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NCLEX RN #44
Terms in this set (35)
A client taking morphine sulfate for acute pain has not voided in 6 hours. The nurse suspects the client has developed urinary retention. What is the PRIORITY nursing intervention?
1. Ask if the client needs to use the bedpan
2. Assess the client's fluid intake
3. Assess the client's skin turgor.
4. Palpate the client's suprapubic area.
The nurse provides teaching for the parents of a 6 year old diagnosed with nocturnal enuresis. Which instructions will the nurse include? SELECT ALL THAT APPLY #70624106 (09)
1. "Allow your child to wear a diaper at bed-time for emotional security."
2. "Have your child assist with wet linen changes."
3. "Prepare a calendar with your child for logging wet and dry nights."
4. "Restrict oral fuids to 8 ounces with each meal."
5. "Wake your child at a specified time each night to void."
A client with a history of diverticular disease is being discharged after an episode of acute diverticulitis. Which instructions should be included in the discharge teaching plan to reduce the risk of future episodes? SELECT ALL THAT APPLY #70624106 (10)
1. Drink plenty of fluids.
2. Exercise regularly
3. Follow a low residue diet
4. Include whole grains, fruits and vegetables in the diet.
5. Increase intake of red meat.
The nurse caring for a client in the intensive care unit reports a critical laboratory value of 120,000/mm3 on admission. The health care provider says this is normal. The client is receiving heparin injections. Which nursing action would be the MOST APPROPRIATE?
1. Contact the appropriate certification and licensing board.
2. Document the exchange in the chart.
3. Report the incident to the hospital's legal team.
4. Report the incident to the state medical board.
A nurse is providing care to a group of post-partum clients. Which client comment should prompt FURTHER investigation?
1. "I feel so exhausted that I started taking naps when the baby sleeps"
2. "I have trouble sleeping well at night because I worry that I won't hear the baby cry."
3. "My aunt has come over every day to care for the baby because the baby's cries bother me."
4. "My spouse thinks that I have been more emotional since I had the baby last week."
The nurse is performing a postpartum assessment 12 hours after the prolonged vaginal delivery of a term infant. Which assessment findings should be reported to the health care provider? #70624106 (13)
1. Complaints of discomfort during fundal palpation.
2. Foul-smelling lochia
3. Oral temperature 100.1 F (37.8 C)
4. White blood cell (WBC) count 24,000/mm3
Which tasks can the registered nurse safely delegate to unlicensed assistive personnel? SELECT ALL THAT APPLY #70624106 (14)
1. Ambulate an oxygen dependent client to the bathroom.
2. Assist client with dentures to perform oral suctioning after the client's meal.
3. Document pulse oximetry of a client with chronic obstructive pulmonary disease.
4. Instruct a client with pneumonia on use of the incentive spirometer.
5. Turn and reposition a client with pneumonia.
The nurse is caring for a client with chronic pain who just had surgery and is receiving patient-controlled analgesia (PCA) morphine . The client is in severe pain, with a rating of 10/10, despite receiving the maximum ordered dose. The nurse calls the health care provider, saying that the client is still having pain and recommending a higher PCA dose. Which nursing role is being implemented in this situation?
The nurse is caring for a client in the first trimester during an initial prenatal clinic visit. Based on the information provided by the client, which factor places the client at an increased risk for preterm labor?
1. Age 25
2. Periordontal disease
3. Vegetarian diet
4. White ethnicity.
The nurse is caring for a 6 year old who is post-operative open right tibial fracture reduction with cast placement. Which finding requires PRIORITY action? #70624106 (17)
1. Blood-tinged on the inner aspect of the cast
2. Capillary refill of 2 seconds on the affected extremity.
3. Mild swelling of toes on the right foot.
4. Pain of 9/10 an hour after a dose of morphine.
The nurse is admitting an infant who has severe growth deficiency and facial characteristics of indistinct philtrum, a thin upper lip and short palpebral fissures. Which question should the nurse ask to assess the cause of these clinical findings? #70624106 (18)
1. "Is the mother of advanced age?"
