preparation for NCLEX 1 Flashcards

Question

A client with a spinal cord injury and subsequent urine retention receives intermittent catheterization every 4 hours. The average catheterized urine volume has been 550 ml. The nurse should plan to a. increase the frequency of the catheterizations. b. insert an indwelling urinary catheter. c. place the client on fluid restrictions. d. use a condom catheter instead of an invasive one.

Answer 1

a. increase the frequency of the catheterizations. As a rule of practice, if intermittent catheterization for urine retention typically yields 500 ml or more, the frequency of catheterization should be increased. Indwelling catheterization is less preferred because of the risk of urinary tract infection and the loss of bladder tone. Fluid restrictions aren't indicated in this case; the problem isn't overhydration, rather it's urine retention. A condom catheter doesn't help empty the bladder of the client with urine retention.

Answer 2

c. a neonate who was born 24 hours ago by cesarean birth who had a respiratory rate of 62 breaths/min 30 minutes ago. The nurse should make rounds and first assess the neonate with the respiratory rate of 62 breaths/min. The respiratory rate is out of the normal range and needs reevaluation. The nurse should next assess the newborn with a borderline low temperature to determine if the newborn's body temperature is increasing. The newborn who is LGA still has 15 minutes before being due for the feeding, and much can be accomplished by the nurse in that time. A 36-week newborn weighing 2270 g (2.27 kg) will need to be fed on time to maintain the blood glucose level.

Answer 3

d. administering I.V. fluids The nurse should first administer I.V. infusions containing normal saline solution and potassium to maintain fluid and electrolyte balance. For the client's comfort and to assist in bowel decompression, the nurse should prepare to insert an NG tube next. A blood sample is then obtained for laboratory studies to help diagnose bowel obstruction and guide treatment. Blood studies usually include a complete blood count, serum electrolyte levels, and blood urea nitrogen level. Pain medication commonly is withheld until obstruction is diagnosed because analgesics can decrease intestinal motility.

Answer 4

c. have an assistant when providing care. It is important for the nurse to recognize that some clients are often modest or simply feel more comfortable with a chaperone or assistant present for intimate care needs. The nurse will need to explain and encourage family visitations. The nurse does not assume the client is embarrassed. The nurse must provide teaching in a way that the client can be receptive to understanding and not focus on sexual gratifications.

Answer 5

a. predict and fulfill client needs until the client is more active. A client in a stuporous state may refuse to eat or drink, which can interfere with life functioning. Although engagement in communication, reorientation to reality, and family functioning are all important concerns, the priority for nursing care is to assess and intervene if the client refuses to eat and drink. Higher levels of care may be required, and it is a priority for the nurse to assess this state.

Answer 6

b. drink plenty of fluids. d. report a sore throat to an adult immediately. f. wash hands before meals and after playing. Sickle cell anemia is an autosomal recessive genetic disease passed down through families in which red blood cells form an abnormal sickle or crescent shape. Fluids would be encouraged to prevent stasis in the bloodstream, which can lead to sickling. Sore throats and all other cold symptoms would be reported promptly because they may indicate an infection, which can precipitate a crisis (red blood cells sickle and obstruct blood flow to tissues). Children with sickle cell anemia would learn appropriate measures to prevent infection, such as proper hand-washing techniques and good nutrition. Folic acid intake would be encouraged to help support new cell growth; new cells replace fragile sickled cells. Warm packs would be applied to promote comfort and relieve pain; cold packs cause vasoconstriction. The child would maintain an active, normal life but would avoid excessive exercise, which can precipitate an attack. When the child experiences a crisis, the child will typically limit activity according to the pain level.

Answer 7

a. notify the charge nurse so an event report can be completed on this sentinel event. The missed orders from the client's transfer from surgery back to the unit resulted in a delay in care. This is defined as a sentinel event by The Joint Commission. Even if no harm came to the client as a result of this delay in care, leadership must still be notified, and an event report must still be completed. The nurse will need to acknowledge and implement orders if applicable and potentially notify the health care provider if clarifications are needed. However, the orders do not expire. The nurse also would not confront the unit the client was transferred from. A breakdown in communication regarding the orders may have occurred, but direct confrontation is not appropriate.

Answer 8

c. "I can return to my normal activities within 7 days." Laparoscopic cholecystectomy is performed through a small incision at the umbilicus. Hospital stays postoperatively are minimal, and clients are encouraged to ambulate the day of the surgery. Clients typically resume all normal activities within 7 days of surgery. There will not be restrictions on lifting heavy objects, and there is no need to avoid sitting upright.

Answer 9

d. encourage a voiding attempt in 2 to 4 hours or if an urge to void is present. The nurse should encourage the client to urinate if the urge is felt or to attempt to void every 2 to 4 hours. This will assist in reestablishing the sensation to void following the use of an indwelling catheter and allow the nurse to conduct a voiding trial. The nurse would assess the client's bladder for distention and pain to note if the bladder is full but would not necessarily do this at the initiation of the voiding trial. A bladder scan would be conducted to assess for postvoid residual urine, not immediately after the removal of the catheter. If there was urine noted on the bladder scan, the nurse would want to provide education to the client on the need to fully empty the bladder with urination.

Answer 10

c. it promotes healing. The nurse should instruct the client with Raynaud disease that nitroglycerine cream is used to promote healing by promoting vasodilation. The drug is not used in this instance to treat pain. The drug does not have properties to treat infection or soften the skin.

