NURSING MISC NCLEX Exam 2_Study Guide. Questions and Answers: Complete Guide for a GRADE BOOST

After undergoing Billroth I gastric surgery, the client experiences fatigue and complains of numbness and tingling in the feet and difficulties with balance. On the basis of these symptoms, the nurse suspects which postoperative complication? Pernicious anemia A client experiencing chronic dumping syndrome makes the following comments to the nurse. Which one indicates the need for further teaching? "I eat at least 3 large meals each day.” The nurse obtains an admission history for a client with suspected peptic ulcer disease (PUD). Which client factor documented by the nurse would increase the risk for PUD? Takes nonsteroidal antiinflammatory drugs (NSAIDs) for osteoarthritis A client who has undergone gastric surgery has a nasogastric (NG) tube connected to low intermittent suction that is not draining properly. Which action should the nurse take initially? Check the suction device to make sure it is working. The nurse is caring for a client with ulcerative colitis. Which finding does the nurse determine is consistent with this diagnosis? Decreased hemoglobin A client with acute ulcerative colitis requests a snack. Which is the most appropriate snack for this client? Applesauce and a graham cracker The nurse is teaching the client with viral hepatitis about the stages of the disease. The nurse should explain to the client that the second stage of this disease is characterized by which specific assessment findings? Select all that apply. Jaundice, Clay-colored stools, Elevated bilirubin levels, Dark or tea-colored urine The nurse is teaching an older client about measures to prevent constipation. Which statement by the client indicates a need for further teaching? "I need to decrease fiber in my diet." Hematological A client enters the hospital emergency department with a nosebleed. On assessment the client tells the nurse that the nosebleed just suddenly began. The nurse notes no obvious facial injury. Which is the initial nursing action? Sit the client down, ask the client to lean forward slightly, and apply pressure to the nose for 5 to 10 minutes. The nurse is performing an assessment on a client with a diagnosis of pernicious anemia. Which finding would the nurse expect to note in this client? Red tongue that is smooth and sore The nurse has provided instructions to a client with sickle cell disease regarding measures that will prevent a sickle cell crisis. Which client statement indicates an understanding of these measures? "I need to avoid situations that may lead to an infection." The nurse is preparing to perform an assessment on a client being admitted to the hospital with a diagnosis of sickle cell crisis, vaso-occlusive crisis. Which findings should the nurse expect to note on assessment of the client? Select all that apply. Pallor, Fever, Joint swelling, Abdominal pain The nurse is preparing a plan of care for a client with sickle cell crisis who will be admitted to the nursing unit. The nurse should include which intervention as a priority in the plan of care for the client? Initiate an intravenous (IV) line for the administration of fluids. The nurse is performing an assessment on a client with a diagnosis of anemia that developed as a result of blood loss after a traumatic injury. The nurse should expect to find which sign or symptom in the client as a result of the anemia? Shortness of breath with activity The nurse has provided medication instructions to a client with an iron deficiency anemia who will be taking iron supplements. Which statement made by the client indicates an understanding of this medication? "I need to increase my fluid intake." A client who was diagnosed with toxic shock syndrome (TSS) now exhibits petechiae, oozing from puncture sites, and coolness of the digits of the hands and feet. Clotting times determined for this client are prolonged. The nurse interprets these clinical signs as being most compatible with which condition? Disseminated intravascular coagulopathy (DIC) The nurse is reviewing the health care provider's prescriptions for a client admitted to the hospital with a diagnosis of idiopathic autoimmune hemolytic anemia. The nurse prepares the client for treatment of this disorder, understanding that which may be recommended? Select all that apply. Transfusions, splenectomy, corticosteroids, immunosuppressive agents The nurse is preparing to care for a client with chronic kidney disease and anemia. Which describes the relationship between chronic kidney disease and anemia? Decreased production of erythropoietin is causing anemia. When obtaining assessment data from a client with a microcytic normochromic anemia, which should the nurse question the client about? Dietary intake of iron The nurse is preparing a client with thrombocytopenia for discharge. Which statement by the client about measures minimizing injury indicates that discharge teaching was effective? Select all that apply. I may continue to use an electric shaver, I will not blow my nose if I get a cold, I should use a soft-bristled toothbrush. Immune 1. The nurse provides home care instructions to a client with systemic lupus erythematosus and tells the client about methods to manage fatigue. Which statement by the client indicates a need for further instruction? "I should take hot baths because they are relaxing." 2. The nurse is conducting a teaching session with a client on their diagnosis of pemphigus. Which statement by the client indicates that the client understands the diagnosis? "I have an autoimmune disease that causes blistering in the epidermis." 