2. "Is there a history of cigarette use during pregnancy."
3. "Is there a history of exposure to alcohol in utero?"
4. "Is there a maternal history of valproate use?"
The nurse receives report in 4 clients. Which client should the nurse see FIRST?
1. Client admitted 12 hours ago with acute asthma who needs a dose of IV methyl-prednisone
2. Client admitted 2 days ago with congestive heart failure who is reporting shortness of breath and had an extra dose of furosemide prescribed recently.
3. Client admitted with intestinal obstructive is reporting abdominal pain and distention and needs nasogastric tube.
4. Client who had cardiac valve surgery 8 days ago but was readmitted with a sternal wound infection and needs antibiotics and at dressing change.
The nurse caring for a client diagnosed with HIV uses which infection prevention and control measures? SELECT ALL THAT APPLY
1. Gloves when contact with body fluids is anticipated.
2. Gloves when starting an intravenous line
3. Gown, gloves , face shield and goggles for every client encounter
4. Hand hygiene before and after providing client care
5. N95 respiratory mask and face shield.
A school nurse is educating the parent of a young client with pediculosis capitis. Which statement by the parent indicates understanding of the teaching? #70624106 (21)
1. "I will launder recently worn clothing, sheets and towels in hot water."
2. "I will make sure all eating utensils are placed in the dishwasher."
3. "I will spray the house with insecticide to control this problem."
4. "I will throw away stuffed animals and toys that can not be washed."
The nurse has received report on 4 pediatric clients on a telemetry unit. Which client should the nurse assess FIRST? #70624106 (22)
1. Adolescent client with coarctation of the aorta and diminished femoral pulses.
2. Infant client with ventricular septal defect with reported grunting during feeding
3. Newborn client with patent ductus arteriosus and a loud machinery like systolic murmur
4. Preschool client with tetralogy of Fallot who has finger clubbing and irritability.
ventricular septal defect
is a cardiac abnormality, with a spetal opening between ventricles, tha may progfress to congestive heart failure (CHF) . The client should be closely monitored for respiratory exertion and signs of CHF (eg. dyspnea, tachypnea)
coarctation of the aorta (COA)
is an abnormal aortic narrowing that results in decreased cardiac output. The client will exhibit elevated pulse pressure in the upper extremities and diminished pressures in the lower extremities.
patent ductus arteriosus
A systolic murmur with a machine sound and poor feeding are expected.
tetralogy of fallot
is a cyanotic congenital heart defect commonly manifested by signs of irritability and clubbing of fingers due to oxygen saturation chronically remaining between 65-85% until the client can undergo surgical repair. Further evaluation of the client's oxygenation is necessary but not urgently required.
A muslim woman is admitted to the inpatient trauma unit after falling and sustaining a head injury. In providing culturally competent care for this client,which consideration is MOST important? #70624106 (23)
1. Allowing the client's husband to be with her during clinical examinations
2. Assigning the client to a private room
3. Ensuring that female health care workers are available to provide care to the client.
4. Obtaining the services of a local Muslim imam
The emergency department triage nurse is assessing 4 pediatric clients. Which client is a PRIORITY for further diagnostic workup and definitive care? #70624106 (24)
1. 1 year old with ventriculoperitoneal shunt who has "lethargy" and pulse of 78/min.
2. 3 year old with history of meningocele who has unilateral ear pain and urinary incontinence.
3. 6 year old with muscular dystrophy who has "flu like" symptoms and temperature of 100.4F (38 C)
4. 8 year old with history of cerebral palsy who has foot injury and spastic clonus.
