NCLEX RN #13 – Flashcards

The nurse is caring for an 83 year old bedridden client experiencing FECAL INCONTINENCE. . Which nursing intervention is the HIGHEST PRIORITY for this client? #71914832 (56) 1. Consult with the wound care nurse specialist 2. Insert a rectal tube to contain the feces 3. Provide perianal skin care with barrier cream 4. Use incontinence briefs to protect the skin.

In which POSITION would the nurse place a client recovering from a RIGHT MODIFIED RADICAL MASTECTOMY who is admitted from the post-anesthesia unit? #71914832 (57) 1. High-Fowler's position with the affected side's arm resting on the bed. 2. Semi-Fowler's position with the affected side's arm on several pillows 3. Supine with the affected side's arm on several pillows 4. Supine with the affected side's arm resting on the bed.

The nurse is caring for a client with an ileal conduit. While assisting the client in removing the external pouch, the nurse observes that the stoma appears bluish grey. What is the nurse's BEST action ? #71914832 (58) 1. Administer an antibacterial agent and assess for further signs of infection. 2. Document the findings and continue to monitor for changes 3. Measure the stoma and apply a larger pouching device 4. Report the findings to the health care provider (HCP) immediately.

is a surgical technique that uses an excised piece of the client's ileum to create an INCONTINENT URINARY DIVERSION. . #71914832 (58)

The nurse is giving a presentation at a community health event. The nurse should provide which instruction on how to prevent BOTULISM ? #71914832 (59) 1. Boil water if unsure of its source 2. Discard canned food with a bulging end 3. Keep milk cold 4. Wash hands.

is the result of ingesting improperly canned or stored food. Food in a can with a bulging end should not be used. #71914832 (59)

The nurse is caring for a client whose PERITONEAL DIALYSIS is beginning to exhibit insufficient outflow. What actions should the nurse perform INITIALLY. SELECT ALL THAT APPLY #71914832 (60) 1. Assess for abdominal distention and constipation. 2. Contact the client's health care provider 3. Examine the catheter for kinks and obstructions 4. Flush the tubing with 100 mL of dialysate. 5. Place the client in a side-lying position.

uses the abdominal lining (i.e. peritoneum) as a semipermeable membrane to dialyze a client with INSUFFICIENT RENAL FUNC-TION. A catheter is placed into the peritoneal cavity and dialysate is infused. The tubing is clamped to allow the fluid to remain in the cavity usually for 20-30 minutes. The catheter is then unclamped to allow dialysate to drain via gravity. #71914832 (60)

is characterized by an increase in INTRAOCULAR PRESSURE and gradual LOSS OF PERIPHERAL VISION (e. tunnel vision) #71914832 (61)

is separation of the RETINA from the underlying epithelium that allows fluid to collect in the space. ex. curtain appearing in the vision #71914832 (61)

is a DEGENERATIVE EYE DISEASE that brings about the GRADUAL LOSS OF CENTRAL VISION. #71914832 (61)

is CLOUDINESS (ie, opacity) of the lens that may occur at birth or more commonly in older adults. #71914832 (61)

The nurse prepares to assess a newly admitted client diagnosed with CHRONIC ALCOHOL ABUSE whose laboratory report shows a magnesium level of 1.0 mEq/L. Which assessment finding does the nurse anticipate? #71914832 (62) 1. Constipation and polyuria 2. Increased thirst and dry mucous membrane 3. Leg weakness and soft, flabby muscles 4. Tremors and brisk deep-tendon reflexes.

is associated with ALCOHOL ABUSE due to poor absorption, inadequate nutritional intake, and increased losses via the gastrointestinal and renal systems. #71914832 (62)

A client diagnosed with hypertension has been prescribed a CLONIDINE PATCH. Which instructions should the nurse include? SELECT ALL THAT APPLY #71914832 (63) 1. Apply patch to the upper arm or chest. 2. Fold used patches in half with sticky sides together before discarding. 3. Remove patch if dizziness occurs when getting up 4. Rotate sites each time a new patch is applied 5. Shave hair before applying patch.