3. The nurse is assisting in planning care for a client with a diagnosis of immunodeficiency and should incorporate which action as a priority in the plan? Protecting the client from infection 4. A client calls the nurse in the emergency department and states that he was just stung by a bumblebee while gardening. The client is afraid of a severe reaction because the client's neighbor experienced such a reaction just 1 week ago. Which action should the nurse take? Ask the client if he ever sustained a bee sting in the past. 5. The community health nurse is conducting a research study and is identifying clients in the community at risk for latex allergy. Which client population is most at risk for developing this type of allergy? Hairdressers 6. Which interventions apply in the care of a client at high risk for an allergic response to a latex allergy? Select all that apply. -Use nonlatex gloves. -Use medications from glass ampules. -Keep a latex-safe supply cart available in the client's area. -Avoid the use of medication vials that have rubber stoppers. 7. A client presents at the health care provider's office with complaints of a bulls-eye rash on his upper leg. Which question should the nurse ask first? "Have you been camping in the last month?" 8. A client is diagnosed with scleroderma. Which intervention should the nurse anticipate to be prescribed? Administer corticosteroids as prescribed for inflammation. 9. A client arrives at the health care clinic and tells the nurse that she was just bitten by a tick and would like to be tested for Lyme disease. The client tells the nurse that she removed the tick and flushed it down the toilet. Which actions are most appropriate? Select all that apply. -Tell the client to avoid any woody, grassy areas that may contain ticks. -Instruct the client to immediately start to take the antibiotics that are prescribed. -Inform the client to plan to have a blood test 4 to 6 weeks after a bite to detect the presence of the disease. 10. The client with acquired immunodeficiency syndrome is diagnosed with cutaneous Kaposi's sarcoma. Based on this diagnosis, the nurse understands that this has been confirmed by which finding? Positive punch biopsy of the cutaneous lesions 11. The nurse is conducting allergy skin testing on a client. Which postprocedure interventions are most appropriate? Select all that apply. -Record site, date, and time of the test. -Give the client a list of potential allergens if identified. 12. The nurse is performing an assessment on a client who has been diagnosed with an allergy to latex. In determining the client's risk factors, the nurse should question the client about an allergy to which food item? Bananas 13. A client with acquired immunodeficiency syndrome (AIDS) is receiving ganciclovir. The nurse should take which priority action in caring for this client? Ensure that the client uses an electric razor for shaving. 14. The home care nurse is preparing to visit a client who has undergone renal transplantation. The nurse develops a plan of care that includes monitoring the client for signs of acute graft rejection. The nurse documents in the plan to assess the client for which signs of acute graft rejection? Fever, hypertension, and graft tenderness 15. A client with acquired immunodeficiency syndrome (AIDS) has been started on therapy with zidovudine. The nurse should monitor the results of which laboratory blood study for adverse effects of therapy? Complete blood cell (CBC) count 16. A client with acquired immunodeficiency syndrome (AIDS) is receiving didanosine. When the nurse reviews the client's laboratory test results, which result should be most closely monitored? Amylase 17. A client is receiving zalcitabine. The nurse should monitor the results of which study to determine the effectiveness of this medication? CD4+ cell count 18. A client who has been receiving pentamidine intravenously now has a fever with a temperature of 102°F (38.9°C). Keeping in mind that the client has a diagnosis of acquired immunodeficiency syndrome (AIDS) and Pneumocystis jiroveci pneumonia, the nurse should interpret that this fever is most associated with which condition? Infection caused by leukopenic effects of the medication 19. A client is diagnosed with stage I Lyme disease, and the nurse assesses the client for disease manifestations. Which should the nurse expect to note as the hallmark characteristic of this stage? Skin rash 20. Assessment and diagnostic evaluation reveal that a client seen in the ambulatory care clinic has stage II Lyme disease. The clinic nurse identifies which assessment finding as most characteristic of this stage? Cardiac conduction deficits 21. The clinic nurse reads the chart of a client just seen by the health care provider (HCP) and notes that the HCP has documented that the client has stage III Lyme disease. Which clinical manifestation should the nurse expect to note in this client? Complaints of joint pain 22. A client arrives at the health care clinic and tells the nurse that he was just bitten by a tick and would like to be tested for Lyme disease. The client reports that he removed the tick and flushed it down the toilet. The nurse should take which nursing action? Tell the client to return to the clinic in 4 to 6 weeks. 23. A client suspected of having stage I Lyme disease is seen in the health care clinic and is told that the Lyme disease test result is positive. The client asks the nurse about the treatment for the disease. In responding to the client, the nurse anticipates that which intervention will be part of the treatment plan? A 14 to 21 day course of doxycycline 24. The nurse is performing an assessment on a female client who complains of fatigue, weakness, muscle and joint pain, anorexia, and photosensitivity. Systemic lupus erythematosus (SLE) is suspected. What should the nurse further assess for that also is indicative of SLE? Facial rash 25. A client has requested and undergone testing for human immunodeficiency virus (HIV) infection. The client asks what will be done next because the result of the enzyme-linked immunosorbent assay (ELISA) has been positive. Which diagnostic study should the nurse be aware of before responding to the client? A Western blot will be done to confirm these findings. 