Answer 11

c. spiritually linked actions that the client has used to manage pain in the past. Religion and spirituality have been related to a client's well-being when facing illness and disease. They can be powerful coping mechanisms when a client is facing life-or-death decisions, as well as chronic conditions such as pain if the client believes in the value of these links. The nurse is seeking interventions and, therefore, the client's past use of spiritual practices for pain management is most relevant. General beliefs about abstract concepts such as meaning and purpose will not be directly helpful in informing interventions. The nurse should not focus on the client's acceptance of prayer as this is making an assumption instead of exploring the client's spiritual practices. Asking the client if they believe pain levels are affected by spiritual thoughts again makes an assumption instead of asking an open-ended, non-leading question about the client's practices or beliefs.

Answer 12

a. discuss the importance of filling new prescriptions and taking them as prescribed. b. ensure that the client has a follow-up appointment scheduled with the health care provider prior to discharge. c. confirm that the client has the means (financial, transportation) to get new prescriptions and to attend appointments. e. educate the client on signs and symptoms that may be experienced and which level of care is appropriate for those situation. In this scenario, discharge teaching for cost-effective care focuses on ensuring the client has appropriate follow-up and continuity of care to prevent readmission to the hospital. Discussing the importance of filling and taking new prescriptions, scheduling follow-up appointments, and ensuring the client has the means to get prescriptions and attend appointments are all critical to ensuring the client continues to improve following discharge from the hospital and are appropriate interventions. Educating the client on signs and symptoms that may be experienced and when to seek medical care or emergency medical care for those symptoms is important to ensuring the client gets appropriate care and prevents deterioration of the condition. Telling the client to return to the hospital for all concerns is not appropriate, as there are other, more cost-effective follow-up options most of the time, such as the client's health care provider.

Answer 13

a. drinking from a cup and spilling little of the liquid. Infants at age 7 months are not capable of drinking from a cup without spilling. At age 6 months, infants can partially lift their weight on their hands, enjoy imitating sounds, and are developing separation anxiety.

Answer 14

a. "I can clean and inspect the skin of my amputated leg weekly." b. "I will make sure the padding is all placed in the front of the stump." c. "I can wear a cotton garment with seams over the stump." The client with a prosthetic limb would want to clean and inspect the skin of the amputated limb daily to ensure skin integrity is maintained. Having the padding of the device distributed evenly can help prevent pressure on the skin with the device. Wearing a cotton garment between the skin and prosthesis that does not have seams also helps decrease pressure and friction on the limb. The client would not want the device to fit too tightly as this can create pressure on the skin that could lead to skin breakdown. While the client needs emotional support with the use of prosthetic limbs, this is not part of skin protection and prevention of skin breakdown.

Answer 15

d. fluphenazine decanoate Fluphenazine decanoate is a long-acting antipsychotic agent administered by injection. Because it has a 4-week duration of action, it's commonly ordered for outpatients with a history of medication noncompliance. Chlorpromazine, also an antipsychotic agent, must be administered daily to maintain adequate plasma levels, which necessitates compliance with the dosage schedule. Imipramine, a tricyclic antidepressant, and lithium carbonate, a mood stabilizer, are rarely used to treat clients with chronic schizophrenia.

Answer 16

c. positive Ortolani's sign e. absence of Moro's reflex The nurse would be concerned about a positive Ortolani’s sign, which could indicate congenital hip dysplasia and the absence of Moro’s reflex. The rest of the findings are to be expected.

Answer 17

c. contact the HCP to clarify the prescription. Illegible writing is one of the most common reasons for medication errors. The nurse should contact the HCP to clarify the prescription. Neither the pharmacist, the nurse, nor the unit secretary can interpret or rewrite a prescription written by an HCP.

Answer 18

c. encouraging a client with depression to eat. Unlicensed assistive personal (UAP) are able to complete tasks that are standard unchanging procedures. Encouraging a client with depression to eat is acceptable. UAP can not complete a sterile dressing change, initial assessment, or provide client education.

Answer 19

b. differentiating realistic self-image from grandiosity. The client is approaching discharge when they are able to differentiate between a realistic self-image and grandiosity. A client with mania typically has a high regard for self or an inflated self-image, seen as grandiosity. The ability to view oneself realistically demonstrates improvement. The client in a manic state exhibits a decreased need for sleep due to feelings of having boundless energy and increased activity. Sleeping 4 hours per night indicates that the client is still acutely ill. Suddenly asking for a divorce could indicate the client’s poor judgment and inability to perceive the situation realistically. A labile affect (an affect that quickly changes) is typically seen in the manic state. A client may be laughing or joking one minute, suddenly start to cry, and then quickly return to euphoria. A labile affect is an indication that the client is acutely ill.

Answer 20

d. "Formula-fed infants usually feed every 3 to 4 hours." Formula is harder to digest than breast milk and therefore, babies typically feed less frequently than breastfed babies. Formula-fed infants should demand feedings every 3 to 4 hours compared to every 2 to 3 hours for breastfed babies.

Answer 21

a. Acute pain related to biliary spasm The chief symptom of cholecystitis is abdominal pain or biliary colic. Typically, the pain is so severe that the client is restless and changes positions frequently to find relief. Therefore, the nursing diagnosis of Acute pain related to biliary spasms takes highest priority. Until the acute pain is relieved, the client can't learn about prevention, may continue to experience anxiety, and can't address nutritional concerns.

