Fundamentals
The nurse is observing a staff member perform an abdominal assessment for a client. The nurse should intervene if the staff member observed....
1) asking the client to void before assessment
2) palpating the abdomen before auscultation
3) performing a visual assessment of the abdomen before auscultation
4) asking the patient their typical bowel habits before physical assessment
2) palpating the abdomen before auscultation
Rationale: Palpating before auscultation can alter the bowel sounds.
The nurse is reviewing new medication prescriptions for a client who has a suspected brain tumor. The client is scheduled for a CT scan of the head with IV iodinated contrast in 24 hours. The nurse should clarify the prescription for
1) gabapentin
2) amlodipine
3) metformin
4) phenytoin
3) metformin
Rationale: In some cases IV iodinated contrast is administered during the CT scan to enhance visualization of blood vessels or certain organs. A potential complication of IV iodinated contrast is acute kidney injury. Lactic acidosis is severe complication of metformin, an antidiabetic medication. Nephropathy caused by the administration of iodinated contrast can result in in an accumulation of metformin in the bloodstream, which increases the risk for lactic acidosis. Because of this metformin should be discontinued 24-48 hours before administration of IV iodinated contrast.
The client screams at the nurse, "You are all incompetent here! I have been waiting for 2 hours!" How should the nurse response initially?
1) "I know you are upset, but I will have to call security if you continue to scream"
2) "I see that you are frustrated, but the delay cannot be avoided"
3) "It is upsetting to wait so long. How can I best help you?"
4) "The wait is long today, but you will receive quality, unhurried care when it is your turn"
3) "It is upsetting to wait so long. How can I best help you?"
Rationale: Therapeutic communication is used to establish trust, encourage communication, and display respect for the client. Validating the client's feelings and offering self convey concern and understanding by the nurse and helps establish a therapeutic dialogue. Together these techniques can be helpful for diffusing negative emotions.
The emergency department nurse receives several prescriptions for a client who was found unresponsive after drinking beer and consuming unidentified pills. Which prescription should the nurse implement first?
1) administer IV push naloxone once now
2) draw specimen for blood alcohol content testing STAT
3) initiate continuous lactated ringer solution infusion
4) obtain urine sample for drug abuse screening ASAP
1) administer IV push naloxone once now
Rationale: respiratory depression occuring after the ingestion of an unknown substance should initially be treated with administration of several reversal agents (Naloxone). Naloxone rapidly reverses the effects of opioids and may restore spontaneous respiration and normal ventilatory pattern, averting initiation of mechanical ventilation, the possibility of respiratory arrest, and death
The nurse is caring for a client at 15 weeks gestation who has hyperemesis gravidarum. Which of the following findings would be consistent with the condition?
1) heart rate less than 60/min
2) moderate to high urine ketones
3) increased serum potassium level
4) blood pressure greater than 140/90
2) moderate to high urine ketones
Rationale: Hyperemesis gravidarum is characterized by severe, persistent nausea and vomiting during pregnancy and weight loss of >5% of pre-pregnancy weight. Laboratory test results associated with HG include moderate to high ketonuria. Ketones are a byproduct of the metabolism of fat for energy due to a significant lack of nutritional intake.
The registered nurse observes a graduate nurse who is inserting a small-bore nasojejunal feeding tube. Which action by the graduate nurse requires intervention by the registered nurse?
1) asking the client to take small sips of water during insertion
2) marking the tube at the exit point of the nares
3) removing the stylet before the x-ray is performed
4) stopping the insertion of the tube while the patient is coughing
4) Removing the stylet before the x-ray is performed
The nurse is assessing a client with hypertension and essential tremor 2 hours after receiving a first does of propranolol. Which assessment is most concerning to the nurse?
1) client reports a headache
2) current blood pressure is 160/88 mm Hg
3) heart rate has dropped from 70/min to 60/min
4) slight wheezes auscultated during inspiration
4) slight wheezes auscultated during inspiration
Rationale: the presence of wheezing in a client taking propranolol may indicate that bronchoconstriction or bronchospasm is occurring.
A client with bipolar disorder is admitted to the psychiatric unit with acute mania and dehydration. What prescription should the nurse question?