For which client is it MOST IMPORTANT for the nurse to provide teaching on ways to prevent the spread of the condition? #71914832 (64) 1. Client with eczema on upper torso 2. Client with oral candidiasis 3. Client with psoriasis on hands. 4. Client with tinea corporis.

is a highly contagious fungal skin infection. It is treated with topical antifungals. #71914832 (64)

is a skin rash caused by an immune disorder that is often triggered by an allergy. Itching is common , but the rash is not contagious. #71914832 (64)

or thrush, often occurs after a course of antibiotics or corticosteroids or can occur in infants with immature immune systems. #71914832 (64)

is a chronic autoimmune disease that most often affects the skin by causing DRY, SCALY, RED RASHES. It is not contagious. # 71914832 (64)

The nurse is caring for a client with a DEEP VEIN THROMBOSIS. The client is prescribed a continuous IV heparin of a standard concentration, heparin 25,000 units in 500 mL D5W . After receiving heparin for 6 hours at the PRESCRIBE RATE of 1,300 units/hr. the client's partial thromboplastin time (PTT) is 44 seconds. The nurse must adjust the infusion rate according to the heparin drip protocol, shown in the exhibit. According to protocol , at what RATE in milliliters per hour should the nurse set the IV infusion pump? Record your answer using a whole number. #71914832 (65) The current dose is 1,300 UNITS/HR. This client's PTT is 44 SECONDS. This is BELOW THE THERAPEUTIC RANGE of 55-70 seconds as slown in the exhibit, indicating that the client requires a higher dose of heparin for adequate anticoagulation. According to the Heparin Anticoagulation Dose Adjustments Protocol (institutions protocols vary) the rate should be increased by 100 units/hr. or to an infusion rate of 1,400 UNITS/HR. 1. Calculate the concentration of the heparin solution. 25,000 units divided by 500 mL = 50 units/mL 2. Calculate the adjusted dose in mL/hr Desired x quantity _____________________________________ Available 1,400 units x 1 mL = 28 mL/hr. ________________________________________ 50 units

The emergency department nurse prepares a male client for surgery. Th client was admitted with a traumatic OPEN FRACTURE OF THE FEMUR, hematocrit of 36% and hemoglobin of 12 g/dL. Which PRESCRIPTION should the nurse VALIDATE with the health care provider before adminis-tration? #71914832 (66) 1. Cefazolin 2. Enoxaparin 3. Morphine 4. Tetanus toxoid.

The nurse cares for a client who return from the operating room after a tracheostomy tube placement procedure. Which of the following is the nurse's PRIORITY when caring for a client with a NEW TRACHEOSTOMY? #71914832 (67) 1. Changing the inner cannula within the first 8 hours to help prevent mucus plugs 2. Checking the tightness of ties and adjusting if necessary allowing 1 finger to fit under these ties. 3. Deflating and re-inflating the cuff every 4 hours to prevent mucosal tissue damage.. 4. Performing frequent mouth care every 2 hours to help prevent infection.

A licensed practical nurse (LPN) is assigned to care for a client who was admitted to the medical unit last night with a moderate asthma excerbation and an upper respiratory infection. Which tasks are APPROPRIATE for the registered nurse to DELEGATE TO THE LPN? SELECT ALL THAT APPLY #71914832 (68) 1. Administering albuterol metered-dose inhaler medication. 2. Auscultating lung sounds to determine the client's response to a bronchodilator. 3. Checking oxygen saturation with the pulse oximeter 4. Measuring morning peak expiratory flow with the client's peak flow meter. 5. Monitoring for labored breathing and use of accessory muscles of respiration.

A client is diagnosed with DIABETIC KETO-ACIDOSIS (DKA) . The client reports frequent urination, thirst and weakness. The nurse assesses a temperature of 102.4F (39.1) , fruity breath, deep labored respirations with a rate of 30/min. and dry mucous membranes. What is the PRIORITY nursing diagnosis (ND) at this time? #71914832 (69) 1. Deficient fluid volume related to osmotic diuresis. 2. Imbalanced nutrition less than body requirements related to inability to metabolize glucose 3. Ineffective breathing pattern related to the presence of metabolic acidosis 4. Ineffective health maintenance related to the inability to manage DM during illness.