26. The nurse is caring for a client with acquired immunodeficiency syndrome and detects early infection with Pneumocystis jiroveci by monitoring the client for which clinical manifestation? Cough 27. A client with acquired immunodeficiency syndrome (AIDS) has a concurrent diagnosis of histoplasmosis. During the assessment, the nurse notes that the client has enlarged lymph nodes. How should the nurse interpret this assessment finding? The client has disseminated histoplasmosis infection. 28. The nurse is caring for a client with acquired immunodeficiency syndrome (AIDS) who is experiencing night fever and night sweats. Which nursing interventions would be helpful in managing this symptom? Select all that apply. -Keep liquids at the bedside. -Place a towel over the pillowcase. -Make sure the pillow has a plastic cover. -Keep a change of bed linens nearby in case they are needed. 29. A client with acquired immunodeficiency syndrome (AIDS) is experiencing nausea and vomiting. The nurse should include which measure in the dietary plan? Remove dairy products and red meat from the meal. 30. The clinic nurse is providing home care instructions to a client who has been diagnosed with a latex allergy. The nurse most appropriately instructs the client to avoid which activity? The use of latex condoms Integumentary A client calls the emergency department and tells the nurse that he came directly into contact with poison ivy shrubs. The client tells the nurse that he cannot see anything on the skin and asks the nurse what to do. The nurse should make which response? "Take a shower immediately, lathering and rinsing several times.” A client is being admitted to the hospital for treatment of acute cellulitis of the lower left leg. During the admission assessment, the nurse expects to note which finding? A skin infection of the dermis and underlying hypodermis The clinic nurse assesses the skin of a client with psoriasis after the client has used a new topical treatment for 2 months. The nurse identifies which characteristics as improvement in the manifestations of psoriasis? Select all that apply. Thinner and decrease in number of reddish papules, Scarce amount of silvery-white scaly patches on the arms The clinic nurse notes that the health care provider has documented a diagnosis of herpes zoster (shingles) in the client's chart. Based on an understanding of the cause of this disorder, the nurse determines that this definitive diagnosis was made by which diagnostic test? Positive culture results -a viral culture of the lesion provides the definitive diagnosis A client returns to the clinic for follow-up treatment following a skin biopsy of a suspicious lesion performed 1 week ago. The biopsy report indicates that the lesion is a melanoma. The nurse understands that melanoma has which characteristics? Select all that apply. Lesion is highly metastatic Lesion is a nevus that has changes in color. When assessing a lesion diagnosed as basal cell carcinoma, the nurse most likely expects to note which findings? Select all that apply. A pearly papule with a central crater and a waxy border Location in the bald spot atop The head that is exposed to outdoor sunlight A client arriving at the emergency department has experienced frostbite to the right hand. Which finding would the nurse note on assessment of the client's hand? A white color to the skin, which is insensitive to touch -Assessment findings in frostbite include a white or blue color; the skin will be hard, cold, and insensitive to touch. The evening nurse reviews the nursing documentation in a client's chart and notes that the day nurse has documented that the client has a stage II pressure ulcer in the sacral area. Which finding would the nurse expect to note on assessment of the client's sacral area? Partial-thickness skin loss of the dermis An adult client was burned in an explosion. The burn initially affected the client's entire face (anterior half of the head) and the upper half of the anterior torso, and there were circumferential burns to the lower half of both arms. The client's clothes caught on fire, and the client ran, causing subsequent burn injuries to the posterior surface of the head and the upper half of the posterior torso. Using the rule of nines, what would be the extent of the burn injury? 36% The nurse is preparing to care for a burn client scheduled for an escharotomy procedure being performed for a third-degree circumferential arm burn. The nurse understands that which finding is the anticipated therapeutic outcome of the escharotomy? Return of distal pulses- The escharotomy releases the tourniquet-like compression around the arm The nurse is caring for a client who sustained superficial partial-thickness burns on the anterior lower legs and anterior thorax. Which finding does the nurse expect to note during the resuscitation/emergent phase of the burn injury? Elevated hematocrit levels- the hematocrit level increases to above normal because of hemoconcentration from the large fluid shifts. The nurse is administering fluids intravenously as prescribed to a client who sustained superficial partial-thickness burn injuries of the back and legs. In evaluating the adequacy of fluid resuscitation, the nurse understands that which assessment would provide the most reliable indicator for determining the adequacy? Urine output The nurse is caring for a client following an autograft and grafting to a burn wound on the right knee. What would the nurse anticipate to be prescribed for the client? Immobilization of the affected leg