1) administer haloperidol and lorazepam IM together for aggressive behavior
2) administer zolpidem at bedtime as needed for insomnia
3) continue prescribed lithium PO every 8 hours
4) infuse 500 mL normal saline IV bolus over 1 hour
3) Continue prescribed lithium PO every 8 hours
Rationale: Lithium is a form of salt; therefore any condition associated with excessive sodium depletion increases receptor site availability, causing lithium to accumulate in the body at toxic levels.
The nurse is assessing a client who has an abdominal aortic aneurysm repair 6 hours ago. Which of the following would require immediate follow up?
1) reports of pain rated as 5 on a scale of 0-10
2) green bile is draining from the nasogastric tube
3) abdomen is soft, non distended, and tender to touch
4) blood pressure of 96/66 mm Hg and heart rate of 112/min
4) blood pressure of 96/66 mm Hg and heart rate of 112/min
Rationale: The client must be monitored postoperatively for graft leakage and hemodynamic instability because adequate blood pressure is necessary to maintain graft patency. Symptoms of graft leakage may be subtle but can include vital sign changes (decreasing blood pressure, tachycardia)
The nurse is caring for a client at 20 weeks gestation who reports consuming raw, powdered cornstarch during the pregnancy. Which of the following laboratory tests should the nurse expect to obtain for the client?
1) urine culture and sensitivity
2) serum hCG level
3) hematocrit and hemoglobin
4) fecal occult blood test
3) hematocrit and hemoglobin
Rationale: Pica is the compulsive consumption of nonfood substances that are not considered nutritionally valuable. Although the relationship between pica and nutritional deficiencies is not fully understood, pica is often accompanied by iron deficiency anemia, perhaps due to insufficient nutritional intake or impaired iron absorption. Therefore, hemoglobin and hematocrit should be obtained to screen for the presence of iron deficiency anemia in a client who is reporting pica.
The nurse has received a new order to discontinue IV fluids for a client who is receiving bolus doses of morphine via an IV patient-controlled analgesia PCA device. Which of the following actions should the nurse take?
1) change the setting on the PCA device to deliver a continuous infusion
2) clarify the order with the health care provider
3) connect the PCA tubing directly to the client's peripheral venous access device
4) discontinue operation of the PCA device
2) clarify the order with the health care provider
Rationale: A PCA device delivers a set amount of IV analgesic each time the client presses the delivery button. With many PCA devices, a continuous IV solution is requires to keep the vein open and flush the medication through the tubing so that the boluses reach the client. To ensure uninterrupted delivery of the client's PCA the nurse should contact the HCP to clarify the order to discontinue the maintenance fluids.
The nurse in the emergency department is caring for a client with anaphylaxis. The client received a dose of IM epinephrine 15 minutes ago, which has not improved the client's condition. It would be a priority for the nurse to administer
1) IM epinephrine
2) lactated ringer solution
3) IV methylprednisolone
4) nebulized albuterol
1) IM epinephrine
Rationale: The first-line treatment for anaphylaxis is epinephrine, a rapid acting vasopressor that stimulates adrenergic receptors to reduce vasodilation, prevent further release of inflammatory mediators, and reverse bronchoconstriction. A repeat dose of epineprhine should be administered every 5-15 minutes if there is no improvement after the initial dose.
The nurse is caring for a client with anorexia nervosa. Which of the following findings would be consistent with the condition? Select all that apply
1) heat intolerance
2) has not menstruated in 3 months
3) avoids participation in physical activity
4) fine, downy hair on the face and back
5) decreased serum potassium level
6) BMI of 16 kg/m2
2) has not menstruated in 3 months
4) fine, downy hair on the face and back
5) decreased serum potassium level
6) BMI of 16 kg/m2
Rationale: Anorexia nervosa is an eating disorder common among adolescent and young adults. Amenorrhea, lanugo, fluid, fear of weight gain, and electrolyte imbalance are common clinical manifestations of anorexia nervosa.
A nurse in the emergency department is caring for a homeless client just brought in with frostbite to the fingers and toes. The client is experiencing numbness, and assessment shows mottled skin. Which interventions should be included in the client's plan of care? Select all that apply
1) apply occlusive dressing after rewarming
2) elevate affected extremities after rewarming
3) massage the areas to increase circulation
4) provide adequate analgesia
5) provide continuous warm water soaks
2) elevate affected extremities after rewarming
4) provide adequate analgesia
5) provide continuous warm water soaks
Rationale: Provide analgesia as the rewarming procedure is extremely painful. Immerse the affected area in water heated to 98.6-102.2. As thawing occurs the injured area will become edematous and may blister. Elevate the injured area after rewarming to reduce edema.
