My NCLEX-PN Review 2 Flashcards

Terms Definitions
8.6 10 mg/dL
Number of pregnancies
135 to 145 mEq/L
Respiratory Acidosis- Treatment
Mechanical Ventilation
Pulmonary Valve Stenosis- Cause
Rheumatic Fever
Right side heart failure symptom
nocturnal polyuria
Abortions or miscariages
A=# of abortions/miscarriages (included in gravida if before 20 weeks; included in parity if past 20 weeks); note that a termination of the pregnancy after 20 weeks is referred to as a therapeutic termination.
A 24-year-old secretary is transferred to the psychiatric unit. Her husband says that she has been overeating and that she vomits soon after she eats. Her weight stays about the same, at 96 lb (43.5 kg). This behavior may indicate which medical diagnosis?
A 14-year-old client diagnosed with acne vulgaris asks what causes it. Which factors should the nurse identify for this client? Select all that apply:
Beta blockers
cause bronchospasms, use with caution in pt's with emphysema (copd)
Chadwick's sign
Violet coloration of the mucous membranes of the cervix, vagina, and vulva that occurs at about week 4.
An 82-year-old client is admitted to the hospital with a diagnosis of pneumonia. The nurse learns that the client lives alone and hasn't been eating or drinking. When assessing him for dehydration, the nurse would expect to find:
An elderly client who underwent total hip replacement exhibits a red, painful area on the calf of the affected leg. What test validates presence of a thromboembolism?
To assess effectiveness of incentive spirometry, the nurse can use a pulse oximeter to monitor the client's:
oxygen saturation.
Several conditions may cause sexual dysfunction in men. Which condition represents one of the most common causes?
Diabetes mellitus
Hyperthyroidism is caused by increased levels of thyroxine in blood plasma. A client with this endocrine dysfunction would experience:
heat intolerance.
Displaced fundus to the right or left
full bladder
Substance abuse
1. Many substances cross the placenta; no drugs, including over-the-counter drugs should be taken unless prescribe by the physician.
2. Alcohol, cocaine, crack, marijuana, amphetamines, barbiturates, heroin, and cigarettes.
3. Substance abuse threatens normal fetal growth and successful term completion of the pregnancy.
4. SA places the pregnancy and fetus/newborn at risk for bleeding, complications, miscarriage, stillbirth, prematurity, low birth weight, and sudden infant death syndrome.
5. Physical signs of drug abuse - dilated or contracted pupils, fatigue, track (needle) marks, skin abscesses, inflamed nasal mucosa, and inappropriate behavior by the mother.
6. Alcohol during pregnancy-fetal alcohol syndrome, congenital anomalies, and growth deficits, can also cause jitteriness and physical abnormalities.
7. Smoking leads to low birth weights, a higher incidence of birth defects, and stillbirth.
8. Neonatal abstinence syndrome can result as the newborn withdraws from the substance abused by the mother.
The nurse is caring for a client experiencing acute addisonian crisis. Which laboratory data would the nurse expect to find?
During a routine follow-up examination, the nurse updates the client's medication history. The client currently receives prednisone therapy. Which drug class increases the risk of peptic ulcer disease when taken with prednisone?
Nonsteroidal anti-inflammatory drugs (NSAIDs)
An infant is diagnosed with patent ductus arteriosus. Which drug may be administered to achieve closure of the defect?
Indomethacin (Indocin)
The nurse is administering neomycin to a client. Which adverse effect should the nurse ask the client to report?
Hearing loss
Which nursing intervention is most appropriate for a client with multiple myeloma?
Preventing bone injury
The nurse is administering eyedrops to a client with glaucoma. To achieve maximum absorption, the nurse should instill the eyedrop into the:
conjunctival sac.
The nurse is providing care for a postoperative client who has undergone a small bowel resection. The client has an epidural catheter. Which of the following can be administered through this catheter?
Po2 (partial pressure of oxygen)
80 to 100 mm Hg
Low oxygen levels caused by a build up of fluid in the lungs and inflammation of lung tissue
Hegar's sign
Softening of the uterus that occurs at about weeek 6.
A client is dissatisfied with his hospitalization. He decides to leave against medical advice and refuses to sign the paperwork. The nurse's next course of action is to:
let him leave.
