NCLEX TEST BANK (2021)

Ref # 4366 The nurse receives a client from the post anesthesia care unit following a left femoral-popliteal bypass graft procedure. Which of the following assessments requires immediate notification of the health care provider?  Left foot is cool to the touch  Absent left pedal pulse using Doppler analysis  Inability to palpate the left pedal pulse  Acute pain in the left lower leg Although the inability to palpate the left pedal pulse, a cool extremity, and increased pain in the left lower leg are important findings, they all require additional nursing assessment prior to contacting the health care provider. In clients without palpable pedal pulses, the next step in the assessment is to perform a Doppler analysis. The inability to locate the left pedal pulse using the Doppler analysis requires immediately notifying the health care provider. Ref # 1028 There's a new medication order that reads: "administer 1 gtt ciprofloxacin solution OD Q 4 h" What action should the nurse take? Call the prescriber to clarify and rewrite the order Abbreviations, symbols and dose designations can be misinterpreted and lead to medication errors. "OD" can mean "right eye" (oculus dexter) or "once daily"; it should never be used when communicating medical information. The abbreviation "Q" should be written out as "every." Although "gtt" is not on the official "Do Not Use List", it's best to use "drop" instead. Asking other nurses to interpret an order is a potentially dangerous "workaround." The nurse should call the health care provider who prescribed the medication and clarify the order. Ref # 1440 Which individual is at greatest risk for the development of hypertension? 45 year-old African-American attorney The incidence of hypertension is greater among African-Americans than other groups in the United States. The incidence among the Hispanic population is rising. Ref # 2446 A woman, who delivered five days ago and who had been diagnosed with pregnancy induced hypertension (PIH), calls a hospital triage nurse hotline to ask for advice. She states, "I have had the worst headache for the past two days. It pounds and by the middle of the afternoon everything I look at looks wavy. Nothing I have taken helps." What should the nurse do next? Ask the client to stay on the line, get the address, and send an ambulance to the home The woman is at risk for seizure activity. The ambulance needs to bring the woman to the hospital for evaluation and treatment. For at-risk clients, PIH may progress to preeclampsia and eclampsia prior to, during, or after delivery; this may occur up to 10 days after delivery. Ref # 2065 A client expresses anger when a call light is not answered within five minutes. The client demanded a blanket. How should the nurse respond? "I see this is frustrating for you. I have a few minutes so let's talk." This is the best response because it gives credence to the client's feelings and then concerns. To say "let's talk" and ask a why question is not a therapeutic approach because it does not acknowledge or validate the client's feelings. To apologize and not notice the client's feelings is inappropriate. To say it could have waited a few minutes is rude and non-accepting of the client's verbalized needs. Ref # 2134 The client is admitted to an ambulatory surgery center and undergoes a right inguinal orchiectomy. Which option is the priority before the client can be discharged to home Post-operative pain is managed An orchiectomy is the surgical removal of one or both testicles. It is usually performed to treat cancer (testicular, prostate or cancer of the male breast), but it may also be performed to prevent cancer (with an undescended testicle.) Due to the location of the incision, pain management is the priority. Most men will be able to eat regularly when they get home; they should at least tolerate liquids before discharge. It's important that the client is able to get up and walk with assistance, but this is not the priority. Psychological counseling may be needed as part of long-term aftercare, but this is not an immediate priority. Ref # 1524 A nurse is teaching a group of adults about modifiable cardiac risk factors. Which of the following should the nurse focus on first? Smoking cessation Smoking cessation is the priority for clients at risk for cardiac disease. Smoking's effects result in reduction of cell oxygenation and constriction of the blood vessels. All of the other factors should be addressed at some point in time. Ref # 1296 The nurse is assigned to a client newly diagnosed with active tuberculosis (TB) and a productive cough. Which of these interventions would be a priority for the nurse to implement? The client would be placed on airborne precautions because this bacteria can be suspended in the air for long periods of time and may be carried for long distances on air currents. Any hospital employee entering the room would need to wear a disposable micron mask or disposable particulate respirator (N-95, for example). The Centers for Disease Control and Prevention (CDC) state that visitors can wear surgical masks Ref # 2338 The nursing team listens to a change-of-shift report and then the RN determines that the unlicensed assistive person (UAP) can measure vital signs for all clients except