The women's health nurse is caring for a 30-year-old client who wants to use the ethinyl estradiol and norelgestromin patch for contraception. Regarding this method of birth control, which finding should be most concerning to the nurse?
1) client reports heavy menstrual cycles
2) history of breast cancer
3) history of deep venous thrombosis
4) weight is 186 lb and BMI is 31.0kg/m
3) history of deep venous thrombosis
Rationale: Absolute Contraindications to combined hormonal contraceptive pills: active breast cancer, migraines with aura, uncontrolled hypertension, active hepatitis/severe cirrhosis/liver cancer, age >35 & >15 cigarettes/day, ischemic heart disease, stroke, <3 weeks postpartum, prolonged immobilization, thrombophilia, venous thromboembolism
The nurse is caring for a client with bacterial meningitis, identified as Neisseria Meningitidis who has a stage 4 pressure injury. What personal protective equipment is most appropriate for the nurse to wear when performing a dressing change? Select all that apply.
1) Disposable gown
2) Face shield
3) Gloves
4) N95 Respirator
5) Surgical Mask
1) Disposable gown
2) Face Shield
3) Gloves
5) Surgical Mask
Rationale: Bacterial Meningitis and many respiratory illnesses are trasnmitted through large droplets and secretions spread into the air by coughing, sneezing, or talking. Droplet precautions for routine care require the use of a surgical mask as the highest risk of transmission is through inhalation of droplets.
The nurse is reviewing new prescriptions for assigned clients. The nurse should clarify the prescription for...
1) allopurinol for a client who has gout
2) dicyclomine for a client who has a paralytic ileus
3) carvedilol for a client who has an elevated BNP level
4) ipratropium for a client who has chronic obstructuve pulmonary diseasr
2) dicyclomine for a client who has a paralytic ileus
Rationale: Anticholinergic medications are used to relax smooth muscle and dry secretion. Anticholinergic effects include pupillary dilation, dry mouth, urinary retention, and constipation. These medications also decrease intestinal motility and are contraindicated in clients with paralytic ileus. The nurse should clarify this prescription with the health care provider.
A teaching plan for the client taking an antipsychotic medication will include which instructions?
1) apply sunscreen before going outdoors
2) drink sugar-free beverages for dry mouth
3) have serum blood levels drawn once a month
4) rise slowly from a sitting position
5) skip any dose that is not taken on time
6) take medication with food to avoid nausea
1) apply sunscreen before going outdoors
2) drink sugar-free beverages for dry mouth
4) rise slowly from a sitting position
Rationale: Mental Health Textbook Chapter 16
The nurse is assigned to care for a client with complete right-sided hemiparesis from a stroke. Which characteristics are associated with this condition? Select all that apply
1) the client is aphasic
2) the client has weakness on the right side of the body
3) the client has complete bilateral paralysis of the arms and legs
4) the client has weakness on the right side of the face and tongue
5) the client has lost the ability to move the right arm but is able to walk independently
6) the client has lost the ability to ambulate independently but is able to feed and bathe self without assistance
1) the client is aphasic
2) the client has weakness on the right side of the body
4) the client has weakness on the right side of the face and tongue
Rationale: Hemiparesis is weakness of one side of the body that may occur after a stroke and involves weakness of the face and tongue, arm, leg, on one side. These clients are also aphasic, unable to discriminate words and letters.
The nurse is preparing to administer misoprostol to a client who is in labor. Which of the following findings would require follow-up prior to administering the medication? Select all that apply
1) IV oxytocin discontinued 8 hours ago
2) abnormal fetal heart rate pattern
3) 6 contractions in 10 minutes
4) 2 previous cesarean births
5) history of renal failure
2) abnormal fetal heart rate pattern
3) 6 contractions in 10 minutes
4) 2 previous cesarean births
5) history of renal failure
Rationale: Misoprostol is a cervical ripening agent that is contraindicated in clients with abnormal fetal heart rate patterns, uterine tachysystole, previous cesarean births, and history of renal failure.
