NCLEX 4 Flashcards

Terms Definitions
ARDS- Causes
Chemical Inhalation
Septic Shock
Postpartum protoepisiotomy medication
Docusate (colace)
22 to 27 mEq/L
Pulmonary Valve Stenosis- Symptoms
Poor weight gain
35 to 45 mm Hg
RSV- Monitor pt's for:
Respiratory Failure
Otitis Media
A client with personality disorder gets along poorly with his immediate family. The client's manipulative behavior most likely shows a failure to develop which of the following?
The nurse is administering captopril (Capoten) to a client with heart failure. Which assessment finding would prompt the nurse to withhold the next dose and notify the physician?
Which of the following clinical findings would the nurse look for in a client with chronic renal failure?
ARDS- Monitor pt for:
Pulmonary Fibrosis
Multiple System Organ Failure
Ventilator Associated Pneumonia
Respiratory Failure
Adolescent pregnancy
Early onset of menarche, changing sexual behaviors in this age group, problems w/family dvelopment, poverty, and a lack of knowledge regarding reproduction and birth control.
A client receives fentanyl through an epidural catheter for control of postoperative pain. The nurse should observe for which common adverse effect?
Non stress test
determines periodic movement of the fetus
Role of nurse
a. Encourage early and continued prenatal care.
b. Refer adolescent for appropriate assistance, which can help counter effects of a negative socioeconomic environment.
The nurse is using the Glasgow Coma Scale to help assess a client's level of consciousness (LOC). Which score on the Glasgow Coma Scale indicates a deep coma?
The nurse is collecting data on a client suffering from stress and anxiety. A common physiological response to stress and anxiety is:
The nurse is preparing to administer morphine to a postoperative client. Before administering morphine, the nurse should assess the client's:
respiratory rate.
When inserting a urinary catheter, the nurse can facilitate the insertion by asking the client to:
breathe deeply.
Trousseau's sign
a carpal spasm induced by inflating a blood pressure cuff above the systolic pressure for a few minutes
Major conerns w/adolescent preg.
Poor nutritional status, emotional and behavioral difficulties, lack of support systems, increased risk of stillbirth, low birth weight, fetal mortality, cephalopelvic disproportion, and increased risks of maternal complications, such as hypertension, anemia, prolonged labor, and infections.
An 89-year-old client is suffering from dementia of the Alzheimer's type. Which intervention would be most useful in managing his dementia?
Provide a safe environment.
A client is scheduled for amniocentesis. What should the nurse do to prepare the client for the procedure? Select all that apply:
Monitor maternal vital signs.
A 2-year-old child is brought to the emergency department with suspected croup. Which of the following data collection findings reflect increasing respiratory distress?
Intercostal retractions
A client is admitted to the substance abuse unit for alcohol detoxification. Which of the following medications is the nurse most likely to administer to reduce the symptoms of alcohol withdrawal?
Chlordiazepoxide (Librium)
A 68-year-old male is being admitted to the hospital with abdominal pain, anemia, and bloody stools. He complains of feeling weak and dizzy. He has rectal pressure and needs to urinate and move his bowels. The nurse should help him:
onto the bedpan.
In the stages of death and dying as defined by Elizabeth Kubler-Ross, feelings of loss, grief, and intense sadness are symptoms of:
The nurse must practice surgical asepsis when performing which procedure?
Indwelling urinary catheter insertion
Apgar score of 9
baby's hands and feet are blue (acrocyanosis - normal adaptation to birth)
A client with hyperemesis gravidarum is on a clear liquid diet. Which foods would be appropriate for the nurse to serve? Select all that apply:
Ginger ale and apple juice
A client reports to the nurse that she feels like she's losing her mind. This fear is most commonly associated with which disorder?
Panic disorder
The nurse should anticipate which psychological reactions during the second trimester of pregnancy?
Self-centeredness and concentration on the behavior and appearance of children
The nurse is teaching a client who suspects that she has a lump in her breast. The nurse instructs the client that a diagnosis of breast cancer is confirmed by:
fine needle aspiration.
When caring for a child with epiglottiditis, the nurse should first:
prepare him for tracheotomy.
A client with iron deficiency anemia has been admitted to the medical-surgical unit. Which assessment findings are characteristic of this type of anemia?
Dyspnea, tachycardia, and pallor
The nurse is collecting data on a 32-year-old client with otosclerosis. The nurse should be aware that the client's hearing loss:
affects both ears.
The nurse is caring for a client with cholelithiasis. Which sign indicates obstructive jaundice?
Clay-colored stools
The nurse is developing a teaching plan for a client with asthma. Which of the following teaching points has the highest priority?