Answer 22

b. determine the severity of the pain. The child is in pain and needs intervention, but before the nurse can determine how to proceed, it is essential to know the severity of the client's pain score to determine whether to give 1 or 2 mg of morphine. In addition, the nurse cannot evaluate the effectiveness of the pain medication if there is no pain score prior to administering the medication. Changing the child's position and administering pain medication may be helpful to relieve the child's pain, but the nurse must first know the severity of the pain before determining the appropriate intervention. The nurse must perform a head-to-toe assessment, but it is not the priority in managing the child's pain.

Answer 23

d. apply the leg splint before beginning the transfer. It is recommended that any braces or devices the client wears to be applied before assisting the client out of bed. The head of the bed should be raised so that the client is in a sitting position before beginning the transfer. There is no reason to roll the client away from the side of the transfer. This would not facilitate the movement and could cause injury to both the client and nurse during the transfer.

Answer 24

c. in functional alignment Muscles that originate at the vertebrae or pelvic girdle and insert on the femur act to abduct, adduct, flex, extend, and rotate the femur. Normal body alignment should be maintained because it facilitates the safe and efficient use of muscle groups for balance and stability. Functional alignment is essential for all bone repair.

Answer 25

a. exercise patterns, nutrition, mobility, and safety. Assessing exercise patterns, nutrition, mobility, and safety provides teaching regarding health promotion and illness and injury prevention for older adult clients living in their homes. It is important to ensure that older adult clients are meeting their needs of exercise, nutrition, mobility, and safety to be able to manage in their own homes. These are the primary physical needs that could pose problems for older adult clients. Assessment of falls, injuries, and rehabilitation focuses only on mobility. Disease identification and management are important but do not address the most important factors that allow older adult clients to remain safe in their own homes. Medical visits are important, but they focus on health problems more than on meeting physical needs.

Answer 26

d. apply the system immediately after removal from a package. The fentanyl transdermal system should be applied immediately after removal from the sealed package. The nurse should press the system firmly in place with the palm for 10 to 20 seconds, not 30 to 60 seconds, to make sure the contact is complete, especially around the edges. The system should be applied to non-irritated and nonirradiated skin on a flat surface of the upper torso. When reapplying a new system, the nurse should choose a different site. Hair at the application site should be clipped (not shaved) before application; the nurse should clean the site with clear water. Soaps, oils, lotions, alcohol, or other agents that might irritate the skin or alter its characteristics shouldn't be used; the skin should be dried completely before application.

Answer 27

a. an identification band. c. an intravenous (IV) line. d. oxygen administration. e. an anesthetist/anesthesiologist The nurse is responsible for the client's safety in the operating room. The nurse should call a time-out if the client is not properly identified with an identification band. In addition, an IV line and oxygen should always be established when an ET tube is placed. This practice applies whenever a client's airway is compromised enough for intubation to occur, not only in the operating room environment. An anesthetist or anesthesiologist should be present during surgery to manage the airway. Postoperative pain medication is administered in the recovery room.

Answer 28

a. decreased cardiac output with slow pulse. d. evening confusion to time and place. e. intravenous diuretics prescribed for edema. f. orthostatic hypotension noted in history. More than 60% of adults hospitalized with CVD have a moderate to high risk for falls. Falls are most often a result of multiple contributing factors. Medication effects, such as those from diuretics, can cause hypotension and increased urination. These effects place clients at risk for falls while moving quickly to the bathroom. Cognitive impairment can cause lack of judgment, which can alter a client’s ability to determine if an activity is risky. Orthostatic hypotension and decreased cardiac output decrease blood flow to the brain, and both contribute to falling as well. Antibiotics are not associated with increased risk for falls. Although visual impairment could contribute to falls, hearing impairment would not affect fall risk.

Answer 29

a. prolonged prothrombin time. The prothrombin time may be prolonged because of decreased absorption of vitamin K and decreased production of prothrombin by the liver. The client should be assessed carefully for bleeding tendencies. Blood glucose, serum potassium, and serum calcium levels are not affected by hepatitis.

Answer 30

a. first intention. Wounds with a small amount of tissue damage that are the result of procedures that use sterile technique and that are properly closed, such as with stitches, heal by first intention. Granulation tissue is generally not visible and scar formation is minimal. Second intention healing occurs in infected wounds or wounds with edges that aren't approximated. These wounds are usually packed with moist dressings. Third intention healing occurs with deep wounds that aren't sutured together, resulting in a deep, wide scar. There is no fourth intention of wound healing.

Answer 31

b. violent behavior. The nurse must be especially cautious when providing care to a client who has taken PCP because of unpredictable, violent behavior. The client can appear to be in a calm state or even in a coma, then become violent, and then return to a calm or comatose state. Visual hallucinations, bizarre behavior, and loud screaming are associated with PCP-intoxicated clients. However, the unpredictable, violent behavior presents a major issue of safety for clients and staff.

Answer 32

d. providing resources to aid in quitting if the parents are smokers. Smoking is a main allergen that can initiate the inflammatory response in children with bronchial asthma. Few children with bronchial asthma will remain asymptomatic for the remainder of their lives. As many as one in two children who had childhood asthma and who are asymptomatic at 18 years of age are likely to have recurrent, symptomatic disease by age 26 years. Asthma usually persists as a low-grade, subclinical condition. Asthmatic episodes may be life threatening in all age groups.

Answer 33

a. washing hands before and after eating and as frequently as possible. Clients should wash hands before and after they eat and as frequently as possible while hospitalized to reduce infections. Klebsiella is spread by person to person contact. The house does not need to cleaned with a bleach solution. The course of antibiotics may continue with discharge. There are no special precautions with a mask for the client because the bacteria does not spread through airborne means.