The nurse is caring for an elderly client who exhibits signs of dementia. The most common cause of dementia in an elderly client is:
Alzheimer's disease.
The nurse is palpating the uterus of a client who is 20 weeks pregnant in order to measure fundal height. Identify the area on the abdomen where the nurse should expect to feel the uterine fundus.
While making her rounds on the pediatric floor, the nurse finds an infant in his crib unresponsive and without respirations. Which action should the nurse take?
Call for assistance.
A client who has been hospitalized with depression is being discharged with a prescription of phenelzine (Nardil). In planning for discharge, the nurse should have a teaching plan that emphasizes which of the following?
Avoid red wine.
The nurse is collecting data on a neonate. Health history findings indicate that the mother drank 3 ounces or more of alcohol per day throughout pregnancy. Which characteristic should the nurse expect to find?
Upturned nose
The nurse is collecting data on an elderly client. When collecting data, the nurse should consider that one normal aging change is:
diminished reflexes.
The nurse is assisting with a screening for testicular cancer. Which client has the highest risk of developing testicular cancer?
A 28-year-old man
The nurse is caring for a client dying of lung cancer. According to Maslow's hierarchy of needs, which dimension of care is considered primary in importance when caring for a dying client?
Should be taken with juice or other desired liquid because it has an unpleasant taste
Oral potassium chloride
A client has a colostomy in the descending colon after surgical removal of a tumor. Which of the following should the nurse anticipate when the client resumes a regular diet?
Formed, soft stools
The nurse should determine that restraints are no longer needed when the client does which of the following?
Is calm verbally and nonverbally
During the acute phase of a burn, the nurse should collect data on which topic?
Circulatory status
The nurse is developing a care plan for a client in her 34th week of gestation who's experiencing premature labor. What nonpharmacological interventions should the plan include to halt premature labor?
Promoting adequate hydration
A 74-year-old man with a history of heart failure is admitted to the telemetry unit. Which of the following parameters should the nurse closely monitor in assessing the client's response to a bolus dose of I.V. furosemide (Lasix)?
Hourly urine output
The nurse is preparing a client with systemic lupus erythematosus (SLE) for discharge. Which instruction should the nurse include in the teaching plan?
Monitor body temperature.
Which of the following statements describing urinary incontinence in the elderly is true?
Urinary incontinence isn't a disease.
The nurse is caring for a client diagnosed with a cerebral aneurysm who reports a severe headache. Which action should the nurse perform?
Call the physician immediately.
The nurse is giving a bath to a client with a decreased level of consciousness who has a normal body temperature. When giving a bed bath, what temperature should the water be?
110<font face="LWWSYM">%</font> to 115<font face="LWWSYM">%</font> F (43.3<font face="LWWSYM">%</font> to 46.1<font face="LWWSYM">%</font> C)
A 2-year-old male is admitted for possible bacterial meningitis. Which of the following nursing actions should the nurse take first?
Assess the client's neurologic status.
When caring for a neonate, what's the most important step the nurse can take to prevent and control infection?
Practice meticulous hand washing.
A client on an inpatient psychiatric unit at a community mental health center is pacing up and down the hallway. The client has a history of aggression. Which of the following is the nurse's best response when approaching the client?
"You're pacing. Let's walk together and talk about it."
Which behavior during dinner suggests a therapeutic response to pyridostigmine (Regonol) in a client with myasthenia gravis?
The client swallows food without difficulty.
A client is in the first postoperative day after a total laryngectomy and radical neck dissection. Which of the following is a priority goal?
Maintaining a patent airway
A parent brings a 19-month-old toddler to the clinic for a regular checkup. When palpating the toddler's fontanels, what should the nurse expect to find?
Closed anterior and posterior fontanels
A 15-year-old client comes to the clinic requesting a test for human immunodeficiency virus (HIV) exposure. The adolescent is concerned that her parents might be notified of her test results. Which response by the nurse is best?
"HIV testing is confidential; after we get the test results, we will discuss your options."
A client is prescribed transcutaneous electrical nerve stimulation (TENS) for pain relief. The rationale for using TENS is to:
block painful stimuli traveling over small nerve fibers.
Minimal bacteria diet for client with neutropenia?
avoid eating pepper, it's not processed and contains bacteria
The nurse administers an I.M. injection to a 6-year-old. Afterward, the nurse should:
discard the uncapped needle in a puncture-proof container.