the 80-year-old female diagnosed with middle-stage Alzheimer's disease. What information mentioned in the report suggests the registered nurse should personally follow up and assess the client with Alzheimer's disease? Increased confusion, agitation and withdrawal Ref # 1418 The nurse and family members, who will be providing care at home, are discussing the client's continuing care needs after discharge to home. Which of these aspects of the discharge planning evaluation should receive priority consideration? Family's understanding of the client's health care needs Family members must be willing and able to provide the required care at the times needed and understand the client's health care needs before the client is discharged home. Ref # 2135 A client diagnosed with testicular cancer has undergone a unilateral orchiectomy. The client expresses fears about his prognosis prior to discharge. What information would the nurse want to include when helping the client better understand this type of cancer? Testicular cancer has a five-year survival rate of 95% with early diagnosis and treatment With aggressive treatment and early detection/diagnosis the cure rate is 90%. Place the client in a negative pressure private room and have disposable particulate respirators available for hospital employee The other options are incorrect information. After unilateral orchiectomy, the remaining testicle can produce adequate sperm for fertility and impotence is unlikely. In bilateral orchiectomy, fertility is lost, so sperm banking prior to surgery is recommended. Dissection of lymph nodes for surgical cancer treatment may cause nerve injury, which would increase the risk of impotence. Ref # 1737 During the change-of-shift report, the assigned nurse notes a client of the Catholic religion is scheduled to be admitted for the delivery of a ninth child. Which comment made by a nurse indicates an attitude of prejudice? "All those people indulge in large families!" Prejudice is a hostile attitude toward individuals simply because they belong to a particular group presumed to have objectionable qualities. Prejudice refers to preconceived ideas, beliefs, or opinions about an individual, group or culture that limit a full and accurate understanding of the individual, culture, gender, race, event or situation. Ref # 4348 The client is a new admission diagnosed with Alzheimer's disease (AD). The nurse reviews all drugs (including complementary & integrated health therapies) routinely taken at home with a family member. Which of the following treatments would be a concern for the nurse? Coconut oil no scientific evidence that coconut oil is safe and effective or prevents cognitive decline. Ref # 1495 The nurse is providing discharge teaching to the parents of a 15 month- old child diagnosed with Kawasaki disease (mucocutaneous lymph node syndrome or infantile polyarteritis). The child has received immunoglobulin therapy. Which instruction point would be appropriate to include during the discussion? The measles, mumps and rubella vaccine should be delayed he MMR vaccine contains three live attenuated viruses and should be delayed until the child's immune system recovers from this treatment. Ref # 1266 A client has just returned to the medical-surgical unit postop for a segmental lung resection. After assessing the client, which is the first action the nurse should take? Suction excessive tracheobronchial secretions This type of surgery involves removing a bronchovascular segment of a lobe. It is typically used to remove small, peripheral lung tumors. Surgical manipulation during this procedure, along with anesthesia, can increase mucus production and lead to airway obstruction, which is why the nurse may need to suction the client if there are excessive secretions Ref # 1802 A nurse is teaching an older adult client to use a metered-dose inhaler (MDI) and is concerned that the client is unable to coordinate the release of the medication with the inhalation phase. What should the nurse recommend to improve the delivery of the medication? Add a spacer device to the MDI canister Use of a spacer is especially useful with older adults because it allows more time to inhale and requires less eye- hand coordination. If the client is not using the MDI properly, the medication can get trapped in the upper airway with an outcome of a dry mouth and throat irritation. Using a spacer will allow more drug to be deposited in the lungs and less in the mouth. There is an order for a 25-year-old client, who is unresponsive after suffering a traumatic brain injury, to be transferred from the hospital to a long-term care facility (LTC) today. To which staff member should the charge nurse assign this client? Registered nurse (RN) The RN is responsible for facilitating continuity of care for clients and their families during the transfer from one health care setting to another. The transfer to a LTC facility often requires referrals and coordinating information from many different providers about treatments, therapies and medications. Which is the appropriate injection site to give an influenza vaccine to an adult? Ref # 2225 A nurse, who is assigned for five days to a client who has exhibited manipulative behaviors, becomes aware of feeling reluctance to interact with