Take prescribed medications as scheduled.
Which nutritional instructions should the nurse provide to a 32-year-old primigravida client? Select all that apply:
Caloric intake should be increased by 300 cal/day.
A client had a nephrectomy 2 days ago and is now complaining of abdominal pressure and nausea. The first nursing action should be to:
auscultate bowel sounds.
A 22-year-old client presents to the maternity clinic for her first prenatal visit. She's gravida 1; approximate gestational age is 10 weeks. What's the simplest and most cost-effective means of determining nutritional status?
Anthropometric measures and 24-hour recall
The nurse is assessing a neonate. How should she assess the rooting reflex?
Stroke the neonate's cheek.
The nurse is preparing a client with Crohn's disease for a barium enema. What should the nurse do the day before the test?
Encourage plenty of fluids.
The nurse teaches a postpartum client about breast-feeding. Which statement best indicates that the client knows how to prevent breast engorgement?
"I'll breast-feed every 1<font face="LWWSYM">r</font> to 3 hours."
A client is receiving a blood transfusion. If this client experiences an acute hemolytic reaction, which nursing intervention is the most important?
Immediately stop the transfusion, infuse normal saline solution, notify the blood bank, and call the physician.
A 23-year-old primigravida client has a normal vaginal delivery. The next day, the nurse monitors the client's lochia for color, amount, and the presence of clots. Which of the following best describes lochia on the first postpartum day?
Dark red (lochia rubra), moderate amount, with a few small clots
What finding would lead the nurse to conclude that treatment for conjunctivitis was effective?
Purulent discharge is resolved.
When evaluating a client's knowledge of symptoms to report during her pregnancy, which statement would indicate to the nurse that the client understands the information given to her?
"If I have blurred or double vision, I should call the clinic immediately."
Which of the following nursing interventions should the nurse perform for a client receiving enteral feedings through a gastrostomy tube?
Change the tube feeding solutions and tubing at least every 24 hours.
A 2-week-old client returned 6 hours ago from surgery to correct pyloric stenosis. Which postoperative nursing care would be most important?
Feed small amounts frequently, assess the amount of emesis, and encourage parental involvement in care.
A client arrives in the emergency department complaining of squeezing substernal pain that radiates to the left shoulder and jaw. He also complains of nausea, diaphoresis, and shortness of breath. What should the nurse do?
Administer oxygen, attach a cardiac monitor, take vital signs, and administer sublingual nitroglycerin
The nurse is repositioning a client in bed. What should the nurse do to maintain proper body mechanics?
Stand with her feet apart.
An 86-year-old female client with generalized arthritis arrives at the clinic for her regular checkup. The client takes aspirin several times per day. Because of the client's heavy use of aspirin, the nurse should gather information about:
easy bruising and reports of unusual bleeding.
The nurse is collecting data on an adult client's stage of psychosocial development. The nurse should consider:
the client's previous problem-solving strategies.
The nurse is teaching a client with a long leg cast how to use crutches properly while descending a staircase. The nurse should tell the client to:
advance both crutches first.
The nurse is assessing pain in a client with appendicitis. Which initial statement or question by the nurse will be most effective in eliciting information?
"Tell me how you feel."
The nurse is caring for a client diagnosed with antisocial personality disorder. The client has a history of fighting, cruelty to animals, and stealing. Which of the following traits would the nurse be most likely to uncover during data collection?
A low tolerance for frustration
The nurse is caring for a 40-year-old client. Which behavior by the client indicates adult cognitive development?
Generates new levels of awareness
The nurse is caring for a client with hyperemesis gravidarum who will need close monitoring at home. When should the nurse begin discharge planning?
On admission to the hospital
The nurse is preparing to remove a previously applied topical medication from a client. The rationale for removing previously applied topical medications before applying new medications is to:
avoid administering more than the prescribed dose.
A client with major depression states, "Everything is my fault, and I would be better off dead." What's the priority nursing intervention?
Assess the seriousness of the client's comment.
During her first prenatal visit to the obstetrician's office, a client complains of increased vaginal drainage. Which of the following responses by the nurse is most appropriate?
"This is normal during pregnancy. Just be sure to wash daily with soap and water."
The nurse is caring for a client admitted with an acute head injury. The client has stabilized and is ready to begin rehabilitation. When transferring the client from his bed to a chair, what should the nurse do to ensure client safety?
Lock the brakes on the bed
The nurse is administering a purified protein derivative (PPD) test to a homeless client. Which of the following statements concerning PPD testing is true?
A positive reaction indicates that the client has been exposed to the disease.
