NCLEX-PN Flashcards

Terms Definitions
1.6 to 2.6
Respiratory acidosis
pH down
Pco2 up
Respiratory Acidosis- Causes
Airway obstruction
Hypoventilation Syndrome
Severe Scoliosis
Severe Asthma
DVT ;arteriosclerosis; s/p stents; CABG; s/p vascular surgery;; s/p CVA; s/p TIA
Affects clotting factors
given to stimulate fetal lung maturation, used for client's in preterm labor (28 to 32 wks gestation if the labor can be inhibited for 48 hrs)
First perception of fetal movement appearing usually in the 16th to 20th week of gestation.
Cleft lip and palate repair restraints
elbow restraints
Pregnanacy Signs
Presumptive Signs
1. Breast changes
2. Amenorrhea
3. Nausea and vomiting
4. Urinary frequency
5. Fatigue
6. Quickening
A client becomes angry and belligerent toward the nurse after speaking on the phone with his mother. The nurse recognizes this as what coping mechanism?
A 10-year-old girl with sickle cell anemia has been admitted for vaso-occlusive crisis. Which of the following would be the best activity for the client?
The nurse is conducting a well-baby examination of a 3-month-old infant. During the examination, the nurse shouldn't be able to elicit which reflex?
Cholinergic Crisis
occurs as an result of an overdose
Use of GTPAL
G= Gravidity; # of pregnancies, including the present one
T= Term births; # of children born at term (longer than 37 weeks)
P=Preterm births; # of children born before 37 weeks
A=Abortions or miscarriages; # 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 therapeuetic termination.
L=Live births, # of live births or living children
A client with pulmonary edema is receiving furosemide (Lasix). To help evaluate the effectiveness of this diuretic, what should the nurse assess?
Breath sounds
The physician prescribes penicillin G, 300,000 units I.M., for a child who is 18 months old. What is the best site for the nurse to administer this injection?
Vastus lateralis muscle
A client is admitted to the hospital with a possible electrolyte imbalance. The client is disoriented, weak, has an irregular pulse, and takes hydrochlorothiazide. The client most likely suffers from:
A male client who has had spinal anesthesia is under the physician's orders to lie flat postoperatively. When the client asks to go to the bathroom, the nurse encourages him to comply with the order. By complying, the client can avoid which complication?
A client has approached the nurse asking for advice on how to deal with his alcohol addiction. The nurse should tell the client that the only effective treatment for alcoholism is:
total abstinence.
The nurse is collecting data on a client about his past medical history. Which preexisting condition may lead the nurse to suspect that a client has colorectal cancer?
A primipara at 32 weeks' gestation comes to the hospital complaining of vaginal bleeding. She has soaked one peripad. She has no pain or cramps. What may be a possible cause of the vaginal bleeding?
Placenta previa
During a prenatal screening of a client with diabetes, the nurse should keep in mind that the client is at increased risk for which complications? Select all that apply:
Still birth
The nurse is using Doppler ultrasound to assess a pregnant client. When should the nurse expect to hear fetal heart tones?
11 weeks
Initiative vs guilt
late childhood, 3-6 yrs of age, becomes purposeful and directive
Respiratory Alkalosis
CO2 levels are reduced and pH is high
A woman who is pregnant for the first time.
The nurse is caring for a school-age child with cerebral palsy. The child has difficulty eating using regular utensils and requires a lot of assistance. Which of the following referrals is most appropriate?
Occupational therapist
The nurse is interviewing the mother of a 7-year-old child. Which of the following symptoms reported by the mother would most lead the nurse to suspect that the child has type 1 diabetes?
Recent bed wetting
While checking a 2-month-old child's airway, the nurse finds that the child isn't breathing. After two unsuccessful attempts to establish an airway, the nurse should:
administer five back blows.
The nurse is assigned to care for a client experiencing acute pain. Which change in vital signs should the nurse expect to find?
A client with hyperemesis gravidarum is on a clear liquid diet. The nurse should serve this client:
tea and gelatin dessert.