the client. The nurse should take what action next? Discuss the feelings of reluctance with an objective peer or supervisor within the next 24 hours The nurse who experiences stress in a therapeutic relationship can gain objectivity through discussion with other professionals. The nurse may wish to have a peer observe the nurse-client interactions with this client for a shift and then have a debriefing of positive and negative actions. The nurse must attempt to discover attitudes and feelings in the self that influence the nurse-client relationship in positive and negative ways. Ref # 1944 A nurse, during an assessment of a day-old newborn, notices that the breasts are enlarged bilaterally with a white, thin discharge. What action should the nurse perform next Record the findings while thinking that they are "normal" Newborn infants of both sexes may have engorged breasts and may secrete milk during the first few days to weeks after birth. Ref # 1840 A client is admitted for first- and second-degree burns on the face, neck, anterior chest and hands. What should be the nurse's priority action for dyspnea or stridor Due to the location of the burns, the client is at risk for the development of upper airway edema and subsequent respiratory distress. The other options are correct, but the priority is to assess breathing and manage the airway. The client with any signs of airway injury will be intubated and given 100% oxygen. Ref # 1460 The nurse is caring for a child who is diagnosed with coarctation of the aorta. Which finding would the nurse expect when assessing the child? Bounding ? Assess pulses in the arms Coarctation of the aorta, which is a narrowing or constriction of the descending aorta, causes increased blood flow to the upper extremities, resulting in a bounding pulse in the arms. Cardinal signs include resting systolic hypertension, absent or diminished femoral and pedal pulses, and a widened pulse pressure. Ref # 2223 A client asks the nurse to call the police and states: "I need to report that I am being abused by a nurse." The nurse should take which action? Obtain more details of the client's claim of abuse by a nurse he advocacy role of the professional nurse, as well as the legal duty of the reasonable prudent nurse, requires the investigation of claims of abuse or violation of rights. The nurse is legally accountable for actions delegated to others. The application of the nursing process requires that the nurse gather more information, assessment before interventions and before documenting or reporting the complaint. Ref # 1240 While caring for a client, the nurse notes a pulsating mass in the client's periumbilical area. Which of these assessments is appropriate for the nurse to perform on the mass? Auscultate Auscultation of the abdomen and the finding of a bruit would confirm the presence of an abdominal aneurysm. This would form the basis of information to be given to the health care provider. Ref # 1292 A nurse is caring for a client who is diagnosed with Hodgkin's disease and is scheduled for radiation therapy. The nurse recognizes that, as a result of the radiation therapy, the client is most likely to experience which difficulty? Nausea As a result of radiation therapy, which is at the lymph nodes throughout the body, nausea often results. Night sweats are a finding in this disease process. These clients are not likely to have a high fever because the lymphatic or immune system is not fully functional. Ref # 1465A hospitalized 8 month-old infant is receiving digoxin to treat tetralogy of Fallot. Prior to administering the next dose of medication, the parent reports that the baby vomited one time, just after breakfast. The heart rate is 72 BPM. What should be the initial response of the nurse? Hold the medication Toxic side effects of digoxin include bradycardia, dysrhythmia, nausea, vomiting, anorexia, dizziness, headache, weakness and fatigue. It isn't necessary to hold the medication for infants and children if there is only one episode of vomiting. However, it is appropriate to hold the medication and notify the health care provider for bradycardia. Normal resting heart rate for infants 1-11 months-old is 100-160 BPM. Ref # 1548 A nurse has been teaching adult clients about cardiac risks when they visit the hypertension clinic. Which evaluation data would be the best measure of learning? Reported behavioral changes If the clients alter behaviors such as smoking, drinking alcohol and stress management, these changed behaviors suggest that learning has occurred. Additionally, physical assessments, observed behaviors and lab data may confirm risk reduction. Ref # 1235 The client, diagnosed with an acute anterior MI, has a triple lumen infusing with nitroglycerin, alteplase and heparin. The client reports experiencing angina. Which intervention is the priority? Administer intravenous morphine sulfate as ordered Nitrates are useful for pain control due to their coronary vasodilating effects. The nurse will titrate the intravenous nitroglycerin infusion for chest pain according to standing orders but if chest pain is unrelieved by the nitroglycerin infusion, the nurse can administer morphine intravenously (IM injections are avoided because they can alter the CPK.) Morphine not only relieves pain and