NCLEX JEOPARDY I

Seizures

100

In planning the diet teaching for a child in the early stage of nephritic syndrome, the nurse would discuss with the parents the following dietary changes: 1. Adequate protein intake, low sodium 2. Low protein, low potassium 3. Low potassium, low calorie 4. Limited protein, high carbohydrate

1.This is the one kidney disease where they can have more protein

200

Which of the following clients is a likely candidate for developing acute renal failure? 1. A female with recent ileostomy due to ulcerative colitis 2. Middle age male with elevated temperature and chronic pancreatitis 3. Teenager in hypovolemic shock following a crushing injury to the chest 4. Child with compound fracture of right femur and massive laceration to left arm

3. All I have to see is one word “shock”. Shock kills kidneys

300

A client is experiencing severe pain from renal calculi. Which of the following is a priority in the nursing care plan? 1. Administer pain medication as often as needed according to doctors orders 2. Encourage fluid intake to help flush the stone through 3. Assist the client to ambulate to promote draining the bladder 4. Irrigate the bladder to maintain urinary patency

1. Identify what the problem is pain, so pick the answer that deals with pain

400

In order to maintain asepsis, the client on home peritoneal dialysis should be taught to: 1. Drink only distilled water 2. Cap the Tenchkoff catheter when not in use 3. Boil the dailysate one hour prior to a pass 4. Clean the arteriovenous fistula with hydrogen peroxide daily

2. Cap the Tenchkoff catheter when not in use

500

A client has a history of oliguria, hypertension, and peripheral edema. Current lab values include BUN 25, K 5.0. Which nutrients should be restricted in this client’s diet? 1. Protein 2. Fats 3. Carbohydrates 4. Magnesium

1. When someone is in renal failure what do nutrients do you have to worry about?

Oncology

100

A low risk 38 week gestation woman calls the labor unit and says, "I have to come to the right hospital right now. I just saw pink streaks on the toilet tissue when I went to the bathroom. I'm bleeding." Which of the following responses should the nurse make first? 1. "Doe it burn when you void?" 2. "You sound frightened." 3."That is just the mucus plug." 4. "How much blood is there?"

2. The nurse is using reflection to acknowledge the client's concerns.

200

A Muslim woman request something to eat after the delivery of her baby. which of the following meals would be most appropriate for the nurse to give her? 1. Ham sandwich 2. Bacon and eggs 3. Spaghetti with sausage 4. Chicken and dumplings

4. Although this is not a traditional Muslim dish, the foods are allowable by Muslim tradition.

300

During a prenatal interview, a client tells the nurse, "My mother told me she has toxemia during preganancy and almost diet!" Which of the following questions should the nurse ask in response to this statement? 1." Does your mother have a cardiac condition?" 2. "Did your mother tell you what she was toxic from?" 3. "Does your mother have diabetes now?" 4. "Did your mother say whether she had a seizure or not?"

4. This is the appropriate question. The nurse is asking whether or not the client's mother developed eclampsia.

400

Which finding should the nurse expect when assesing a client with placenta previa? 1. Sever occiptial headache 2. History of renal disease 3. Previous premature delivery 4. Painless vaginal bleeding

4. Painless vaginal bleeding is often the only symptom of placenta previa.

500

A nurse is monitoring the labor of a client who is receiving IV oxytocin (Pitocin) at 6ml per hour. Which of the following clinical signs would lead the nurse to stop the infusion?

1. Change in maternal pulse rate from 76 to 98 bpm. 2. Change in fetal heart from 128 to 102 bpm. 3. Maternal blood pressure of 150/100. 4. Maternal temperature of 102.4F

MS

100

A 3 year old female is hospitalized for a femur fracture. As her nurse, what nursing action would be help foster the child's sense of autonomy? 1. Allow the child to choose what time to take her oral antibiotics. 2. Allow the child to have a doll for medical play. 3. Allow the child to administer her own dose of Keflex (cephalexin)via oral syringe. 4. Allow the child to watch age-appropriate video's.

3. Allowing toddlers to participate in actions of which they are capable is an excellent way to enhancer their autonomy.

200

A 17-year-old male is being seen in the E.R. In order to obtain the adolescent's health information, his nurse should: 1. Interview the adolescent using direct questions. 2. Gather information during a casual conversation. 3. Interview the adolescent only in the presence of his parents. 4. Gather information only from the parents.

