NCLEX Review Study Guide 2 100% VERIFIED ANSWERS ACCURATE 2024/2025, Exams of Nursing

Download NCLEX Review Study Guide 2 100% VERIFIED ANSWERS ACCURATE 2024/2025 and more Exams Nursing in PDF only on Docsity! NCLEX Review Study Guide 2 100% VERIFIED ANSWERS ACCURATE 2024/2025 A clinic nurse is assessing a client who has had a cast applied to the lower left arm 1 week ago. The client tells the nurse that the skin is being irritated by the edges of the cast. What is the appropriate action on the part of the nurse Place small pieces of tape over the rough edges of the cast A nurse developing a plan of care for a client with HIV infection identifies several concerns. List them in order of priority, from highest to lowest. 1 Possible infection 2 Decreased nutrition 3 Fatigue 4 Despair An emergency department nurse has a physician's prescription to irrigate a client's ears. List in order of priority the steps that the nurse should take in performing this procedure. 1 Use an otoscope to ensure that the tympanic membrane is intact. 2 Warm tap water to body temperature. 3 Fill an irrigating syringe with warm water. 4 Insert the irrigating solution by directing the solution toward the wall of the ear canal. 5 Document the completion of the procedure and how the client tolerated it. The nurse is preparing to administer a tube feeding by way of a nasogastric tube. Which action does the nurse carry out as a priority before starting the flow of the solution? Checking for gastric residual volume and assessing tube placement A client with schizophrenia says to the nurse, "I decided not to take my medication because it can't help. I am the only one who can help me." Which nursing response is therapeutic in this situation? "Your doctor wants you to continue this medication because it's helping you. Do you recall needing to be hospitalized because you stopped your medication?" A client is brought to the emergency department by ambulance, and diabetic ketoacidosis is suspected. Blood samples are taken, and the nurse obtains supplies that will be needed to treat the client. Which type of insulin does the nurse take from the medication supply room for intravenous (IV) administration? Regular (Humulin R) A nurse is assessing a client who is experiencing chest pain. Which of the following observations indicates to the nurse that the pain is most likely a result of angina? The pain is relieved by rest and nitroglycerin. While being seen by a physician, a client complains of persistent fever, malaise, and night sweats. On physical examination, the physician palpates enlarged lymph nodes, and the client states that the nodes are painless. Hodgkin's lymphoma is suspected, and several diagnostic studies are performed. Which characteristic of this type of lymphoma does the nurse expect to note while reviewing the results of the diagnostic studies? Reed-Sternberg cells on biopsy of a lymph node Iodine solution (Lugol solution) is prescribed to a client who is scheduled for subtotal thyroidectomy. The client calls the nurse at the clinic and complains of a burning sensation in the mouth and soreness of the gums and teeth. The nurse most appropriately tells the client: To contact the physician A client with chronic back pain asks a nurse about the use of complementary and alternative therapies to treat the pain. The nurse would initially: Identify the client's treatment goals A child with growth hormone deficiency will be receiving somatropin (Humatrope). The nurse provides information to the mother about the medication. Which of the following laboratory values does the nurse tell the mother will require monitoring? Thyroid-stimulating hormone (TSH) A client who has sustained an acute myocardial infarction (AMI) is receiving intravenous reteplase (Retavase). For which adverse effect of the medication does the nurse monitor the client? Epistaxis A client arrives at the clinic for her first prenatal assessment. The client tells the nurse that the first day of her last menstrual period (LMP) was September 25, 2012. Using Nagele's rule, the nurse determines that the estimated date of delivery (EDD) is: July 2, 2013 A nurse provides instructions to a client who has been prescribed lithium carbonate (Lithobid) for the treatment of bipolar disorder. Which of these statements by the client indicate a need for further instruction? Select all that apply. "I need to avoid salt in my diet." "It's fine to take any over-the-counter medication with the lithium." "Diarrhea and muscle weakness are to be expected, and if these occur I don't need to be concerned." An adult client with an ileostomy is admitted to the hospital with a diagnosis of isotonic dehydration. What findings does the nurse expect to note during the admission assessment? Select all that apply. Skin tenting Flat neck veins Weak peripheral pulses Warfarin sodium (Coumadin) is prescribed for a hospitalized client. While transcribing the physician's prescription, the nurse notes that the client is taking levothyroxine (Synthroid) to treat hypothyroidism. The nurse calls the physician to confirm the prescription for warfarin sodium because: Levothyroxine amplifies the effect of warfarin sodium A nurse caring for a client with preeclampsia prepares for the administration of an intravenous infusion of magnesium sulfate. Which of the following substances does the nurse ensure is available at the client's bedside? Calcium gluconate A client with hypoparathyroidism is taking calcium gluconate to treat hypocalcemia. The client calls the clinic nurse and complains of becoming constipated since starting the medication. The nurse tells the client to: Increase intake of high-fiber foods The wife of a client with diabetes mellitus calls the nurse and reports that her husband's blood glucose level is 60 mg/dL and that her husband is awake but groggy. The nurse tells the client's wife to immediately: Place some honey in her husband's mouth, between his gums and cheek A nurse is reviewing the medical record of a client with a suspected systemic lupus erythematosus (SLE). Which manifestations of SLE would the nurse expect to find noted in the client's medical record? Select all that apply. Fever Vasculitis Abdominal pain A nurse is providing information to a client who will be self-administering regular insulin about storage of the insulin. The nurse tells the client: That the vial in current use may be kept at room temperature for as long as 1 month without significant loss of activity A nurse reviewing the medical record of a client with a diagnosis of infiltrating ductal carcinoma of the breast notes documentation of the presence of peau d'orange skin. On the basis of this notation, which finding would the nurse expect to note on assessment of the client's breast? Pick the photo that has the nipple that resembles a sunburned orange peel. Peau d'orange means orange peel in French. Which finding in a client's history indicates the greatest risk of cervical cancer to the nurse? Multiple sexual partners A client with tuberculosis will be taking pyrazinamide (Pyrazinamide), and the nurse provides instructions about the adverse effects of the medication. For