Answer 34

d. give the client the prescribed opioid analgesic. The nurse's first action should be to administer the prescribed opioid analgesic to the client because this phenomenon is a phantom sensation and interventions should be provided to relieve it. Pain relief is the priority. Phantom sensation is a real sensation. It is incorrect and inappropriate to tell a client that it is impossible to feel the pain. Although it does relieve the client's apprehensions to be told that phantom sensations are a real phenomenon, the client needs prompt treatment to relieve the pain sensation. Usually, phantom sensation will go away. However, showing the client that the toes are not there does nothing to provide the client with relief.

Answer 35

a. "You can continue to breastfeed, feeding your baby more frequently." The client being treated for mastitis should continue to breastfeed often, or at least every 2 to 3 hours. Treatment also includes bed rest, increased fluid intake, local heat application, analgesic agents, and antibiotic therapy. Continually emptying the breasts decreases the risk for engorgement or breast abscess. The client should not discontinue breastfeeding unless they choose to do so. The client may continue breastfeeding while receiving antibiotic therapy. Generally, the breast milk is not contaminated by the offending organism and is safe for the neonate.

Answer 36

d. "I will use a breast pump to remove any milk that may appear." The use of a breast pump to remove milk is contraindicated in bottle-feeding clients. Nipple and breast stimulation and emptying of the breasts produce milk, rather than eliminate milk production. The bottle-feeding client is discouraged from stimulating the breasts in any way. A sports bra that is well fitting provides support and decreases stimulation (binders are not suggested). Having the water in a shower land on the shoulders of the client rather than the breasts also decreases stimulation. Only water is necessary to clean nipples when breastfeeding or bottle-feeding.

Answer 37

d. intense fear of becoming obese, emaciation, and a disturbed body image. An intense fear of becoming obese, emaciation, and a disturbed body image all are considered to be characteristics of anorexia nervosa. Near-normal weight is not associated with anorexia. The weight of others is not a primary factor. “Concern about dieting” is not strong enough language to describe the control of food intake in the individual with anorexia nervosa.

Answer 38

a. autonomy The principle of autonomy informs decisions when conflicts arise between maternal and fetal rights. The birth parent has the right to choose for themselves what they believe to be in their best interest versus the well-being of the fetus. This is the concept of self-determination, of being in charge of one’s person rather than another person determining what behavior or decision represents justice. Nonmaleficence refers to doing no harm. The client has the right to make choices that align with their belief system. Jurisprudence is the actual theory or study of law.

Answer 39

a. "We'll have a family member change the batteries in our smoke detectors when they come by this week." Ensuring that smoke detectors are in working order is critical to fire safety. In addition, electrical appliances, such as heating pads, should be in good condition and functioning properly, with cords not positioned under carpets or rugs. Space heaters are a common cause of fires and should be at least 3 feet (0.9 meters) away from anything flammable, such as curtains, bedding, and furniture. Assistive devices (such as mobility aids, eyeglasses, and hearing aids), a flashlight, a telephone, and emergency numbers should be within reach at all times, should the need for escape be necessary.

Answer 40

a. "Work with the school nurse to develop a plan." c. "Your child will need to drink plenty of liquid at school." d. "Your child should keep a change of clothing at school." Ulcerative colitis is a chronic inflammatory bowel disorder with exacerbations and remissions. In ulcerative colitis the colon develops continuous ulcerations that cause the common symptoms of pain and bloody diarrhea. Drugs such as anti-inflammatory medications, antidiarrheals, and immunosuppressants have been used for management. A child with a chronic condition should have an action plan with the school nurse to provide needed medication and monitor symptoms. A change of clothing may be needed if clothing is soiled as a result of diarrhea. The child should be careful to avoid foods that increase symptoms (commonly raw vegetables, dairy products, and gas-producing foods such as beans, broccoli, or cabbage). Most school lunches are not individualized to a specific child. Liquids are important to prevent dehydration from diarrhea.

Answer 41

b. resolve the immediate problem. During a period of crisis, the major goal is to resolve the immediate problem, with hopes of getting the client to the level of functioning that existed before the crisis or to a higher level of functioning. Withdrawing from stress doesn't address the immediate problem and isn't therapeutic. The client's anxiety will decrease after the immediate problem is resolved. Providing support and safety are necessary interventions while working toward accomplishing the goal. Documentation is necessary for maintaining accurate records of treatment; it isn't a major goal.

Answer 42

b. improvement in client outcomes. The goal of a quality improvement (QI) program is to ensure that the best care is delivered to clients and families. This can be achieved by attention to client outcomes. Staff performance evaluations should be completed according to institutional policy and focus on staff, not client outcomes. Improved care efficiency may be an aspect of quality client care, but it is not the primary outcome. Accreditation agencies have strict parameters to which an institution must adhere to ensure accreditation. QI is one method to demonstrate adherence to the parameters. The goal of QI is to ensure that the best care is delivered to clients and families, not to ensure accreditation.

Answer 43

b. abbreviated grief Abbreviated grief is short in duration but sincere. It results in reconciliation of feelings. This client experienced a short but real period of grief following their miscarriage, but it was abbreviated likely due to becoming pregnant again quickly, thus “replacing” the loss. Unresolved grief is extended in length and severity; the grief does not resolve and can lead to dysfunctional grief. Inhibited grief is when someone does not show any typical signs of grief, which can be a conscious effort to keep the grief private. Inhibited grief can lead to physical manifestations when an individual does not allow oneself to grieve. This can cause dysfunctional grief. Anticipatory grief is grieving prior to the actual loss, which would not cause failure to reconcile feelings of grief.

