinine levels. Which laboratory result would be reported to the RN and surgeon's office by the nurse, knowing that it could cause surgery to be postponed? Laboratory Results Hemoglobin 8.0 g/dL (12-18 g/dL) Sodium 145 mEq/L (135-145 mEq/L) Creatinine 0.8 mg/dL (0.5-1.2 mg/dL) Platelets 210,000 cells/mm3 (150,000-400,000/mm3)
Hemoglobin level
A client scheduled for a pulmonary angiography is fearful about the procedure and asks the nurse if the procedure involves significant pain and radiation exposure. The nurse gives a response to the client that provides reassurance, based on which understanding?
Discomfort may occur with needle insertion, and there is minimal exposure to radiation.
The nurse is discussing with a student the importance of the presence of a nurturing caregiver for healthy early brain development. The nurse includes information on which special population that may be at risk for negative effects on brain development?
Foster children
The nurse is preparing to care for a client following a lumbar puncture. The nurse plans to place the client in which position immediately after the procedure?
Prone with a pillow under the abdomen
The nurse employed in the ambulatory care department hears a client in the waiting room call out, "Help, fire!" The nurse rushes to the waiting room and finds the wastebasket on fire. Which is the immediate action of the nurse?
Remove the clients from the waiting room.