reduces anxiety, but also dilates blood vessels. After giving the pain reliever, the nurse can do a more in-depth assessment of the client (auscultate heart and lung sounds, review ECGs, vital signs and labs.) There is no need to administer an antidysrhythmic drug if the client is asymptomatic. Ref # 2252 An RN from a woman's wellness health clinic is temporarily reassigned to an adult medical unit. Which of these client assignments would be appropriate for this nurse? A client from a motor vehicle accident with an external fixation device on the leg The nurse from the wellness clinic should be assigned to the client with the leg fracture. This client is the most stable and providing care for this client has predictable outcomes. The clues in the other options are: "newly diagnosed," "after a TIA," and "newly admitted... severe dehydration" - all of these clients have an health condition that's less stable than the client who is basically healthy (except for a fracture from an accident). Ref # 1848 A client is about to have an intravenous pyelogram (IVP). After the contrast material is injected, which client reaction should be acted upon immediately by a nurse? Hives with severe itching over the body Hives over the body with severe itching is a sign of anaphylaxis and should be acted upon with the administration of epinephrine (adrenaline) immediately. The other reactions are considered normal after the dye injection. Prior to any dye injection procedure clients should be informed that these symptoms may occur. Excessive salty taste in the mouth, Face turning a deep ruddy red color, Feeling of excessive warmth Ref # 1321 The nurse receives a report on a client being admitted with the diagnosis of cirrhosis of the liver and ascites. What should the nurse emphasize to the nursing assistant about providing care for this client? The client should ambulate as tolerated, resting in bed with legs elevated between walks Encourage alternating periods of ambulation and bed rest with legs elevated to mobilize edema and ascites. Encourage and assist the client to gradually increase the duration and frequency of walks. Ref # 2461 A 35 year-old female client talks to the nurse in her health care provider's office about her new diagnosis of uterine fibroids. What statement by the woman is incorrect and indicates that more teaching is needed? "Even if the fibroids cause no problems, they will still need to be taken out." Fibroids that cause no findings may require only "watchful waiting." The client may just need pelvic exams or ultrasounds every once in a while to monitor the fibroid's growth. Treatment for the symptoms of fibroids (such as painful menses and heavy periods) may include oral contraceptives, IUDs, iron supplements to prevent or treat anemia (due to heavy periods), NSAIDs for cramps or pain or even short-term hormonal therapy to help shrink the fibroids. Surgical removal using myomectomy or hysterectomy is usually reserved as a final alternative after other treatment options have failed to provide adequate relief. In addition, concerns about loss of fertility with this diagnosis and its treatment may be important to this client who is still in her childbearing years. Ref # 5270 The nurse is providing care for a school-age child with cerebral palsy who has recently been admitted for repeated episodes of aspiration pneumonia and weight loss. During a discussion with the child's caregivers, which statement by the nurse best demonstrates client advocacy? "It is possible that we may need to discuss inserting a feeding tube." Ref # 2037A woman in labor calls a nurse to assist her in the bathroom. The nurse notices a large amount of clear fluid on the bed linens. The nurse should act based on knowledge that fetal monitoring must now assess for what complication? Variable decelerations When the membranes rupture, there is increased risk initially of cord prolapse if the head is at a minus level. Fetal heart rate patterns may show variable decelerations, which require immediate nursing action to reposition the client, apply oxygen and notify the health care provider. Ref # 1973 The nurse is caring for a toddler who is diagnosed with an infection and whose temperature is 103 F (39.4 C). Which intervention would be most effective in lowering the client's temperature and promoting comfort? Administer the prescribed antipyretic medication Ref # 4420 The 72 year-old client has an estimated blood loss of 600 mL during a gastric resection. The surgeon orders two units of packed cells (PC) to be administered in the post anesthesia care unit. During the administration of the second unit of PC, the nurse notes the following findings: hypertension, a bounding pulse, and increasing dyspnea. What is the probable cause of these findings? Circulatory overload Older clients are at risk for circulatory overload, especially when solutions are administered rapidly. Hypertension with a bounding pulse and dyspnea are key signs of fluid overload. The nurse should stop the infusion and contact the health care provider Ref # 4416 Following a surgical procedure, a pneumatic compression device is applied to the adult client. The client reports that the device is hot and the client is sweating and itching. Which of the following steps should the nurse take? (Select