An elderly client becomes extremely agitated and attempts to remove his endotracheal tube. The physician orders physical restraints. Which action indicates that a nurse has correctly applied the restraints?
A quick-release knot is used to tie the restraint.
A child ingests a caustic toilet bowl cleaner during a visit to a friend's house. The child's mother tells the nurse she feels guilty. What should the nurse say to the mother?
Tell me about your guilty feelings.
The nurse is assigned to care for an elderly client diagnosed with labyrinthitis (inflammation of the inner ear). Which of the following should the nurse expect to occur in the client?
Sudden onset of incapacitating vertigo, usually accompanied by nausea and vomiting
The nurse is planning a teaching session for new parents. What's the best way to teach new parents about the care of their neonate?
Focus on the behavior of their own neonate.
An elderly client with pneumonia has a nursing diagnosis of <i>Ineffective airway clearance.</i> Which intervention would be most appropriate?
Monitor the need for suctioning every hour.
In a client who is having a myocardial infarction, which of the following assessment findings are typical?
Hypotension, rapid pulse, and chest pain
The nurse caring for an 8-month-old infant diagnosed with respiratory syncytial virus is unable to read a medication dosage written in the infant's medical record. What is the ethical solution for the nurse?
Call the physician and ask for a verbal order to clarify the dosage.
The nurse is assigned to care for a client in the immediate postoperative recovery phase. Although all are important, which criteria take priority during monitoring?
Airway, respiratory rate and depth, other vital signs, and skin color
The nurse is teaching family members of a client with hepatitis A (HAV). Family members were exposed to the client and, therefore, should receive immunoglobulin (Ig). The nurse should tell the family members that Ig:
must be administered within 2 weeks of exposure.
The nurse is caring for a client with a brain tumor and increased intracranial pressure (ICP). Which intervention should the nurse include in the care plan to reduce ICP?
Provide rest periods in between nursing interventions.
A nurse is caring for a female client who's taking 1 mg of alprazolam (Xanax) twice per day for panic attacks. The nurse knows that the client understands teaching about the drug when the client states:
"I'll discuss my plans for pregnancy with my physician."
A child, age 3, is brought to the emergency department in respiratory distress caused by acute epiglottiditis. Which clinical manifestations should the nurse expect to assess?
Severe sore throat, drooling, leaning forward to breathe
The nurse is caring for a child with celiac disease. How should the nurse evaluate the effectiveness of nutritional therapy?
Monitor the appearance, size, and number of stools.
The nurse is preparing a client with a malignant tumor for colorectal surgery and subsequent colostomy. The client tells the nurse that he's anxious. What would the nurse's initial step be in working with this client?
Determining what the client already knows about colostomies
A woman is pregnant for the 4th time. She had one elective abortion during the first trimester, a daughter who was born at 40 weeks' gestation, and a son who was born at 36 weeks' gestation.
She is gravida, G=4; parity=2; term T=1; preterm P=1; abortion A=1; and live births L=2
The nurse is caring for a client with glaucoma who has gradually lost his eyesight. When assisting the client with ambulation, the nurse should walk:
slightly in front of the client offering an elbow for the client to hold.
The nurse is teaching a client who has been prescribed allopurinol for the treatment of gout. Which instruction would the nurse give to the client?
Avoid foods that are rich in purine.
The nurse is providing home care to a client with failing vision due to macular degeneration. The nurse is concerned about the client's safety. Which of the following activities would help to lessen the client's risk of a fall?
Installing handrails on steps and in hallways and bathrooms
A nurse is caring for a client whose cultural background is different from her own. Which actions are appropriate? Select all that apply:
Consider that nonverbal cues may have different meanings in different cultures.
A client undergoes a total hip replacement. Which statement made by the client would indicate to the nurse that the client requires further teaching?
"I don't know if I'll be able to get off that low toilet seat at home by myself."
The nurse is assigned to a client with infectious tuberculosis (TB). When assisting with creating a care plan for this client, how should the nurse plan to prevent disease transmission to other staff members?
Teach about safe disposal of tissues after coughing or sneezing.
What should the nurse do to prevent infection transmission when caring for a client with hepatitis A?
Put on gloves to empty the emesis basin.
The nurse is about to give a full-term neonate his first bath. How should the nurse proceed?
Bathe the neonate only after his body temperature has stabilized.
The nurse is teaching a client how to use transcutaneous electrical nerve stimulation (TENS) to manage pain. Which client statement indicates an accurate understanding of its use?
"If I have a headache, nausea, or unpleasant sensations, I'll use my troubleshooting techniques."
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