Answer 44

a. bring up the suspected physical elder abuse with a trusted authority figure. c. report the suspicion to the local Adult Protective Services Agency within 24 hours. d. Monitor the situation during the subsequent home visits. A nurse is a mandated reporter of elder abuse. If the nurse suspects elder abuse, they must report it to the local Adult Protective Services Agency. The nurse can protect seniors by bringing up the issue of elder abuse with a trusted authority member. While monitoring alone is not sufficient, the nurse would continue to monitor the situation. Trying to convince a client with dementia to report the abuse themselves is inappropriate. Doing nothing is not an appropriate nursing action.

Answer 45

b. acute respiratory distress syndrome. c. pneumonia. d. pulmonary edema. Crackles are typically heard on inspiration, can be low- or high-pitched, and occur when air is drawn through fluid in the lung's passageways. They can be classified as fine or course. They may be present on auscultation in a client with acute respiratory distress syndrome, pneumonia, and pulmonary edema. Crackles are not heard in clients with epiglottitis or cardiac tamponade.

Answer 46

d. milk A client on an acid-ash diet must avoid milk and milk products because these make the urine more alkaline, encouraging bacterial growth. Other foods to avoid on this diet include all vegetables except corn and lentils; all fruits except cranberries, plums, and prunes; and any food containing large amounts of potassium, sodium, calcium, or magnesium. Cranberry and prune juice are encouraged because they acidify the urine. Coffee and tea are considered neutral because they don't alter the urine pH.

Answer 47

c. assist with moving the client's bed to the hallway. Following the RACE acronym, the nurse's priority is to rescue anyone who is in danger during a fire. The second step would be to activate the alarm by pulling the wall alarm and notifying emergency services using the facility protocol. Extinguishing the fire would be the last step and should only be attempted if the fire is small. The nurse would not want to walk to the site of the fire to obtain visual confirmation before acting as this could put the nurse in danger and delay the correct actions.

Answer 48

a. the infant should respond to gentile tactile or verbal stimulation. An infant under moderate sedation should respond to verbal or tactile stimuli. Infants under general anesthesia have decreased or absent reflexes. Infants who undergo general or moderate sedation rarely remember the procedure. PCA pumps aren't used during sedation.

Answer 49

a. provide firm pressure to the client's sacral area. The client who has back pain during labor experiences marked discomfort because the fetus is in an LOP position. This pain is much greater than when the fetus is in the anterior position because the fetal head impinges on the sacrum in the course of rotating to the anterior position. Application of firm pressure to the sacral area can help alleviate the pain. Problems of severe back pain during labor do not typically require a cesarean birth. The health care provider (HCP) may elect to do an episiotomy, but it is not necessarily required. It is unlikely that a primigravid client with a fetus in an LOP position will have a precipitous birth; rather, labor is usually more prolonged. A hands-and-knees position or a right side-lying position may help rotate the fetal head and thus alleviate some of the back pain.

Answer 50

a. the client whose body mass index (BMI) is 14.5 and who has a recent history of weight loss. A client with a BMI of 14.5 is significantly underweight. This fact, combined with recent weight loss, would likely necessitate a dietitian referral. The client with recent seizures and the client with pain would normally be treated by the medical team. A client with pneumonia may require a referral to respiratory therapy, but this would be more likely if the client was experiencing significant respiratory distress, which is not noted.

Answer 51

d. wash hands Because measuring blood pressure doesn’t involve contact with the client’s blood or secretions, the nursing student should wash the hands before proceeding.

Answer 52

a. Prevent the development of Wernicke encephalopathy. Thiamine specifically prevents the development of Wernicke encephalopathy, a reversible amnestic disorder caused by a diet deficient in thiamine secondary to poor nutritional intake that commonly accompanies chronic alcohol use disorder. It is characterized by nystagmus, ataxia, and mental status changes. Because the client would rather drink alcohol than eat, the client is depleted of vitamins and nutrients. Alcohol also is an irritant that causes a “malabsorption syndrome” in which vitamins and nutrients are not absorbed properly in the gastrointestinal tract. Thiamine is not associated with decreasing withdrawal symptoms, helping clients regain their strength, or promoting elimination of alcohol from the body.

Answer 53

a. teach parents to promote adequate fluid intake. Urinary stasis is a major cause of UTIs, and can be partially prevented by increasing fluid intake. Baths and hand hygiene are less significant factors in the development of UTIs. Urinary tract infections are increased in uncircumcised male infants under 1 year of age, but unaffected thereafter.

Answer 54

c. a client with uterine contractions who reports "they are getting stronger and closer now." True labor is defined as the onset of regular uterine contractions that increase in frequency, intensity, and duration. The passing of the mucous plug (may be thick and red tinged) implies softening and effacement of the cervix, which is a sign of impending labor (24-48 hours prior), not true labor. Lightening (the fetus settles or drops into the pelvic inlet) is another sign of impending labor and may occur up to 2 weeks prior to birth. The client who is past the due date is showing no signs of distress.

Answer 55

b. splint For a simple and stable fracture, a splint is used. This device is faster and easier to apply, is noncircumferential, will not compromise circulation, and can be easily removed to inspect the injury site. A cast is indicated for a more complicated fracture. A brace is used for long-term stabilization. Traction is used to align the bones of lower extremities and would not be indicated for a minor fracture of the wrist.