all that apply.) Ref # 1825 The parents of a 6 year-old child who normally enjoys school tells a nurse that the child has not been doing well since a grandmother died two months ago. Which statement most accurately describes thoughts on death and dying at this age? Death is personified as the bogeyman or devil Personification of death is typical of this developmental level. Recall that this age is at the end of the preschool period where magical thinking for the animation of inanimate objects is present. Ref # 2450 An internal disaster has occurred at the hospital. The charge nurse is asked to review client acuity and determine which clients can and cannot be discharged. Which of these clients should not be discharged? young adult in the second day of treatment for an overdose of acetaminophen An overdose of acetaminophen requires close observation for several days. Also, the duration of the course of treatment for the oral antidote N-acetylcysteine (NAC) is approximately 72 hours. NAC will protect the liver if given within 8 hours after an acute ingestion, least stable Ref # 1761A nurse is preparing a client for discharge following inpatient treatment for pulmonary tuberculosis (TB). Which of these instructions should be given to the client? Continue taking medications as prescribed Early cessation of treatment may lead to development of drug resistant TB. Active TB is usually treated with a combination of four different antibiotics (isoniazid, rifampin, ethambutol and pyrazinamide) and can take anywhere from 6 to 12 months to completely kill the bacteria Ref # 1812 The parents of a 7 year-old tell the nurse that their child has started to "tattle" on siblings. In interpreting this new behavior, how should the nurse explain the child's actions to the parents? Ref # 1812The parents of a 7 year-old tell the nurse that their child has started to "tattle" on siblings. In interpreting this new behavior, how should the nurse explain the child's actions to the parents? The ethical sense and feelings of justice are developing developing a sense of justice and a desire to do what is right. At 7, children are increasingly Check for appropriate fit Confirm pressure setting of 45 mm Hg Collaborate with health care provider for anti-embolism stockings to be worn under the sleeves of the device aware of family roles and responsibilities. They also do what is right because of parental direction or to avoid punishment. This age group, 6 to 12 years of age, is called the school-aged group. Ref # 1910 The nurse witnesses a client who is exhibiting seizure activity. Which observation is the priority and will be used to help determine sequence and types of movement during the seizure event, the nurse needs to observe the client's facial expression, muscle tone, movements (jerking or twitching, for example), the part(s) of the body involved, and any automatic or repeated movement (lipsmacking, chewing, swallowing, for example. Ref # 2096 Two hours after receiving the first does of lithium, the client reports fine hand tremors. What is the nurse's best explanation for these findings? "These are common and expected side effects and should subside in a few days." Ref # 2368 At the client's request, the nurse performs a fingerstick to test the client's blood glucose and the results are 322 mg/dL (17.89 mmol/L). Following standing orders, the nurse administers 3 units of insulin lispro at 11 am. When does the nurse anticipate the insulin lispro will begin to act? 11:15 am The onset of action and peak for insulin lispro (Humalog), which is a rapid-acting insulin, is 10 to 15 minutes after administration. This type of insulin will peak in about 1.5 to 2.5 hours. It is designed to cover meals and lower high blood sugar readings. ///////////////////////////////////////////////////////////////////////////////////////////////////// Ref # 2430 A primigravida in the third trimester is hospitalized with a diagnosis of preeclampsia. The nurse determines that the client’s blood pressure has a trend of increased readings. Which action should the nurse take first? Have the client turn to the left side The priority action in this situation is to turn the client to the left side to decrease pressure on the vena cava and promote adequate circulation to the placenta and kidneys. Urine protein level and output should be checked with each voiding. Temperature should be monitored every four hours or more often if indicated, but no data in the stem supports a check of temperature. The deep tendon reflexes are checked as needed especially when magnesium drips are being infused. Ref # 4347 The nurse is assessing a client who had a stroke and underwent a carotid endarterectomy. The client is now experiencing motor deficits and communication problems. Which of the following findings requires immediate follow-up? Increased pulse and decreased blood pressure Increased pulse and decreased blood pressure may indicate hemorrhage, which is a complication of the surgery. Ref # 4371The client is admitted to the hospital with a diagnosis of exacerbation of right ventricular heart failure. Which of the following findings would the nurse expect with right-sided heart failure? (Select all that apply.) treatment Observe the Abdominal discomfort Peripheral edema Anorexia and nausea