A client notices that her neonate's eyes appear to be crossed. She anxiously points this out to the nurse. What's the nurse's best response?
"This is a temporary condition caused by immature neuromuscular control of the eye muscles."
A male client has arteriosclerosis with intermittent claudication. The nurse has worked with him to develop a walking program. Which client statement indicates that he understands the program?
"I should walk until pain occurs, then rest."
A 46-year-old male client is admitted to the hospital with a suspected diagnosis of hepatitis B. He's jaundiced and complaining of weakness. Which of the following should the nurse include in the client's care plan?
Rest periods after small, frequent meals
The nurse is speaking to a group of women about early detection of breast cancer. The average age of the women in the group is 47. Following the American Cancer Society guidelines, the nurse should recommend that the women:
have a mammogram annually.
A nurse needs assistance transferring an elderly, confused client to bed. The nurse leaves the client to find someone to assist her with the transfer. While the nurse is gone, the client falls and hurts herself. The nurse is at fault because she didn't:
arrange for continual care of the client.
A 69-year-old client asks the nurse what the difference is between osteoarthritis (OA) and rheumatoid arthritis (RA). Which response is correct?
"OA is a noninflammatory joint disease. RA is characterized by inflamed, swollen joints."
The nurse is preparing to teach a 13-year-old client with asthma to administer his own breathing treatments. Which principle should the nurse keep in mind when planning the teaching session?
Adolescents are worried about appearing different from their peers.
Autonomy vs shame & doubt
early childhood, 18 mos - 3 yrs old, gains control over self & envirnoment
A client who has recently had surgery for prostate cancer expresses to the nurse feelings of anger toward God, his church, and the clergy. Which intervention is appropriate for this client?
Encouraging the client to discuss concerns with the clergy
Which of the following clients would be a priority for the nurse to evaluate when assuming responsibility for their care at the beginning of the day shift?
The client who had a total laryngectomy the previous day
A bulimic client admitted to the psychiatric unit suddenly shouts, "I want to leave right now. I'm not crazy and don't belong here." Which response should the nurse make?
"You seem upset; I'll stay with you."
A client comes to the emergency department while experiencing a panic attack. The nurse can best respond to a client having a panic attack by:
staying with the client until the attack subsides.
The nurse is teaching parents how to reduce the spread of impetigo. The nurse should encourage parents to:
teach children the importance of proper hand washing.
A client with pneumonia has a nursing diagnosis of <i>Ineffective airway clearance related to increased secretions and ineffective cough.</i> Which intervention would facilitate effective coughing?
Sipping water, hot tea, or coffee
A 13-year-old visits the school nurse because he's experiencing back pain, fatigue, and dyspnea. The nurse suspects that the child may have scoliosis. The nurse should first:
inspect the child for uneven shoulder height or uneven hip height.
The nurse is caring for a 45-year-old married woman who has undergone hemicolectomy for colon cancer. The woman has two children. Which concepts about families should the nurse keep in mind when providing care for this client? Select all that apply:
Changes in sleeping and eating patterns may be signs of stress in a family.
A newly pregnant client tells the nurse that she hasn't been taking her prenatal vitamins because they nauseate her. In addition to telling the client how important taking the vitamins are, the nurse should advise her to:
take the vitamin on a full stomach.
A client with a history of duodenal ulcers tells the admitting nurse that he takes antacids once in a while to relieve the pain. Which statement by the client should be reported immediately?
"My bowel movements have been sticky and black."
The nurse gives a neonate an initial feeding of plain sterile water. The mother asks why this was given. What's the nurse's best response?
"Plain sterile water will cause less irritation to the respiratory tract if the baby accidentally breathes some in."
Proximal end of a double-barrel colostomy
the end that is the opening on the client's right side
To treat cervical cancer, a client has had an applicator of radioactive material placed in her vagina. Which observation by the nurse indicates a radiation hazard?
The client receives a complete bed bath each morning.
The nurse is demonstrating how to clean dentures to a nursing assistant. What should the nurse teach the nursing assistant to do?
Place a washcloth in the sink to prevent damage if the dentures are dropped.
A client with anorexia nervosa who's on bed rest stares at her dinner tray. She has made little effort to eat. Which statement by the nurse would be most therapeutic?