2. Frequently adolescents will share more information when it is gathered during a casual conversation.

300

How can the nurse best facilitate the trust relationships between infant and parent while the infant is hospitalized? 1. The nurse should encourage the parents to remain at their child's bedside as much as possible. 2. The nurse should keep parents informed about all aspects of their child's condition. 3. The nurse should encourage the parents to hold their child as much as possible. 4. The nurse should encourage the parents to participate actively in their child's care.

3. Having parents hold their child while in the hospital is an excellent means of building the turst relationship. Infants are most secure when they are being held, patted, and spoken to.

400

The nurse is caring for a 7-year-old female on the school-age unit. Her mother is concerned that she may be some developmental delays. Whic of the following statments would indicate to the nurse that the child is not developmentally on track for her age: 1. The child is able to follow a four-to-five-step command. 2. The child started wetting the bed on this admission to the hospital. 3. The child has an imaginary friend named Kelly. 4. The child enjoys playing board games with her sister.

3. Most school-age children do not have imaginary friends. This is much more common for children of 3 and 4 years of age.

500

The nurse is caring for a 12-month-old girl. The child's mother asks if the unit has any toys that her daughter can play with. The nurse goes to the toy area in search of a toy for the child. Which toy is the best choice for this child? 1. A doll 2. A musical rattle 3. A board book 4. Colorful beads.

2. A musical ratle is the perfect toy for this child. Infants have short attention spans and enjoy auditory and visual stimulation.

Parkinson's

100

The nurse has finished receiving the morning change-of-shift report. Which client should the nurse assess first? 1. The client diagnosed with pneumonia who has bilateral crackles. 2. The client on strict bed rest who is complaining of calf pain. 3. The client who complains of low back pain when sitting in a chair. 4. The client who is upset because the food is cold all the time.

2. The client with claf pain could be experiencing deep vein thrombosis (DVT), a complication of immobility, which may be fatal if a pulmonary embolus occurs;therefore, this client should be assessed first.

200

A client's nursing diagnosis is Deficient Fluid Volume related to excessive fluid loss. Which action related to fluid management should be delegated to a nursing assistant? 1. Administer IV fluids as prescribed by the physician. 2. Provide straws and offer fluids between meals. 3. Develop plan for added fluid intake over 24 hours. 4. Teach family members to assist client with fluid intake.

2. The nursing assistant can reinforce additional fulid intake once it is part of the care plan. Administring IV fluids, developing plans, and teaching families require additional education and skills that are within the scope of practice fore the RN.

300

An otherwise healthy 28-year-old woman has just been diagnosed with stage 1 hypertension. The patient is 5'6" tall and weighs 115 pounds. She says she has a glass of wine once or twice a week and eats "fast food" frequently because of her busy schedule. Which topic will you plan one including in the patient teaching plan? 1. Benefits and adverse effects fo beta-blockers 2. Adverse effects of alcohol on blood pressure 3. Methods for decreasing dietary caloric intake 4. Low-sodium food choices when eating out.

4. Lifestyle management, including sodium reduction, is appropriate initial therapy for a patient with stage 1 hypertension and no cardiovasuclar disease or risk factors. Antihypertensive medications would not be prescribed unless lifestyle changes were attempted for several months with out a decrease in blood pressure. This patient's assessment datea indicate that she is not overweight and does not drink excessive alcohol, do discussing changes in these risk factors would not be appropriate.

400

The patient with migraine headaches has a seizure. After the seizure, which action can you delegate to the nursing assistant? 1. Document the seizure. 2. Perform neurologic checks. 3. Take the patient's vital signs. 4. Restrain the patient for protection.

3. Taking vital signs is within the education and scope of practice for a nursing assistant. The nurse shoud perform neurologic checks and document the seizure. Patients with seizures whould not be restrained; however, the nurse may guide the patient's movements as necessary.

500

You are the admission nurse for a patient with nephrotic syndrome. Which assesement findings supports this diagnosis? 1. Edema formation 2. Hypotension 3. Increased urine output 4. Flank Pain

1. The underlying pathophysiology of nephrotic syndrome involves increased glomerular permeablility that allows larger molecules to pass through the membrane into the urine and be removed from the blood. This process causes massive loss of protien, edema formation, and decreased serum albumen levels. Key features included hypertension and reanl insufficiency (decreased urine output). Flank pain is seen in patients with acute pyleonephritis.