Answer 56

a. stay with the family while they view the body. The family may go to great lengths to ensure that their loved one will not die alone. However, despite the best intentions and efforts of the family and clinicians, the client may die at a time when no one is present. If the client dies while family members are not present, the family may express feelings of guilt and will need emotional support. This would be provided by staying with the family while they view the body. Even though the time of death cannot be predicted, some clients appear to “wait” until family members are away from the bedside to die. The family does not need to hear how the client is no longer in pain and at rest. The family needs emotional support. The family should not be permitted to feel guilty for leaving the client. The family should take rest periods away from the bedside in order to provide the best support to the client.

Answer 57

c. a punishment for wrongdoing. Preschool-age children may view illness as punishment for their fantasies. At this age children do not have the cognitive ability to separate fantasies from reality and may expect to be punished for their “evil thoughts.” Viewing illness as a necessary part of life requires a higher level of cognition than preschoolers possess. This view is seen in children of middle school age and older. Perceiving illness as a test of self-worth or as the will of God is more characteristic of adults.

Answer 58

d. directing the conversation to realistic concerns. The nurse directs the conversation to realistic concerns or issues to decrease denial and focus on rebuilding a substance-free life. Allowing the client to continue with the stories or questioning the client further about their exploits reinforces the denial. The nurse telling the client they have heard the stories before is nondirective. Additionally, these actions do nothing to help the client focus on rebuilding a substance-free life.

Answer 59

c. administer an analgesic agent. Removing dressings from severe burns exposes sensitive nerve endings to the air, which is painful. The client should be given a prescribed analgesic agent about one-half hour before the dressing change to promote comfort. The other activities are done as part of the whirlpool and dressing change process and not one-half hour beforehand.

Answer 60

b. "Your report was subjective and did not address the cause of the behavior." The nurse’s report was subjective regarding the observed behavior of the client. It was value laden and did not establish the cause of the behavior, which could have been anything from anxiety to uncontrolled pain. The other options are incorrect because the report was not informative or constructive. It was subjective and inappropriate.

Answer 61

b. the client's vital signs will stabilize, returning to normal range. During the acute phase of a neurological injury, the goal of nursing management is to stabilize the client to prevent further neurological damage. A client goal would be to have the vital signs stabilize, indicating an improvement in status, and also returning to normal range. Using adaptive devices would occur in the recovery or chronic phase of a neurological deficit. The client’s skin and returning to optimal level of functioning is a goal for later in the recovery process.

Answer 62

c. reduced sneezing. Decongestants relieve congestion and sneezing and reduce labored respiration rate. It is anticipated that decongestants dry the mucous membranes, these are commonly reported side effects. The anticipated therapeutic effect would be demonstrated with a decrease in sneezing.

Answer 63

d. apply the leg splint before beginning the transfer. It is recommended that any braces or devices the client wears to be applied before assisting the client out of bed. The head of the bed should be raised so that the client is in a sitting position before beginning the transfer. There is no reason to roll the client away from the side of the transfer. This would not facilitate the movement and could cause injury to both the client and nurse during the transfer.

Answer 64

a. check the last serum electrolyte results for the child. It is most important to know the child’s serum potassium level when administering digoxin. Digoxin increases contractility of the heart and increases renal perfusion, resulting in a diuretic effect with increased loss of potassium and sodium. Hypokalemia increases the risk of digoxin toxicity. Verifying the dosage is specified by facility policy and varies among facilities. Although the child may take the medication better from the parent than from the nurse, asking the parent to give the medication is not necessary. In addition, this would be done after the nurse has checked the electrolyte levels. Teaching the parent how to measure the child’s heart rate can be done at any time, not necessarily when preparing to give digoxin.

Answer 65

a. Ask the client if they have trouble breathing. The nurse should first assess the client's breathing. A complication of a carotid endarterectomy is an incisional hematoma, which could compress the trachea causing breathing difficulty for the client. Although the other measures are important actions, they aren't the nurse's top priority.

Answer 66

d. "I raised the rails to stop my client from trying to get out of bed constantly." A side rail may or may not be considered a restraint. A side rail is not considered a restraint if the client requests that it be raised to aid in getting in or out of bed. Some clients may request that side rails be used at night while they sleep so they feel more secure. Clients requesting side rails must be able to raise and lower the side rails themselves. Side rails that are raised with the intent to prevent the client from voluntarily attempting or actually getting out of bed would be considered a restraint. If the intent of raising the side rails is to prevent a client from inadvertently falling out of bed, or if the client lacks the physical ability to even attempt to get out of bed, side rails would not be considered a restraint.

Answer 67

b. educate the client about the accompanying risk of cervical cancer. This client’s external lesions should be treated, and they should receive education regarding the relationship between HPV and cervical cancer. Antibiotics would be ineffective because of the viral etiology of HPV. Hormonal contraceptives are of no benefit, and HPV is not normally the cause of systemic infection.

Answer 68

b. check the connectors between the chest and drainage tubes and where the drainage tube enters the chest drainage system. There should never be constant bubbling in the water-seal system; normally, the bubbling is intermittent. Constant bubbling in the water-seal bottle indicates an air leak, which means that less negative pressure is being exerted on the pleural space. Decreasing the suction will not reduce the leak. It is not necessary to notify the HCP until the system has been checked and the problem identified.

Answer 69

d. urine drains from it continuously. The ureters are implanted in a segment of the ileum, and urine drains continually because there is no sphincter. The other choices all reflect bowel-associated problems.