A nurse in the emergency department assesses 4 clients. Based on the laboratory results, which client is the HIGHEST PRIORITY for treatment? #71914832 (70) 1. Client with abdominal pain, respirations 28/min and blood alcohol level 80 mg/dL 2. Client with chronic obstructive pulmonary disease, pH 7.34 pO2 86 mm Hg,PCO2 48 mm Hg and HCO3 30 mEq/L 3. Client with dull headache, pulse oximeter reading 95% and serum carboxyhemoglobin level 20% 4. Client with emesis of 100 mL coffee-ground gastric contents and serum hemoglobin 15 g/dL

The nurse is administering CLEANSING ENEMA to a client the night before bowel surgery. During instillation of the enema, the client reports cramping and pain. What ACTION should the nurse take? #71914832 (71) 1. Have the client take slow, deep breaths 2. Stop infusing the solution for 30 seconds, then resume at a slower rate. 3. Tell the client that the process will not take much longer. 4. Withdraw the tube approximately 2 cm and continue the infusion.

The nurse is caring for a female young adult newly diagnosed with EPILEPSY and treated with PHENYTOIN. Which of the following should the nurse include in client teaching? SELECT ALL THAT APPLY. #71914832 (72) 1. Avoid excess caffeine 2. Do not stop antiepileptic medicine abruptly 3. Do not use oral contraceptives for birth control 4. Go to an emergency department if a seizure occurs 5. Wear MediAlert identification.

The nurse is caring for pediatric clients in an acute care setting. Which of these clients should the nurse see FIRST? #71914832 (73) 1. A 1 day post tubal myringotomy client with purulent tympanic drainage 2. A 4 day post valve replacement client with a temperature of 102.F (38.8 C)and petechiae 3. A 10 day old client with a patent ductus arteriosus who has a continuous murmur. 4. A 6 year old client with epiglottitis who is drooling and has a severe sore throat.

When caring for a client immediately after a LAPAROSCOPIC CHOLECYSTECTOMY which nursing intervention has the HIGHEST PRIORITY? #71914832 (74) 1. Apply anti-thromboembolism stockings 2. Assist with ambulation 3. Place client in the Sims' position 4. Teach about the importance of a low fat diet.

A client is being discharged on ENOXAPARIN therapy following total knee replacement surgery. Which TEACHING INSTRUCTION does the nurse include in the teaching plan? #71914832 (75) 1. "Eliminate green, leafy vitamin K rich vegetables from your diet." 2. "Mild bruising or redness may occur at the injection site." 3. "You can take over the counter drugs such as ibuprofen to relieve mild discomfort." 4. "You will need PT/INR assessments at regular intervals while on enoxaparin therapy. "

requires monitoring of CBC (thrombocytopenia) but not coagulation studies. #7914832 (75)

A client has been admitted with a catheter-associated, VANCOMYCIN-RESISTANT ENTEROCOCCAL BACTEREMIA. . Which INTERVENTION should the nurse implement? SELECT ALL THAT APPLY #71896532 (01) 1. Keep dedicated equipment for client 2. Perform hand hygiene before exiting the room 3. Place a "No visitors"signs on the client's door. 4. Wear a face mask when in the room 5. Wear an isolation gown when providing direct care.

The school nurse is called to the classroom to assist with a 7 year old with attention-deficit hyperactivity disorder who is throwing books and hitting the other children. what is the BEST INITIAL action for the nurse to take? #71896532 (02) 1. Administer a PRN dose of methylphenidate 2. Ask the child to blow up a balloon 3. Give the child a "time out" in a quiet place 4. Reinforce the consequences of disruptive behaviors.

A newly admitted client with SCHIZOPHRENIA has been exhibiting severe social withdrawal, odd mannerisms, and regressive behavior. The client is sitting alone in the room when the nurse enters says "good morning"and proceeds to sit down next to the client. Without responding, the client stands up and starts to leave. Which of the following actions is BEST for the nurse to take? #71896532 (03) 1. Ask where the client is going 2. Immediately follow the client out the door. 3. In a loud voice, direct the client to come back to the room. 4. Remain silent and allow the client to leave.