When prioritizing a client's care plan based on Maslow's hierarchy of needs, the nurse's first priority would be:
administering pain medication.
The nurse is instructing a premenopausal woman about breast self-examination. The nurse should tell the client to do her self-examination:
immediately after her menses.
RSV (Respiratory synctial virus)
spread by contact, virus can survive for various time periods on different surfaces
An alcoholic client is hospitalized with cirrhosis of the liver. In this client, which data collection findings may be early signs of alcohol withdrawal?
Hand tremor, irritability, and anxiety
The nurse is assisting with developing a care plan for a client who's at risk for impaired coping due to the effects of chronic illness. Which factor provides the best evidence that the client is at risk for difficulty in coping with his illness?
Lack of social support
In the first stage of labor, a client with a full-term pregnancy has an electronic fetal monitoring (EFM) device in place. Which EFM pattern suggests adequate uteroplacental-fetal perfusion?
Average variability
A 2-month-old infant hasn't received any immunizations. Which immunizations should the nurse prepare to administer?
Hib; DTaP; HepB; and IPV
The nurse is caring for a client undergoing a cystoscopy to diagnose bladder cancer. Following the test, the client returns to his room. Which signs should alert the nurse to a potential complication?
Chills and tachycardia
The nurse is caring for a client receiving spironolactone (Aldactone) to treat hypertension. Which instruction should the nurse give the client?
Avoid salt substitutes.
The nurse is administering neostigmine (Prostigmin) to a client with myasthenia gravis. Which nursing intervention should the nurse implement?
Schedule the medication before meals.
A client is admitted for an overdose of amphetamines. When collecting data on this client, the nurse should expect to see:
tension and irritability.
Removal of central venous catheter
hold breath and bear down (valsalva maneuver)
A mother brings her 12-month-old infant to the pediatrician's office for a check-up. Which finding suggests that the infant has cystic fibrosis?
Presence of fat in the stool
The nurse is caring for an L1-L2 paraplegic undergoing rehabilitation. Which of the following goals is appropriate?
Establishing an intermittent catheterization routine every 4 hours
The nurse is caring for an adolescent female who reports amenorrhea, weight loss, and depression. Which additional data collection finding would suggest that the client has an eating disorder?
Excessive and ritualized exercise
A 26-year-old male reports losing his sight in both eyes. He's diagnosed as having a conversion disorder and is admitted to the psychiatric unit. Which nursing intervention would be most appropriate for this client?
Not focusing on his blindness
A client undergoing prenatal blood testing tests positive for human immunodeficiency virus (HIV). What should the nurse do with this information?
Follow facility policy for documenting and communicating HIV status.
The mother of a neonate expresses concern about how she'll continue to breast-feed when she returns to work in 6 weeks. What's the best response by the nurse?
"You can continue breast-feeding after you go back to work. You can pump your breasts and put the milk in a bottle."
The nurse is assessing a client diagnosed with appendicitis. Which of the following signs or symptoms should the nurse expect to find?
Rebound tenderness, McBurney's sign, low-grade fever
A woman in her 8th month of pregnancy is having dinner with her husband at their favorite restaurant. The woman suddenly chokes on a piece of chicken and appears to lose consciousness. What would be the best action by a nurse sitting at the next table?
Apply chest thrust.
The nurse is caring for a postoperative client. What intervention should the nurse perform to prevent thrombophlebitis?
Applying a sequential compression device
Many clients are brought to the emergency department after sustaining injuries in a building explosion. Using disaster management principles, which client should be triaged first?
A 62-year-old client with tachypnea
A nanny is taught to administer digoxin (Lanoxin) to a 6-month-old infant at home. Which statement by the nanny indicates that teaching was successful?
"I'll measure the dose carefully."
When should the client with type 2 diabetes take the oral antidiabetic agent glipizide?
30 minutes before breakfast
A client has undergone a left hemicolectomy for bowel cancer. Which activities prevent the occurrence of postoperative pneumonia in this client?
