Unit 2 Nclex Review
Which statement by a nursing student about Kohlberg's theory of moral development indicates the need for further teaching about the theory?
"Individuals move through all six stages in a sequential fashion."
The parents of a 4-year-old child tell the nurse that they are concerned because the child has been masturbating. Which is the appropriate response by the nurse?
"This is a normal behavior at this age." According to Freud's psychosexual stages of development, the child is in the phallic stage between the ages of 3 and 6 years. At this time, the child devotes much energy to examining his or her genitalia, masturbating, and expressing interest in sexual concerns.
A client has a history of mild renal insufficiency. Which serum creatinine level should the nurse determine is consistent with this problem?
1.9 mg/dL The normal serum creatinine level is 0.6 to 1.3 mg/dL. The client with mild renal insufficiency would have a slightly elevated level, which would be the value of 1.9 mg/dL
A client is going to be transfused with a unit of packed red blood cells (PRBCs). The nurse understands that it is necessary to remain with the client for what time period after the transfusion is started
15 minutes The nurse must remain with the client for the first 15 minutes of a transfusion, which is the most likely time that a transfusion reaction will occur. This enables the nurse to detect a reaction and intervene quickly. The nurse engages in safe nursing practice by obtaining coverage for the other clients during this time.
When reinforcing instructions to a client with acute diverticulitis, which should the nurse include?
Avoid whole-grain products Diet therapy for acute diverticulitis involves allowing the bowel to rest by avoiding high-fiber foods, such as whole-grain products and raw fruits and vegetables. Fluids are encouraged rather than restricted. Seeds and nuts are to be avoided so that they do not become trapped in the diverticula and cause irritation.
The nurse is reading the health care provider's (HCP's) progress notes in the client's record and sees that the HCP has documented "insensible fluid loss of approximately 800 mL daily." Which client is at risk for this loss?
Client with a fast respiratory rate. Sensible losses are those that the person is aware of, such as those that occur through wound drainage, GI tract losses, and urination. Insensible losses may occur without the person's awareness. Insensible losses occur daily through the skin and the lungs.
The nurse is caring for a client with a diagnosis of hyperparathyroidism. Laboratory studies are performed, and the serum calcium level is 12.0 mg/dL. Based on this laboratory value, the nurse should take which action?
Inform the registered nurse of the laboratory value. The normal serum calcium level ranges from 8.6 to 10.0 mg/dL. The client is experiencing hypercalcemia
The nurse witnesses a neighbor's husband sustain a fall from the roof of his house. The nurse rushes to the victim and determines the need to open the airway. The nurse opens the airway in this victim with the use of which method?
Jaw thrust maneuver If a neck injury is suspected, the jaw thrust maneuver is used to open the airway. The head tilt-chin lift produces hyperextension of the neck and could cause complications if a neck injury is present.
The nurse is turning a postoperative client who had extensive spinal surgery on the previous day. Which turning intervention or position would be best for repositioning this client?
Logrolling Logrolling is used to maintain neck and spinal alignment after injury or surgery. A minimum of three to four staff members is recommended to prevent injury to the client, and a draw or pull sheet is also suggested
The nurse is reviewing the health records of assigned clients. The nurse should plan care knowing that which client is at risk for a potassium deficit?
The client receiving nasogastric suction. Potassium-rich gastrointestinal (GI) fluids are lost through GI suction
The nurse reviews electrolyte values and notes a sodium level of 130 mEq/L. The nurse expects that this sodium level would be noted in a client with which condition?
The client with the syndrome of inappropriate secretion of antidiuretic hormone (SIADH) Hyponatremia is a serum sodium level less than 135 mEq/L. Hyponatremia can occur secondary to SIADH.
The nurse obtains a prescription from the health care provider to restrain a client using a jacket (safety) restraint and instructs the unlicensed assistive personnel (UAP) to apply the restraint. Which observation, if made by the nurse, should indicate unsafe application of the restraint?
The restraint straps are safely secured to the side rails. The restraint strap is secured to the bed frame (never to the side rail) to avoid accidental injury in case the side rail is released
A client is scheduled for blood to be drawn from the radial artery for an arterial blood gas (ABG) determination. The nurse assists with performing Allen's test before drawing the blood to determine the adequacy of which?
Ulnar circulation Before performing a radial puncture to obtain an arterial specimen for ABGs, Allen's test should be performed to determine adequate ulnar circulation. Failure to assess collateral circulation could result in severe ischemic injury to the hand if damage to the radial artery occurs with arterial puncture
The registered nurse reviews the results of the arterial blood gases with the licensed practical nurse (LPN) and tells the LPN that the client is experiencing respiratory acidosis. The LPN should expect to note which on the laboratory result report?
pH 7.25, PCO2 50 mm Hg The normal pH is 7.35 to 7.45, and the normal PCO2 value is 35 to 45 mm Hg. In respiratory acidosis, the pH is down and the PCO2 is up.
A client with a history of cardiac disease is scheduled for a dose of furosemide (Lasix). Which serum potassium level warrants a call to the health care provider by the nurse before administering the furosemide?
3.2 mEq/L The normal adult serum potassium level is 3.5 to 5.0 mEq/L. A serum potassium level of 3.2 mEq/L is the only value that falls below the therapeutic range. Administering furosemide (Lasix) to a client with a low potassium level and a cardiac history could precipitate ventricular dysrhythmias in the client.
The nurse is assigned to assist with caring for a client with esophageal varices who had a Sengstaken-Blakemore tube inserted because other treatment measures were unsuccessful. The nurse should check the client's room to ensure that which priority item is at the bedside?
A pair of scissors When the client has a Sengstaken-Blakemore tube, a pair of scissors must be kept at the client's bedside at all times. The client needs to be observed for sudden respiratory distress, which occurs if the gastric balloon ruptures and the entire tube moves upward. If this occurs, the registered nurse is notified immediately and the balloon lumens will be cut.
The nursing instructor asks a nursing student to describe the procedure for relieving an airway obstruction on an unconscious pregnant woman at 8 months' gestation. How should the student describe the procedure correctly?
Place a rolled blanket under the right abdominal flank and hip area. To relieve an airway obstruction on an unconscious woman in an advanced stage of pregnancy, the woman is placed on her back. A wedge, such as a pillow or rolled blanket, is placed under the right abdominal flank and hip to displace the uterus to the left side of the abdomen
According to Kohlberg's theory of moral development, at the preconventional level, moral development is thought to be motivated by which factor?
Punishment and reward
The nurse reinforces instructions to a client to increase the amount of riboflavin in the diet. The nurse should tell the client to select which food item that is high in riboflavin?
Milk Food sources of riboflavin include milk, lean meats, fish, and grains. Tomatoes and citrus fruits are high in vitamin C. Green leafy vegetables are high in folic acid.
A client arrives to the surgical nursing unit after surgery. What should be the initial nursing action after surgery?
Patency of the airway If the airway is not patent, immediate measures must be taken for the survival of the client. After checking the client's airway, the nurse would then check the client's vital signs