Answer 70

c. atropine. Succinylcholine is an ultra-short-acting depolarizing agent used for rapid-sequence intubation. Bradycardia can occur, especially in children. Atropine is the drug of choice in treating or preventing succinylcholine-induced bradycardia. Lidocaine is used in adults only. Epinephrine bolus and isoproterenol aren't used in rapid-sequence intubation because of their profound cardiac effects.

Answer 71

a. "This medication will help my tight, aching muscles." Buspirone, a nonbenzodiazepine anxiolytic, is particularly effective in treating the cognitive symptoms of anxiety, such as worry, apprehension, difficulty with concentration, and irritability. Buspirone is not effective for the somatic symptoms of anxiety (muscle tension). Therapeutic effects may be experienced in 7 to 10 days, with full effects occurring in 3 to 4 weeks. This drug is not known to cause physical or psychological dependence. It can be taken with food or small meals to reduce gastrointestinal upset.

Answer 72

b. reinforce that the client should continue taking prenatal vitamins for the entire pregnancy. Pregnant clients with hemoglobin levels less than 11 g/dl (110 g/L) are considered to be anemic. A hemoglobin level of 13 g/dl (130 g/L) is considered normal, so extra interventions to improve the client's hemoglobin level are not needed. The client should just be encouraged to continue taking prenatal vitamins for the entire length of the pregnancy to assure they continue to maintain a sufficient intake of iron.

Answer 73

c. applying gentle pressure to the baby's head. Gentle pressure applied to the neonate's head as it's delivered prevents rapid expulsion, which can cause brain damage to the neonate and perineal tearing in the birth parent. No one should ever pull at the neonate's head or hold the head back. Placing the parent in the Trendelenburg position won't halt labor and may cause respiratory difficulties.

Answer 74

a. discontinue administration of digoxin. b. begin continuous electrocardiographic monitoring. c. determine serum digoxin and electrolyte levels. Symptoms of digoxin toxicity include severe sinus bradycardia, colorful halos around lights, nausea, anorexia, and vomiting. If digoxin toxicity is suspected, the steps the nurse should implement include discontinue administration of drug; begin continuous electrocardiographic monitoring for cardiac dysrhythmias; administer any appropriate antidysrhythmic drugs as ordered; determine serum digoxin and electrolyte levels; administer potassium supplements for hypokalemia if indicated, as ordered; institute supportive therapy for gastrointestinal symptoms (nausea, vomiting, or diarrhea); and administer digoxin antidote (digoxin immune fab) if indicated, as ordered. Inserting a nasogastric tube or administering oxygen is not appropriate for digoxin toxicity.

Answer 75

a. a meta-analysis of randomized controlled trials (RCTs) about fall prevention. Evidence-based practice requires valid and reliable evidence sources. Evidence sources are prioritized according to a hierarchy, with meta-analyses and systematic reviews of RCTs being the highest level of evidence. Such reviews supersede findings from any one individual RCT. Individual RCTs are considered to be more powerful than cohort studies, which are in turn more powerful than expert opinion.

Answer 76

c. The client's feeling of grief is a normal reaction. Feelings of loss, grief, and guilt are normal after a cesarean birth, particularly if it was not planned. The nurse should support the client, listen with empathy, and allow the client time to grieve. The likelihood of the client experiencing postpartum blues is not known, and no evidence is presented. Although maternal-infant bonding may be delayed owing to neonatal complications or maternal pain and subsequent medications, it should not be difficult. Although the nurse is aware that this type of birth was necessary to save the client's life, using this as the basis for the response does not acknowledge the client's feelings.

Answer 77

b. application of an ice bag. Application of cold or heat requires a health care provider’s prescription. The nurse can initiate massage, distraction, and deep breathing as pain management strategies.

Answer 78

b. initiate seizure precautions. SIADH causes the release of excessive ADH resulting in fluid retention and dilutional hyponatremia. The client is exhibiting symptoms of hyponatremia, which can lead to seizures. Thus the priority is to place client on seizure precautions. Although administering declomycin, increasing salt intake, and monitoring serum osmolarity are appropriate interventions, they are not the priority.

Answer 79

b. conventional. Level two, stage three behaviors of Kohlberg's conventional level of moral reasoning focus on the approval of others. Moral dilemmas are solved by the group standard, with an emphasis on conformity. Adolescents usually function at this level of moral development. Before entering school, children typically function at the preconventional level, which is characterized by avoiding punishment and obeying those who have power. Typically, adults function at the postconventional, or autonomous, stage of moral development, which is characterized by defining moral values and understanding that correct behavior is determined by society.

Answer 80

b. loose, watery stool in the diaper. A loose, watery stool in the diaper is indicative of diarrhea and needs immediate attention. The infant may become severely dehydrated quickly because of the higher percentage of water content per body weight in the neonate, compared with the adult. Frequent hiccups are considered normal in a neonate and do not warrant additional investigation. Pink papular vesicles (erythema toxicum) on the face are considered normal in a neonate and disappear without treatment. Dry, peeling skin is normal in a post-term neonate.

Answer 81

a. helping the parents accept their feelings as a normal reaction. The parents of children born with defects often have feelings of guilt and ask what they might have done to cause the condition or how they might have avoided it. It is important to allow parents to express their feelings and accept these feelings as normal reactions. Explaining that the parents are not at fault would not be appropriate until they have dealt with their feelings of guilt. Encouraging long-term planning generally is of little benefit to parents who are emotionally distraught. Additionally, the parents may interpret this as ignoring their feelings and confirming that they played a role in causing their child's anomaly. Urging the parents to visit their infant as often as possible would generally be of little help and could appear to the parents as though they are being “talked out” of their feelings.