Coughing, breathing deeply, frequent repositioning, and using an incentive spirometer
The nurse is caring for a client who required chest tube insertion for a pneumothorax. To confirm pneumothorax resolution, the nurse can anticipate that the client will require:
a chest X-ray.
Why is Demerol and Phenergan given together?
for their synergistic effects (one drug increases the effects of the other)
A pregnant client is receiving heparin. Which of the following should be a part of nursing assessment on every shift?
Any signs of preterm labor and bleeding from an orifice
A 35-year-old client is in the eighth month of her first pregnancy. Her physician orders a biophysical profile to be conducted the next day. What equipment would the nurse assemble to conduct this test?
Ultrasound machine and fetal monitor
A 4-year-old girl is admitted to the hospital to rule out a diagnosis of leukemia. Which of the following would be the best room assignment?
Alone in a private room
A 20-year-old female's pregnancy is confirmed at a clinic. She says her husband will be excited, but is concerned because she herself isn't excited. She fears this feeling may mean she'll be a bad mother. The nurse should respond by:
telling the client such feelings are normal in the beginning of pregnancy.
The nurse has just taught a client about the signs of true and false labor. Which client statement indicates an accurate understanding of this information?
"False labor contractions usually occur in the abdomen."
A client with coronary artery disease reports intermittent chest pain that occurs with exertion. The physician prescribes sublingual nitroglycerin. When teaching the client about nitroglycerin administration, the nurse should include which instruction?
Be careful after taking nitroglycerin because it may cause dizziness.
The nurse knows that dietary management is part of the treatment regimen for clients with diabetes. Which information should the nurse include in client-teaching sessions with clients who have diabetes?
Meals should be eaten at consistent times each day.
A client became seriously ill after a nurse gave him the wrong medication. After his recovery, he files a lawsuit. Who's most likely to be held liable?
The nurse and the hospital
A client underwent a retinal detachment repair. The nurse receives the following order from the client's physician: Keep client in upright sitting position, with head over the bed table, until first dressing change. What should the nurse do?
Follow the order because this position will help keep the retinal repair intact.
A client's blood glucose level is 45 mg/dl. The nurse should be alert for which signs and symptoms?
Decreased level of consciousness (LOC), anxiety, confusion, headache, and cool, moist skin.
A mother tells the nurse that she wants to begin toilet training her 22-month-old child. The most important factor regarding toilet training that the nurse should stress to her is:
developmental readiness of the child.
To prevent hip flexion deformities
lie prone every 4 hrs for 30 minutes during the day
A 70-year-old client who's alert and oriented refuses to take his regularly scheduled medications. Which action should the licensed practical nurse (LPN) take?
Inform the physician, document in the client's medication administration record that the medications weren't given, and document in the medical record why the client refused to take them.
A client with major depression begins to improve and participates in treatment programs on the unit. The nurse should recognize that the client is ready for discharge when the client does which of the following?
Discusses plans to return home and continue outpatient treatment
A client who has discovered a breast lump is tearful and expresses concern over her situation. The best way for the nurse to respond to her is by:
encouraging a discussion of her problems and fears.
A postpartum client is scheduled for discharge tomorrow. During discharge teaching, the nurse should advise her to report which of the following to her health care provider?
Redness, warmth, and pain in a breast
The nurse is providing care to a client with catatonic type of schizophrenia who exhibits extreme negativism. To help the client meet his basic needs, the nurse should:
tell the client specifically and concisely what needs to be done.
After learning that a roommate has tested positive for the human immunodeficiency virus, a client asks the nurse about moving to another room on the psychiatric unit because the client doesn't feel "safe" now. What should the nurse do first?
Ask the client to describe his fears.
The nurse is teaching a female client about preventing osteoporosis. Which of the following teaching points is correct?
The recommended daily allowance of calcium may be found in a wide variety of foods.
The nurse is assisting with an exercise group for older adults who live in a retirement community. Which statement is appropriate for the nurse to make to this group of clients?
If you have arthritis, exercise your affected joints to the point of discomfort.