The nurse prepares to provide instructions to a client with a low potassium level about the foods that are high in potassium and plans to tell the client to consume which foods? Select all that apply
1) peas
2) raisins
3) potatoes
4) cantaloupe
5) cauliflower
6) strawberries
2) raisins
3) potatoes
4) cantaloupe
6) strawberries
Rationale: pg 142 Nclex book question 10
The nurse is administering prednisone to a newly admitted patient who is taking multiple other drugs. The nurse would consider which drug interaction with prednisone? Select all that apply
1) Cardiac and central nervous system actions are increased when drug is taken with an adrenergic agent
2) Potassium-wasting diuretcs increase potassium loss, resulting in hypokalemia
3) Risk for gastrointestinal bleeding and ulceration increases when drug is taken with aspirin or other non-steroidal anti-inflammatory drugs (NSAIDS)
4) The action of prednisone is decreased when taken with phenytoin because phenytoin increases glucocorticoids.
5) Risk for dysrhythmias and digitalis toxicity increase when drug is taken with cardiac glycosides
6) Dosage of anti-diabetic agents may need to be decreased when taken concurrently with glucocorticoids
2) Potassium-wasting diuretics increase potassium loss, resulting in hypokalemia
3) Risk for gastrointestinal bleeding and ulceration increases when drug is taken with aspirin or other non-steroidal anti-inflammatory drugs (NSAIDS)
4) The action of prednisone is decreased when taken with phenytoin because phenytoin increases glucocorticoids.
5) Risk for dysrhythmias and digitalis toxicity increase when drug is taken with cardiac glycosides
Rationale: Pharmacology Textbook Ch: 49
A client is admitted with a recent history of severe anxiety following a home invasion and robbery. During the initial assessment interview, which statement by the client would indicate to the nurse the possible diagnosis of post-traumatic stress disorder? Select all that apply
1) "I'm afraid of spiders"
2) "I keep reliving the robbery"
3) "I see that face everywhere I go"
4) "I don't want anything to eat now"
5) "I might have died over a few dollars in my pocket"
6) "I have to wash my hands over and over again many times"
2) "I keep reliving the robbery"
3) "I see that face everywhere I go"
5) "I might have died over a few dollars in my pocket"
Rationale: Reliving an event, experiencing emotional numbness, and having flashbacks of the event are all common occurrences with post-traumatic stress disorder.
Which of the following physiologic mechanisms best explains why patients with severe liver failure are at increased risk for hypoglycemia, metabolic acidosis, and coagulopathy?
1) Impaired gluconeogenesis, decreased lactate clearance, and reduced production of clotting factors
2) Increased glycogenolysis enhanced bicarbonate reabsorption, and platelet hyperactivity
3) Excess insulin production, increased anaerobic metabolism, and decreased hepatic protein synthesis
4) Reduced ketone body formation, enhanced ammonia excretion, and increased hepatic glucose intake
1) Impaired gluconeogenesis, decreased lactate clearance, and reduced production of clotting factors
Rationale:
Patients with severe liver failure experience multiple metabolic derangements due to loss of hepatic function, including:
• Hypoglycemia → The liver is responsible for gluconeogenesis (glucose production from non-carbohydrate sources). In liver failure, this function is impaired, leading to decreased blood glucose levels.
• Metabolic acidosis → The liver normally clears lactate from circulation. In liver failure, lactate accumulates, contributing to lactic acidosis and metabolic acidosis.
• Coagulopathy → The liver synthesizes clotting factors (e.g., fibrinogen, prothrombin, factors V, VII, IX, and X). A failing liver leads to prolonged PT/INR and increased bleeding risk.
The nurse is preparing for the admission of an infant with a diagnosis of bronchiolitis caused by respiratory syncytial virus (RSV). Which interventions would the nurse include in the plan of care? Select all that apply.
1) place the infant in a private room
2) ensure that the infant's head is in a flexed position
3) wear a mask, gown, and gloves when in contact with the infant
4) place the infant in a tent that delivers warm, humidified air
5) position the infant on the side, with the head lower than the chest.
6) ensure that nurses caring for the infant with RSV do not care for other high-risk children
1) place the infant in a private room
3) wear a mask, gown, and gloves when in contact with the infant
6) ensure that nurses caring for the infant with RSV do not care for other high-risk children
Rationale: NCLEX Book pg 466. Question 10