Answer 82

d. moral distress. Moral distress occurs when one is unable to act because of internal or external constraints. The nurse is not able to change the way they interacted with their friend the last time they saw them and is feeling anguish. Secondary traumatic stress is distress that is a result of hearing first-hand traumatic experiences from another person. A boundary violation is behavior by a professional that has violated the limits of a professional–client relationship. Compassion fatigue is disengagement on the part of the caregiving professional.

Answer 83

The client would have a regularly prescribed dose of 1.5mg X 3 (tid)= 4.5mg. The client only has 2 doses or 3 mg possible to remain under the maximum dosage cap.

Answer 84

c. need for a feeding tube. As muscular dystrophy progresses, the client becomes more susceptible to aspiration due to progressive decreasing ability to clear secretions and muscle weakness. A feeding tube will prevent problems with dysphagia resulting in aspiration. Avoiding crowds and hand hygiene might be a part of the overall teaching but are not a priority. All clients should be instructed regarding the need for an advance directive.

Answer 85

a. identifying the client's internal and external cues related to eating. If a client has lost and gained weight several times, identifying and recognizing internal and external cues related to eating would be the most important factor in stopping this process of weight cycling. Reinforcing the health risks of obesity would not be necessary as the client has proactively sought out care for weight management. A weight-loss management program and working with a nutritionist may be part of the care plan, but identifying the root causes of why past weight management has not worked would be the priority.

Answer 86

a. "Smoking puts you at a higher risk for experiencing infection, which is already a potential complication after having surgery." c. "Your incision may not heal as quickly as in a client who does not smoke because smoking results in delayed healing." Complications associated with the physiological effects of nicotine may include an increased risk related to impaired heart and lung function, increased risk for infection, and potentially delayed wound healing. The nurse may offer the client a nicotine patch when they are admitted to the hospital to help provide some nicotine to the client and minimize cravings. While not smoking during hospitalization may affect the client's overall mood, the client is not likely to be at a higher risk for suicidal thoughts. Smoking will not have an impact on the client's motivation to regain functional ability after surgery.

Answer 87

d. the facility should provide the family with an opportunity to speak with an organ procurement coordinator. The facility should offer the family an opportunity to speak with an organ procurement coordinator who is knowledgeable about organ donation and who should have exceptional interpersonal skills for dealing with grieving family members. Health care provider support in the process is desirable but referral to the organ procurement organization does not require a health care provider's consent or written order. The requestor must believe in the benefits of organ donation and support the process with a positive attitude. The possibility of speaking with an organ procurement coordinator should be introduced only after the family has been made aware of the client's condition and prognosis. Approaching a family member who believes there's still hope for recovery will likely result in a negative outcome.

Answer 88

b. A Rinne test shows air conduction longer than bone conduction. Presbycusis is the most common type of sensorineural hearing loss and is a gradual loss of hearing in both ears occurring during the aging process. Based on the client's report, the left ear seems worse than the right ear. Therefore with the Weber test, sound would lateralize to the nonaffected ear, which in this case would be the right ear (less affected than the left). If the hearing loss was conduction, the sound would lateralize to the affected (left) ear. With the Rinne test and sensorineural hearing loss, air conduction sound is heard longer than bone conduction sound. Vestibular function is not involved with presbycusis, so electronystagmography would not be indicated. Infection also would not be a finding suggesting presbycusis.

Answer 89

c. clamp the catheter. If a central venous catheter becomes disconnected, the nurse should immediately apply a catheter clamp. If a clamp isn't available, the nurse may place a sterile syringe or catheter plug in the catheter hub. After cleaning the hub with alcohol or povidone-iodine solution, the nurse must replace the I.V. extension set and restart the infusion. Calling the health care provider, applying a dry sterile dressing to the site, and telling the client to take a deep breath aren't appropriate interventions at this time.

Answer 90

c. "Take zidovudine every 4 hours around the clock." To be effective, zidovudine must be taken every 4 hours around the clock. Food doesn't affect absorption of this drug, so the client may take zidovudine either with food or on an empty stomach. To avoid serious drug interactions, the client should check with the health care provider before taking OTC medications.

Answer 91

c. the presence of blood or drainage on the dressing. After a splenectomy, the client is at high risk for hypovolemia and hemorrhage. The dressing should be checked often; if drainage is present, a circle should be drawn around the drainage and the time noted to help determine how fast bleeding is occurring. The nasogastric tube should be connected, but this can wait until the dressing has been checked. A urinary catheter is not needed. The last pain medication administered and the client’s current pain level should be communicated in the hand-off-of-care report. Checking for hemorrhage is a greater priority than assessing pain level.

Answer 92

a, communicate in a way that models the expected behavior of the client. Clients who are displaying symptoms of histrionic personality disorder need to have appropriate communication modeled for them. Therefore, the nurse should use that approach to assist in the client receiving appropriate care. The nurse will assess the client for risk for suicide, but this is not the priority for this client. Understanding the frequency of attention-seeking behavior will be a piece of the assessment for this disorder, but it is not the priority for this exchange to occur. When engaging in a therapeutic relationship with a client, the nurse should actively listen to the client regarding their health care but does not need to necessarily engage in conversations that are meaningful and heartfelt.

preparation for NCLEX 1 Flashcards

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