is used to treat hydrocephalus and is usually placed at age 3-4 months. Blockage and infection are complications of shunt placement. Blockage results in signs of increased intracranial pressure (ICP). The normal pulse range for a 1 year old is 100-160/min. A pulse of 78/min is considered bradycardia, a part of Cushing's triad (bradycardia, slowed respiration, widened pulse pressure.) #70624106 (24)
is a saclike protrusion through a bony defect that contains meninges and cere-brospinal fluid. It is corrected with surgery. #70624106 (24)
Several 12 month old infants are brought to the clinic for routine immunizations. Which situation would be MOST important for the nurse to clarify with the provider before administering the vaccination? #70624106 (25)
1. Haemophilus influenzae type b vaccine for client allergic to penicillin.
2. Hepatitis A vaccine for a client with a "cold" and temperature of 99.0 F (37.2 C)
3. Pneumococcal vaccine for client with local swelling after last immunization.
4. Varicella-zoster vaccine for client recently diagnosed with leukemia.
An overweight toddler is diagnosed with iron deficiency anemia. Which is the most likely ex-planation for the anemia? #70624106 (26)
1. Excessive intake of meat products
2. Excessive intake of milk.
3. Gastrointestinal blood loss
4. Impaired iron transfer from the mother.
A client recently admitted to an inpatient unit for treatment of alcoholism says to the nurse.,"I only came here to get away from my nagging spouse. Sometimes I think my spouse is the one who should be here.I can stop drinking any time I want" The nurse recognizes that the client is exhibiting which of the following defense mechanisms? #70624106 (27)
1. Denial and projection
2. Rationalization and depression
3. Regression and displacement
4. Sublimation and reaction formation.
The nurse is caring for a client with an inflam-matory bowel disease exacerbation. The client client is prescribed sulfasalazine. Which finding would require a PRIORITY follow-up by the nurse? #70624106 (28)
1. Elevated erythrocyte sedimentation rate
2. Hemoglobin 10.5 g/dL
3. Urine with yellow orange discoloration
4. Urine specific gravity 1.035
Normal urine specific gravity is
A continuous regular insulin IV infusion of 0.2 units/kg/hr is prescribed for a 10 year old weighing 48 lb with new-onset diabetes mellitus. How many units would the nurse administer to this client per hour? RECORD YOUR ANSWER USING ONE DECIMAL PLACE #70624106 (29)
The nurse is caring for a client on IV heparin infusion and oral warfarin. Current laboratory values indicate that he client's aPTT is 5 times the control value and the PT/INR is 2 times the control value. What action does the nurse anticipate? #70624106 (30)
1. Clarify vegetable consumption with client
2. Decrease the heparin rate
3. Decrease the warfarin dose
4. Obtain an order for vitamin K injection.
is the antidote for warfarin
is the antidote for heparin #70624106 (30)
The nurse in the student health center at a large university received student telephone messages. Which return telephone call is the PRIORITY?
1. Student who feels well but is considered about possible exposure to viral meningitis at an off campus party 2 weeks ago.
2. Student who was in a baseball tournament yesterday and is now unable to lift the arm past the waist due to extreme shoulder pain.
3. Student who woke from a deep sleep in an unfamiliar dormitory room and is panic-stricken with severe vaginal pain.
4. Student with itchy, cottage-cheese like vaginal discharge who is sexually active and worried about having sexually transmitted infection.
A laboring client with epidural anesthesia experiences spontaneous rupture of membrane, immediately followed by an abrupt change in the fetal heart rate. The nurse knows that considering the probable cause of the change in fetal heart rate, which action should be taken FIRST/ CLICK ON THE EXHIBIT BUTTON FOR ADDITIONAL INFORMATION.
1. Administer IV fluid bolus
2. Assess for umbilical cord prolapse
3. Notify the health care provider
4. Reposition client to alternate side.
The nurse is working in the emergency depart-ment. Which client should the nurse see FIRST?
1. 12 year old with severe neck muscle spasms who is taking haloperidol for Tourette syndrome
2. 80 year old with irritability and agitation who has taken alprazolam for 2 weeks
3. Client taking clozapine who has sudden onset of high fever, diaphoresis, and change in mental status.
4. Client taking olanzapine who has dry mouth, blurry vision and constipation.
what is the nursing care for GERD?
when does a baby begin to walk
What are some medical interventions for CP?
what is patent ductus arteriosus? what is it associated with?
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