"I'll stay with you while you eat and help you fill out tomorrow's menu."
The nurse is caring for a client admitted to the emergency department after a motor vehicle accident. Under the law, the nurse must obtain informed consent before treatment unless:
the client is in an emergency situation.
The nurse is caring for a 25-year-old client with end-stage testicular cancer who has been referred to hospice care. Which criterion excludes the client from hospice care?
The client entered a clinical trial through the National Cancer Institute.
A nurse is reviewing prenatal care with a client. Which of the following statements by the client best expresses an adequate understanding of the nutritional needs during pregnancy?
"I'll need to eat more so that I'll gain about 25 pounds, but I want to make sure I don't fill up with junk food."
A first-time mother-to-be is in the labor room, her husband at her bedside. The client states that her contractions began 6 hours ago. Which of the following assessment findings would confirm that the client is in true labor?
Cervix that's 100% effaced and 2 cm dilated
The nurse provides care for a client with a detached retina who has both eyes patched. When communicating with the client, the nurse should:
identify herself every time she enters the room.
The nurse is caring for a client who underwent a total hip replacement. What should the nurse and other caregivers do to prevent dislocation of the new prosthesis?
Prevent internal rotation of the affected leg.
The nurse is collecting data on an 80-year-old widow. Which statement best describes the developmental stage of the client at this age?
The client realizes that she can provide others with an example of wisdom and courage.
The nurse is caring for a client with manic depression. The care plan for a client in a manic state would include:
listening attentively with a neutral attitude and avoiding power struggles.
The nurse is giving nutritional counseling to the mother of a child with celiac disease. Which statement by the mother would indicate understanding?
My son can't eat wheat, rye, oats, or barley.
A 55-year-old black male is found to have a blood pressure of 150/90 mm Hg during a work site health screening. What should the nurse do?
Recommend he have his blood pressure rechecked within 2 months.
Which nursing action takes priority when admitting a client with right lower lobe pneumonia?
Elevate the head of the bed 45 to 90 degrees.
The nurse is caring for a client with schizophrenia. Which of the following outcomes is the least desirable?
The client spends more time by himself.
A client has just been admitted to the postpartum unit after an uncomplicated vaginal birth of a healthy neonate. Which factor is the best predictor that this client will experience afterpains?
The client has given birth five times.
A client is in labor with her first baby. Which of the following would indicate that the client has moved into the second stage of labor?
The client has an uncontrollable urge to bear down.
A 15-month-old male is brought to the ambulatory care clinic for well-child care by his mother. He's crying and pulling at his left ear, which appears erythematous. Which of the following actions should the nurse take first?
Examine the affected ear last in order to minimize distress early in the exam.
The nurse is teaching a male client to perform monthly testicular self-examinations. Which of the following points would be appropriate to make?
Testicular cancer is a highly curable type of cancer.
A 25-year-old client asks the nurse how often and when she should perform breast self-examinations. The nurse should tell her:
every month, 7 to 10 days after menses starts.
The nurse is caring for a client who sustained a chemical burn in his right eye. She's preparing to irrigate the eye with sterile normal saline solution. Which steps are appropriate when performing the procedure? Select all that apply:
Direct the solution onto the exposed conjunctival sac from the inner to outer canthus.
The nurse is teaching the mother of an infant about the importance of immunizations. The nurse should teach her that active immunity:
results from exposure of an antigen through immunization or disease contact.
The nurse is caring for a client after evacuation of a hydatidiform mole. The nurse should tell the client to:
use birth control for at least 1 year.
The nurse is caring for a client with <i>Impaired gas exchange.</i> Which of the following outcomes is desired based on this nursing diagnosis?
The client has normal breath sounds in all lung fields.
A client is admitted to the inpatient unit of the mental health center with a diagnosis of paranoid schizophrenia. He's shouting that the government of France is trying to assassinate him. Which of the following responses is most appropriate?
"I find it hard to believe that a foreign government or anyone else is trying to hurt you. You must feel frightened by this."
The nurse is providing postoperative care for a client recovering from abdominal surgery. The client is receiving morphine through a client-controlled analgesia pump. Which finding would indicate that the client is obtaining adequate pain relief?
Pain rating of 2 or 3 on a scale of 0 to 10
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