The nurse is caring for a 16-year-old female client who isn't sexually active. The client asks if she needs a Papanicolaou (Pap) test. The nurse should reply:
"No, because you aren't sexually active."
The mother of a 4-year-old child tells the nurse that her child is a poor eater. What's the nurse's best recommendation for helping her increase her child's nutritional intake?
Allow the child to feed herself.
A client sustains a C5 spinal cord injury that results in quadriplegia. Several days after being moved out of the intensive care unit, he complains of a severe throbbing headache. What should the nurse do next?
Check the client's indwelling urinary catheter for kinks to ensure patency.
A client with chronic renal failure (CRF) is admitted to the urology unit. Which diagnostic test results are consistent with CRF?
Blood urea nitrogen (BUN) 100 mg/dl and serum creatinine 6.5 mg/dl
The nurse is calculating the proper dosage of medication for a child. Which parameter provides the most accurate dosage?
Body surface area in relation to weight
A nurse is caring for a client whose cultural background is different from her own. Which actions are appropriate? Select all that apply:
Respect the client's cultural beliefs.
Before preparing a client for surgery, the nurse assists in developing a teaching plan. What's the primary purpose of preoperative teaching?
To reduce the risk of postoperative complications
The nurse is assisting with a screening for colorectal cancer. The client with the highest risk of colorectal cancer is a:
52-year-old man with a family history of polyposis.
For a client who must undergo colon surgery, the physician orders preoperative cleansing enemas and neomycin (Mycifradin). What's the rationale for neomycin use in this client?
To decrease the intestinal bacteria count
A client with advanced cancer has been receiving chemotherapy and is experiencing stomatitis. To promote comfort and nutrition while the client's mouth is sore, the nurse should plan to speak with the client's family about:
rinsing the client's mouth with diluted hydrogen peroxide every 2 hours.
The nurse is documenting a care plan for a client who has undergone electroconvulsive therapy. The nurse should include which intervention?
Reorienting the client to time and place
The nurse is caring for a client with panic disorder who has difficulty sleeping. Which nursing intervention would best help the client achieve healthy long-term sleeping habits?
Encouraging the use of relaxation exercises
In the course of providing care, the nurse discovers a possible error in the physician's order. How should the nurse respond?
Confer with the physician and then decide whether or not to carry out the order.
The nurse is helping a client with her meal choices. Which breakfast selection indicates that the client understands her low-potassium diet?
Scrambled eggs and toast with tea
A 10-year-old boy falls, injures his left shoulder, and is taken to the emergency department. While the client waits to be seen by the physician, what intervention should the nurse perform first?
Keep him in a comfortable position and apply ice to the injured shoulder.
The client tells the nurse he was involved in a car accident while he was intoxicated. What would be the most therapeutic response from the nurse?
"Tell me how you feel about the accident."
A family member is caring for a client diagnosed with Alzheimer's disease. Which of the following is most likely to cause the caregiver depression and role strain?
The caregiver feels unable to control the client and unable to cope with caregiving.
A mother, who's visibly upset, carries her 2-month-old infant into the crowded emergency department. The child appears limp and lifeless. The mother screams to the nurse for help. The nurse should:
take the infant and mother back to a treatment room.
A 50-year-old male is diagnosed with multiple myeloma and the prognosis is poor. He's tearful and trying to express his feelings, but he's having difficulty. The nurse should first:
ask if he would like her to sit with him while he collects his thoughts.
A 21-year-old client recently has been diagnosed with type 1 diabetes. The client's receiving 5 units of regular insulin and 15 units of NPH insulin every morning before breakfast at 7 a.m. Which statement is correct?
The NPH insulin will begin to act in 1 to 1<font face="LWWSYM">r</font> hours and will peak in 4 to 12 hours (by mid-afternoon)
The nurse is caring for a comatose client who has suffered a closed head injury. What intervention should the nurse implement to prevent an increase in intracranial pressure (ICP)?
Elevate the head of the bed 30 to 45 degrees.
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